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microfiches 
(monographies) 


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D 

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Cover  title  missing  /  Le  titre  de  couverture  manque 
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n 


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D 


7 


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[i]-xiv,   17-1238  p. 


D 


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Ce  document  est  filme  au  taux  de  reduction  indique  ci-dessous. 


10x 

14x 

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26x 

30x 



/ 

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The  copy  filmed  hare  has  been  reproduced  thanks 
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Health  Sciences  Library 
Hontreal 

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Original  copies  in  printed  paper  cover*  are  filmed 
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other  original  copies  are  filmed  beginning  on  the 
first  page  with  d  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — '^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
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beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


1 

2 

4 

5 

;>"  »u'ji»:i*,.^>'iBL'f 


L'axemplairs  filmi  fut  reproduiv  grace  i  la 
gAnArositA  de: 

McCill   University 
Health  Sciences  Library 
Montreal 

Les  images  suivantas  ont  iti  reproduites  avec  le 
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de  la  neneiA  de  I'exemplaire  fllmA,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimAe  sont  film^s  en  commencant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  compone  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmAs  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniAre  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — ^-  signifie  "A  SUIVRE",  le 
symbole  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  '   re 
filmAs  A  des  taux  de  reduction  diff^rents. 
Lorsque  le  document  est  trop  grand  pour  etre 
reproduit  en  un  seul  cliche,  il  est  filmd  d  partir 
de  Tangle  sup^rieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  nAcessaire.  Les  diagrammes  suivants 
itiustrent  la  m^thode. 


2  3 

5  6 


MICROCOPY   DESOIUTION   TEST   CHART 

iANSI  and  ISO  TEST  CHART  Nc    2j 


A  /APPLIED  IfVHGE  J 

^r.  "^^-i   tasl    MO''-    S'/eet 

E^S  Wochestef.    New    Tr-rh         i46C9        USA 

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HSKASKSiiF  rilK  KVK.  \(»SK, 
i<i\T  \M>  KAIi. 


Foil  STIDENTS  AND  PKA(  TITIONERS. 


BY  VARIOUS  AUTHORS. 


EDITED   UY 

WILLIAM  CAMPBELL  POSEY,  A.B.,  M.D. 

I  KuKKS.'.llR  IIP  OPHTHALMOLOGY   IN  TH«  PHILADCU'HIA    TOLVCUNIC  ;   SIROEON  TO  TH«  WIL1.«   KV« 

HO'I'ITAL;  OI'HTHALMIC  SI'KQEON  TO  THP.   HOWAKD  AND  KPM.EPTK    HOSI'ITALS ; 

MEMBEK   OP  THE  AMEKH  AN'  OPHTHALMOIXX.ICAL  SOCIETY, 

AND 

JONATHAN  WRIGHT,  M.D., 

irrKSlllNU    LARYSUOLOUl>r  TO   K1NU3  COUNTY    HOSITTAL  i    LARYNGOI/XilST  TO  THE    BROOKLYN 

EVE   AM>  EAR  HO^I'ITAL  ;  SIRGEON  TO  Tl   '  MANHATTAN  EYE  AND  EAR  HOSPITAL,  THROAT 

1>K1>AI;IMKNT:    PATHiM.OUIST  TO  THE  MANHATTAN  EYE  AND   EAR   HOSPITAL. 


ILLUSTRATED  WITH  650  ENGRAVINGS  AND  35  PLATES 
IN   COLORS  AND  MONOCHROfylE. 


('M«fiiCAL  FACULTY 
^\      M«QILL 


LEA  BROTHERS  «fe  CO., 

PHILADELPHIA     AND    NEW    YORK. 
]  903. 


1 


Entered  .ccording  to  the  Aol  of  Congrew,  in  the  year  I»02,  bv 

LEA   BROTHERS  ±   CO., 

In  the  Office  of  the  Librarian  of  Congre...     All  righU  reserved. 


,o'=\ 


D0RN4N,     PRIJITEIl. 


PREFACE. 


Tin:  practical  convenience  affor^lcd  by  cdinhiiiing  the  sui)jects 
of  the  Kve,  I.'ar,  Nose,  and  Tliioat  within  a  single  volume  needs 
no  demonstration.  It  rests  upon  obvious  reasons.  The  anatomical 
and  patholfigical  relations  of  these  organs  .-ire  so  close  that  the 
speci.iiist  in  one  subject  shonhl  have  a  thorough  knowledge  of  the 
others:  their  aHections  are  so  connnon  anil  widespread  that  they 
form  ,1  large  share  of  general  jjractice,  and  their  bearings  upon  inter 
nal  medicine  are  ,so  nianifold  ,,iid  direct  tliat  no  i)hysician  can  igiuu. 
their  influence  or  dispenx"  with  the  light  they  cast  upon  morbid 
st.'ites  elsewhere. 

The  present  volume  has  been  arninged  in  view  of  the.se  facts  and 
in  Older  to  give  a  comprehensive,  authoritative,  and  practical  expo- 
sition of  these  cognate  de|)artment«!.  The  contril)iitors  are  men 
who  h.Mve  demonstrated  their  .s])i'cia!  ability  in  connection  with  the 
subjects  a.ssigned.  It  may  be  noted  that  the  matter  has  fM-en 
distributed  so  that  each  author  has  been  enabled  to  treat  the 
subject  committed  to  him  in  its  entirety.  KeiH>titioii,  .so  frequent 
a  fault  in  systems,  has  thus  been  avoideil.  Separate  chapters 
on  anatomy  and  physiology  have  been  omitted,  as  such  general 
knowledge  is  presuj)posed ;  but  enough  information  will  be  found 
in  connection  with  each  subject  to  exj)lain  the  pathology  and 
symptomatology. 

The  authors  have  aimed  to  adai)t  the  book  particularly  to  the 
needs  (,f  general  practitioners  and  students,  though  it  is  hoped 
that  even  specialists  may  find  the  latest  expositions  of  these  .subjects 
by  their  colleagues  to  jjo.s.sess  much  of  interest  and  value. 

The  arrangement  of  the  Ophthalmological  Section  differs  con.sider- 
ably  from  that  usually  employed:  it  has  been  adopted,  however,  for 
the  puri)ose  of  bringing  the  reader  into  immediate  clinical  relation- 
.ship  with  the  i)atient.  without  confusing  him  with  the  formuh-e  of 
optics  until  the  necessity  of  comprehending  them  arises  in  the  fur- 
ther unfolding  of  the  subject.    The  chapter  on  the  Eye  in  its  RelatUm 


■■ 


VI 


I'liKFME. 


to  General  ^/.srrrsr.  w  vory  (•(.inpri-hciisive.  an,|  it  is  lH.|>ed  tliat  it 
will  r.r.)v<>  .,f  f.sp..,.iMl  value  t.>  the  Roneral  practitioner  ii,  acquaint- 
inKlani  with  tho  , .Hilar  lesions  of  every  jjeneral  and  I,,,.;,!  a.  ec-tion 
exhihitini;  sudi  manifestations. 

In  the  sertion  on  the  Throat,  Xose,  an.!  I-ar.  the  general  chai)ters 
on  Pathology,  on  Instruments,  and  or  Routine  Operations  were 
introduced  to  secim-  conciseness  without  curtailment  of  the  matter 
necessary  for  the  thorough  elucidation  of  th.-  subjects  dealt  with. 


LIST  OF  CONTRinUTORS. 


ALDKKTON,  HEMIY  AHXuLD,  M.l)., 

thief  of  Aural  flinic  arj  AsHi.«tanl  M  llir  (hair  ..f  Otolojfv  in  the  Long  Island 
Modical  CoUrn.-;  Aural  .Surgr.m  to  th.-  Urooklvn  Eye  and  Ear  Hospital; 
Aural  .Surgeon  to  the  Kings  County  Hospital  and  to  the  Bushwick  Hoh- 
pital;  Attending  Surgeon  to  the  Ear,  Xose,  and  Throat  Department  of 
the  Nassau  Couniy  Hospital;  Meniher  of  the  American  Otological  Society; 
of  the  New  York  ((tologieal  Society-  of  tiie  American  LarvngoloRical, 
Uhuiologieal,  and  Otological  Society;  of  the  Associated  Physicians  of  Long 
Island;  of  the  Medical  Society  of  Gn-ater  New  York:  of  the  Kings  County 
Society  atid  Association,  of  the  Long  Island  Medical  Society;  of  the 
Brooklyn  Medical  Society;  Chairman  of  the  .Section  on  Laryngology, 
I{hinol.)gy,  and  Otology,  Kings  County  .Me.lical  ,Society;  Attending  I'hvs'i- 
cian  for  I)iseas<.s  of  the  Ear,  Xose.  and  Throat  to  the  Home  for  friendless 
Women  and  Children. 


BIUKKTT,  H.  S..  Ml).. 

Professor  of  lihinolog>  and  Laryngology  in  the  McGill  T  nnersity.  Moi.ireai 
Khinologist  and  LaryngoloRi..*t  to  the  l{oyal  A'ictoria  Hom-' ,1.  Montrea;. 
F'ellow  of  the  American  Laryiigologi,  al  A-M.eiation. 

CASSELBEUHY,  \V.  E.,  M.l)., 

Profcsor  of  Laryngology  and  Pl.inology  in  the  Northwestern  Iniversitv 
Medical  School;  Laryngologist  and  Uhinologisi  to  the  Si.  I  uke's  and 
Wesley  Hospiials,  Chicago,  111.;  FelUv  of  the  .American  Larvngologica I 
Association,  etc. 

CHE.VTLE,  AUTHITR  h.,  F.R.C.S.  Exo., 

Assistant  .\ural  Surgeon  to  the  King's  College  Hospital.  London;  Surgeon 
to  th<'  lioyal  Ear  Ho.spital,  London. 

CLARK.  C.  I.,  Mil, 

Professor  of  Ophthalmology  and  Otology  in  the  Starling  Medical  College; 
Attending  Eye  and  Ear  Surgeon  to  the  St.  Francis  Hospital,  and  Con- 
sulting Surgeon  to  the  Children's  Hospital,  Colunihu.s,  Ohio. 

COLLINS,  E.  T1{EACHE1{.  F.H.C.S.  Eve, 

Surgeon  to  the  Royal  London  Ophthalmic  Hospital  (M.iorfields);  Ophthalmic 
Surgeon  to  the  Charing  Cro.ss  Ho.spital,  and  Lectun'r  on  Ophthalmology 
at  the  Medical  School. 

(vii) 


VIII 


l.l\r  iiF  inSTIiinrrnHs 


(.IlnrKKI  I.  K.   \..  MM, 

Vi»i»taiil  111  Ori.li.uy  ill  ill.'  Hiii'Minl  I  iiiM-rsity  MrWniil  ^.Iiih.I,  .\«.si»i;iiii 
SiirKcoii  til  thr  Ma«wirlinwil«  Kyc  unit  Kiir  Intirin,.  ,  ;  \  iiitiii)f  Aural 
''iirisiuii  til  till'  IiiluMl>'  .iiiij  Niniiiii  Mnipiliil-,  l»ii»tiiii,  Mii!«>, 

DI   \.\K,   \I.i:.\ WhKlf    Mil. 

IiiMiniilor  ill  (•iililliiiliiiiilui.'v  iiikI  Siirniiiii  in  ihi-  Ilin|Hii»urv  <>f  ihf  tnriii-ll 
Mfili.  al  Ci.ll.tfr.  Nrw  Vork:  ^iukioh  In  ill.  niilitlmliiiic  ami  Aural  liij.ti- 
Hilc:  <  )|i|itliuliiiiil(i)fist  to  till- Saiii.iritaii  lliiiiic:  ^  iMitiiiK  0|)ht>iuliiiiilogii>t 
ti.  the  Italiilall's  Maiiil  Hospital.  Niw  \ciik. 

Kl  I.KI  1,  KDWAIfO  (  .,  Ml). 

Oplitliuliiiicainl  Aural  .Siiiifii  HI  i,i  llir  St.  .lu-n'iili'^  Hospital,  llie  City  Hospital, 
.iiiil  till'  Lratli  (Irpliaii   \<\liiiii,  Mciiipliis,  Trmi. 

GIKI(>I!1»,  H.,  M.I)., 

I'rofi'ssor  of  (»plitlial:iioloi;v  ami  O|olo(ty  in  the  riiivcrsitv  of  Nfl  ka. 
Oinalia.  Ni'li. 

(JOOKALK.  J.  I,.,  M.n.. 

Assistant  I'livsiiiaii  lor  hisiaws  of  ilir  Nose  ami  Throat  in  tlic  Massarlmst'tis 
•  JentTal  Hospital  anil  in  tin'  Huston  Cliildren's  Hospital,  Hoston,  Mass.; 
Miiiihcr  of  the  Amcriiiin   l.aiyiiKiilo)tiraI  .Vssociation. 

HOI'KIN.s;,  F.  E.,  M.l).. 

I.arynKolonist  ami  Otologist  to  llir  SpriiiKti.liI  Hospital,  Sprinnfield.  Mass.: 
Fellow  of  tlir  -New  York  .Vcadpmy  of  Mciliiiiir  ami  of  tho  Atiicrican  l.aryti- 
polociial  Assiiiiiiiion,  rir. 

MAVKll,  K.\in..   Ml). 

MiritiM.ii  to  till'  Nrw  'I'ork  Kyi'  ami  Far  Inliiniary  (Throat  Department); 
Fellow  of  the  AiiM  liiaii  I-aryiiKulojfiral  A.ssoriatioii;  I'hairnian  of  the 
Section  on  I.aiyii)j;iilo(jy  of  the  New  Vork  Academy  of  Medicine;  Kx- 
Pre.sidont  of  the  Section  on  I.aryiiKoloay  and  t)tolo(fy  of  the  American 
Medical  .\ssociation,  etc. 

NK\V(  ')Mli,  J.   V...  M.I).. 

Instructor  in  Laryn(rolo)ty  in  the  Coniell  Iniversity  .Medical  (^ollege.  New 
Vork;  .VttendiiiK  I,aryn){"loKist  to  the  I{oo..«'vell  Hospital,  Out-patient 
Department,  and  to  the  Deinilt  Dispeii.sary,  New  Vork. 

Pt)SEV.  WII.I.IAM  CAMI'HKI.I,  M.I)., 

Professor  of  Ophthalmology  in  lh,  Philadelphia  Polyclinic;  .Surgeon  to  the 
Wills  F;ye  Hospital:  Ophthalmic  Siirceon  to  the  Howard  and  Kpileptic 
Hospitals,  Philadelphia:  .Miiiilier  of  the  .\merican  Ophthalmological 
Society. 

HKKVK.  I{.  A.,  Ml).. 

I 

Professor  of  Ophthalmolo).",     mil   Otology    in    the    I'niversity   of  Toronto; 

Ophthalmic  and  .\unil  Siiiffeon  to  il  .■  fjeneral  Hospital  and  Hospital  for 

Sick  riiildr'n,    Inroiilo,  ( '.inada. 


IPIRl 


ItHHMIDSitN,  (  M  Mil.Ks  \\  ,  M.i». 


SHI  MV  •        KDW  AIM)  A  ,  US  ,   M  |>.. 

Opi      .liiiolojri^t  lo  ihi'  l'ri'»l,\  ii'iiiiii  He 

■  .'I'liiisyh  Hiiiii:  \'(iliiiititrv  As^mmm 

■  il' (liiiiciil  Mriliriiic,  I'hiluilflphlH 

SIMI'soN.  WILLIAM  KKLLV,  M  I>. 

Siirgpon   to   thf    Ni'iv    Vmk    Ey    :,i„\   K.ir   Iiil 
<  hicf  of  (  linic  iirul  I 


for  Wiilou.  ,'iri(l  >iii(flc  Woiiicii 
William  I'l-piHT  L.iliiinitory 


f'liicf  of  (linic  iiriil  Iii..lni<toi-  in  Larvii^folon.v  in  Ihi'  (  ollcjf.-  of  I'lu>iciHii 
anil  Siirifr.iii..,  Coliiinhia  fiiivrrsiiy,  \c-w  ^ork :  IVIlow  of  the  Amtiri-ni 
I.aryiiKciloKical  A-<soiialii)ii,  ••ti-. 

SPICFIi.   I.  HOLM  I       I  .Ii.(;..-«.  Ia,,  , 

-iirK<'oii   to   li,.    Moorfiflds   Kyi-    Hospital;  Opiithaliiiii-  Siirnpor.' to  the   St 
M.irtholoin.'w's  Hospitnl,  Loniloii,  Kii»tlaml. 

STAIil;.  KLMKH  (i  ,  M.I>,. 

Cliiiii-al  I'rofissor  of  l  iphlliaiinoloKy  in  the  Mcliral  Drparln.  nt  of  the 
v.T»ity  of  UiilTalo;  Siiwoii  to  the  Km'  and   Ear  Dt-partiiifnt,  Iniv. 
I)isp<.n«ary.   Muffalo,  N.   V, ;    Kye  and  Kar  Siirjjeon      .  tlii>   Erie  founty 
Hosi.ital.CtMin.iii  DfacoM.'-s'  Hospital,  and   UtitTalo  Hospital  of  Sis 


Ini- 
Tsitv 


itcru  of 


f'liarity,  Hi-ffalo.  N.  V. 

sr  TEK,  willia:       ^HWooD,  m  d. 

I  to  the  Kpivopal  Eyi',  Kar,  and   Throat  Hospital,  Wash' 


A«»i«tant  Siir 
it  r^f.n.  T).  » 


THOMSC'  ,,  .>■(  LAIli,  Mil..  K.K.C.S.  Kno., 

As  :,  .  I'hvsi.ian  for  Disi.nsf.s  of  the  Throat  in  tho  King's  College  Hospital ; 
Pi.v  ician  to  the  Ihro.it  Hospital,  (iolden  Square;  Lecturer  on  LarvnRoloRy 
.It  the  Pnlvclinir;  lai.-  Surgeon  to  the  Royal  Ear  Hospital,  London;  (.or- 
respondinK'  Kellow  of  the  American  Laryngological  A"sociation;  of  the 
Acadenia  .Medica  of  l'lr)rence.  and  of  the  ,Socirt#  Francaise  d'Otologie  et 
de  LarynRnlogic :  Honorary  Liliranan  of  the  Larvngologioal  Societv  of 
London. 

VE.^SEV,  CLAHENC  K  A.,  A.M..  Mi).. 

nemnnstrator  of  Diseases  of  the  Eye  in  the  .hfferson  Medical  College;  A.ssist- 
ant  Ophthalmic  Surgeon  in  the  JpfTerson  Medical  College  Hospital;  Oph- 
thalmic Surgeon  in  the  Methodist  Kpiscopal  Hospital;  Consulting  Ophthal- 
mologist in  the  Philadelphia  Lying-in  Charity. 

WEEKS,  JOHN  E..  M.P., 

^r  .eon  to  the  Ophthalmic  Department  of  the  \ew  York  Eye  and  Ear 
Infirmary;  Professor  of  Clinical  Ophthalmology  in  the  University  and 
Hellevue  Hospital  Medical  CoUtg^;  Fellow  of  the  New  York  Academy  of 
Medicine;  Member  of  the  American  Medical  A-isociat ion. 


x  LIST  iiF  C/JMllllllTOUS. 

WOOD,  CAUSEY  A.,  M.I)., 

Proffssor  iif  OplithaliiKiloKy  in  the  Cliicago  I'dsl-graduate  .Medical  .■^choiil; 
l'rofes->(ir  of  Clinual  (^plitlialiiioUigj-  in  the  University  of  Illinois;  Oph- 
thalmic SiifRi'iin  to  the  I'assavant  Memorial  Hospital  and  to  St.  Luke's 
Hospital.  Chicaeo;  Consulting  Ophthalmologist  to  St.  Anthony's  Hos- 
pital, Chicago,  III. 


WHHDK.MA.N.N.  H.  V.,  M.I)., 

Prot'es.sor  of  Ophthalmology  to  the  .Milwaukee  .Medical  College,  and  Chief  of 
Eye  Clinic,  Ophthalmic  and  .Kural  Surge<in  to  the  Trinity  Hospital;  to 
the  M  iiikee  Childri'ii's  Hospital;  to  tlie  .Milwaukee  County  Hospital; 
to  the  -Milwaukee  County  Hospital  for  llie  Chronic  Insane. 


CONTENTS. 


THE    EYE, 


CHAPTER  I. 


EXAMIXATIOX  OF  THE  EVE 

Hy  William  Campbell  Posev,  M.D. 

CHAPTER  11. 

THE  PHYSIOLOGY  OF  VISION 

Bv  William  No^iwooi)  StTEii.  M.D. 

CHAPTER  III. 

liKFIiACTIVE  KliliOliS  IN  GENEHAI 

Hy  Alexandeh  Diane,  M.D. 

CHAPTER   1\-. 

THE  MOTIONS  OF  THE  EYEHALL  AND  THEII!  DEIiANOEMENTS  . 
liY  Ca^^ey  a.  Wood.  M.D. 

CHAPTER  V. 

DISKASES  OF   IHK  OUMIT,  I.VCRYMAL  AFPAHATCs,  AND  LIDS 
Hv   I!.  A.   IJeeve.  M.D 


PACE 
19 


.53 


14.- 


192 


chapti:r  \r. 

DISEASES  (IF  THE  CON.IFNCTIVA,  (OliXEA,  .\N1)  SCLEHA 
Hy  .Iohn  E,  Wkkks,  M.D. 

chapti:r  \ir. 

F\IHi;VOLO(;V     OF     MIK      EVE;     .WOMALIES,     DISEASES      wn 
\.H  lilES    OF    THE    ims,    (TLIAHY    H(.DY,    CHOROID,   AND 
\  11  ItEOF.S 


2,5S 


Hv  H.  W  Wi  udemaw,  .M.D. 


3.'?1 


(xi^ 


XII 


(t»Mi:.\rs. 
CHAl'TKR  VIII. 


SVMI'AIHKTIC  OI'HTHAI.MIA 

i?v  H.  (lienMii).  M.D. 

CHAPTKR  IX. 

1)1SK.\SKS  ol-  THK   1>KT1NA.  i  )1>TI('   NKUVK.  AND  ITS  CKliKKl!  \l. 
I5i    I'.   Hoi.MKs  Sri(  Kii.  !.!'.(  .>.  Km.. 


I'AGE 


OIUC.IN 


CHAPTKU  X. 

DISKASKS  Ol'  THK  (TtYSTAI.LlNK  I.KNS  . 

Hv   Ki)«  Mil)  ('.  Ki.i.Kii.  Ml). 


(il.ArCOMA 


('hai'ti:h  XI. 


Hv   K.    rnKvriiKii  ('(.i.i.i\~,  1  .l!.( '.>.  Km;. 


CHAITKH  Xil. 


DISIT  KinNCKS  OK  VlSloN   WllHOl   I    .M'l'AliKM    I.KSloN 

H\      Kl.MKH    (i.    SlMill.    M.l>. 


417 


474 


.)24 


Otis 


(MIAITKH   XIII. 

THK   KVK  IN   US   liKI.AlToN    I"  CKNKIiAI.   DlSKASKS 

Hv    ('.    1'.    Cl.MIK.  M.l>. 


.>s:} 


("IIAITKR   XI\. 

(IKNKKAI.   IMtKrAKAIToN    l(  H{  Ol'Kli.VIToNS  lI'o.NTHKKVK  UM 

Hi   f'f.MiK-    '     \.  Vk.\>k.y.   A.m.,  M.D. 

CIIAI'TKU    XV. 

THK  TKCHMql  K  oK    IHK   HA  I  Hol.O(  IK  Al.   AND   HA(TKI!loI.(  •(;!- 

CAK  KWMINVTIONS  ol     IHK  KVK •">' 

Hv   Ki)«  Mill  .\.  SinMWAV.  H.S,,  M.D. 


COXTKXrs. 


xin 


NOSE   AND  THROAT. 


C'HAPTKH   XM. 

THK  nisToi.dcrcAr,  i'athomkiy  of  diskasks  or  thk  .\(isk 


AMJ  THUOAT 


(1S9 


MV    .1.     I,.    (looDAI.K.    M.l), 


CHAPTKH   X\II. 

MKTHoDS   (ir    K.\AMI.\ATI(l\:    INSTItlMKNTS   AM)   AITAUAIT 


AM)  THKIH  ISE 


Mv  .1.   !■:.   Nk 


VMOMIi.    M.I). 


CIIAPTKK  XVIir. 

IM  l..\MM.\T()l{V  DISlvVSK-^OI'THK  VVVVM  AIU   I'\SS\(iK-;    H  \V 
IKNKI!:  I!HIN()HHH(1;A;  .\STHM.V.  I.MI.r:.:xz A 

Rv    ClIAHLES    W.     UlCHMIDSON.   .M.l). 


("HAPTKR    XIX. 

nil'HTHKIil.V  Ol     .NOSK  .\M)  THUO.U':    I.NTIHATIO 


•iVl'Hir.b 


TrMKUCll.o.slS,  HITS  .VM)  LKl>|{().sv  OK  .\(  )SK  AM 
THl!oAT;("HI(oMC  l..\l{V\fiEAL  STKXOSI.S;  KoHKKi.V  HOI)IK.> 
I.N   \o.sK  A.NI)  THito.Vr;    liHINol.ITHS        .  .  .  .       ' 

IJv  Wii.MAM   Kki.1..    SnTi'sdx,  M.l). 


829 


("HAI'TKH  XX. 

NKOIT.A.sMS   ol'   THK   NosK  AM)   I.AliV.W:   THK  I.OC.M,.  MKDI- 
Cl.WI..  A.NI)  .slTUilCAI,    ri!KATMK\T  OK  THK  I..VI{V.\.\  . 


Mv   W.   K.  Cassk 


I.IIKHHY.   .M.l). 


(•iiapti:h  XXI. 

l)l.<KA.SK.s  (,i.    rn|.;  .U'CKSSOliV  .sKMSK.s 

Hv  StCi.aih  Thomsdn,  M.I)..  K.IM'.S.  K.\o. 


022 


("HAITER  XXII. 

DI.-iK.XSKS  oK    IHK  oliol'H.Mn.NX  AM)  .\.\.S()I'H.U{YN.\ 
Hv  H.  ,S  HiRht,rT,  M.I). 


()S.i 


XIV 


COSTEXTS. 

CHAPTER  XXIII. 


NKUROSES  OF  THE  NOSE  AND  THROAT  .         .         .         ■ 

Bt  Emil  Mayer,  M.U. 

CHAPTER  XXIV. 

EXTERNAL  UEFORMITIES  OF  THE  NOSE;  CLEFr  PALATE  . 
By  F.  E.  Hopkins,  M.D. 


PAGE 

103G 


1053 


THE  EAR. 

CHAPTER  XXV. 

FVVMINATION  OF  THE  EAR;  DISEASES  OF  THE  EXTERNAL  EAR; 
PHEXSES  OF  THE  EXTERNAL  AUDITORY  MEATUS;  OTOMY- 
COSIS;   FOREIGN    BODIES;    WOUNDS    OF    THE    MEMBRAXA 

TYMFANI        

Bv  v.  K.  HopK.Ns,  M.D. 


lOT.'i 


CHA1»TER  XXVI. 

DISKASKS   OF     IHK    INTKRNAI.    EAR    AND   AUDITORY    NERVE; 
DKAl    MUTISM        .  . 

Bv    K.    A.   (■llnCkKTT.  M.I). 


1097 


CHAPTKR  XXVII. 


PUHll.KM-  INFLAMMATION  OF  THF,  MIDDLE  EAR 
li\    Hf.miv  .\iin<ii,ii  Ai.dkrton.  M.D. 


IIOS 


ch.\pti:r  XXVIII. 


(■HHt.NIC  NON-SUIM'IHATIVK  MIDDLE-EAK   DISEASE 
By  Autih  u   H.  Ciieati.k.  F.R.C.S.  Eno. 


1!76 


THE  EYE. 


CHAPTER    I. 
EXAMINATION    OF   THE   EYE. 

Bv  WILLIAM  CAMPHKLL  POSEY,  M.D. 

General  Considerations.  The  studeiu  of  niediciiu"  should  ap- 
proach the  study  of  tlic  eye  with  a  twofold  purpose:  tirst,  to  ohtain 
throufili  it  further  iuforiiiatiou  r;j-ardiiig  the  state  of  the  geiiend 
system,  and,  secondly,  to  becon.e  accjuainted  witli  the  morbid  |)roc- 
esses  which  attack  one  of  th(  most  important  orj^ans  of  the  hody. 
There  is  no  other  orj;an  in  the  body  in  which  the  ge'ieral  systemic 
condition  can  l>e  studieil  to  better  advantage  than  the  eye,  for  it 
presents  in  a  compact  form  representation  of  nearly  all  the  tissues  of 
the  l)ody.  and  by  reason  of  the  transparency  of  some  of  its  coats 
the  stude  I  is  enabled  actually  to  witness  i)hysiolo(rical  and  patho- 
iofricai  ])ioces,ses  occurrinfi  within  it.  A  living  nerve  head,  the  optic 
papilla,  and  the  retinal  vessels  are  unfolded  to  the  gaze  of  the  oph- 
thalmologist, and  an  opportunity  aHorded  luiu  of  ob.serving  the 
perfect  cycle  of  the  supply  of  an  organ  with  arterial,  and  the  escape 
of  its  venou-\  blood. 

For  the  proi)er  study  of  this  important  organ  it  is  e.s.>ieiitial  that 
the  stu<lent  procee.l  systematically  and  thoroughly,  for  while  it  often 
hapjx'ns  that  a  trained  clinician  is  enabled  by  the  brief  recital  of 
.symptoms  or  by  a  rai)id  glance  at  the  eye  to  make  a  i)roper  diagnosis, 
if  is  better  that  the  student,  who  has  yet  to  attain  experience  and 
skill,  should  tVjllow  some  settled  order  of  investigation,  and  that  for 
the  purpo.se  of  future  reference,  as  well  as  to  ensure  accuracy,  he 
should  accustom  himself  to  record  faithfully  all  his  observations  in 
an  appropriat<^  case-book. 

Inspection  of  ths  General  Physical  Condition.  Before  proce<iling 
to  an  inmiediat(>  inspection  of  the  eye  itself,  it  is  ailvantageous  that 
the  general  physical  condition  of  the  i)atit-nt  should  be  taken  account 
of.  For  this  purpose  he  should  be  seat"'"  in  a  chair  facing  a  win- 
dow, the  student,  with  his  back  to  the  'ight,  seating  himself  several 
feet  di.-itai.r ,'  the  patient.  I'nder  this  .strong  illuir.itiatioii  i'-- entire 
person  of  the  patietit  should  be  raimlly  inspected,  and  any  de|)arture 
from  the  noriuaHff^liS^^^Lportions  of  the  skin  and  of  the  glandu- 


GU^|G 


20 


riir:  eye. 


lar  sysiciii.  ;is  well  ;is  the  cliMiMclcr  111'  ;iiiy  cniplion,  iintcil.  Iiiili- 
catioiis  111'  arin'riiia  nr  ]il('llinia  slupiihl  he  sraiclicd  for,  ami  any 
t'vidciKM's  (if  jaiiiiilicc.     I'itially.  tlii'  jrciicral  ('\|ircssi((ii  uf  tlu-  palii'iil 

aiiil  tlic  prcsciK r  alisciicc  nf  pain,  or  of  any  iiitolcraiu-c  to  lijjlit. 

slirttilil  III'  laki'ii  into  ai'i'oiuit. 

Inspection  of  the  Eyes  and  Their  Adnexae.  1'liis  p>ncral  survey 
of  tlic  casi'  l)i'in<;  rotnpli'tcil.  the  atli'iition  of  tlic  stmlcnt  slioiiid  he 
iliri'cti'il  niori'  rspci-ially  lowani  llic  rrfiion  of  the  eves,  'i'lic  sliapi' 
am!  jjcnrral  nmlijiuralion  of  tin'  head  and  the  character  of  tlie 
wrinkles  in  tlie  skin  of  the  forehead  and  at  the  root  of  the  nose  should 
be  studied.  Any  tendency  toward  laeial  asyniinelry  siiould  Im' 
noted,  ;ini|  coinparison  made  whether  l)oih  orbits  are  on  the  same 
horizontal  plane,  and  whether  their  cav-  .es  arc  deep  or  shallow. 
Tile  dejrree  of  prominence  and  the  size  of  tlie  eyeballs  should  be 
remarked,  and  the  relationship  which  the  eyes  bear  to  one  another. 
MsiM'cially  should  the  |iresence  or  absence  of  iiiflarnination  of  tlio  eve- 
balls  be  taken  into  accotmt :  if  but  one  eye  is  diseased,  it.s  condition 
should  be  compared  with  that  of  the  sound  eye,  as  comparative 
examinations  of  this  kind  are  frei|uetitly  of  irreat  value.  The  student 
should  I'arefully  scan  the  rejrion  of  the  sinuses  accessory  to  the  eye, 
to  detect  swelling  or  si<;iis  of  inflammation  in  then..  Any  sifjiis  of 
jirevious  injury  about  the  eyes  should  be  recorded.  Tiio  attention 
siiould  then  be  directed  particularly  to  the  lids  as  to  any  inversion  or 
('Version  of  their  edf^es,  or  thickening;  or  distortion  or  swelling  of  them: 
estimation  should  lie  made  of  abnormal  narrowness  or  width  of  the 
lialp<'bral  fissures.  The  action  of  the  orbicularis:  in  closinji  the  lids 
should  be  tested,  and  any  twitchini,'  of  the  lids  and  .-issociated  muscles 
ol  the  face  noted.  The  rejiion  of  the  iimer  canthus  should  be  in- 
spected for  evidences  of  swellinsr.  or  retained  tears,  or  other  sipis  of 
faulty  drainajce  in  the  lacrymal  apparatus. 

Havin-i  ol).-;erved  the  <i;enei;il  apitearance  of  the  jiatient.  and  having 
obtained  by  the  inspection  of  the  region  of  the  eves  in  a  f;ener;il  wav 
.some  idea  of  the  nature  of  the  ocular  complaint,  before  attemptinjr 
a  cliser  inspection  of  the  eye  the  student  should  next  obtain  bv  care- 
ful iinestioninjr  ;i  precise  ;md  complete  history  of  the  patient's  family 
.-Hid  person.'il  history. 

Family  and  Personal  History.  The  six.  race,  and  afre  of  the  patient 
should  be  recorded,  and  account  tn.'ideof  the  n.'itureof  the  i>ccu|)ation, 
certain  callings,  !)y  reason  cf  the  accidents  to  which  they  expo.se  the 
eyes.  ;inil  others,  by  the  enforced  strain  which  they  pl.'ice  upon  them, 
bein-;  particularly  li.ible  to  produce  ocular  lesions.  Inquiry  should 
also  be  m;ide  into  the  inarit.il  relations:  and  if  the  patient  be  married, 
of  the  mimber  .•md  health  of  any  ofl'spriiij;.  Any  hereditary  ten- 
dency, particularly  to  ocular  disease  in  the  .•incest ry,  should  "be  re- 
corded, also  the  temperament  of  the  p:itient,  w '  'ther  it  be  saiiftuine 
or  the  contrary,  in  order  to  ascertain  the  value  a\u\  deirree  of  reliance 
to  place  upon  the  patient's  statenients  ri'<,';tiditi<r  tiie  sevcritv  of  the 
symptoms,  iicr%-(ius  sul).iects  pxajifieratinn;  and  lymphatic  ones  sup- 


KXAMIXATIOX  OF  Till-:  Fit:. 


21 


|iif>siii;;  tlicir  sensations.  The  lial>its  slmulil  he  iii(|iiiro(l  into,  espe- 
.-ially  rejianlin;;  I  lie  use  of  alcoliol  and  tobacco.  If  .s\|)liilis  lie 
suspected,  (|iiestioii  should  !)(•  made  rej;ardin>:  the  primary  sore,  a.-^ 


as  the  tune  ot  appearand'  i 


if  anv 


s<'condarv  manit'estatinn: 


.Ml 


previous  illnesses  should  he  taken  account  of,  especially  of  the  exist- 


ence ol  j;()ut,  rlieumatism,  tuberculosis,  malaria  or  other  dyscrasia. 
The  urine  should  he  tested  in  ;dl  douhtful  cases,  and  its  examiiuitioii 
made  a  part  of  the  routine  in  all  ca.ses  rec|uirin};  important  o|>erations 
upon  the  eyehall,  such  as  cataract.  If  the  jiatient  he  a  female,  she 
should  he  (|Ui'stiotied  rejiardinj;  menstrual  disorders,  and  particularly 
as  to  the  iiilluence  of  the  menstrual  epocli  ujioii  the  ocular  symptoms. 
I'inally.  should  the  inspection  of  the  patient  have  aroused  suspicion 
as  to  invoh  nient  of  the  central  nervous  system,  in(|uii>-  should  lie 
maile  of  all  ,.ossihle  .sensory  and  motor  <listurhaiices. 

Ocular  History.  Ilaviiifi  ol)taiiied  hy  direct  and  searching  cross- 
ipiestioninji  a  i)recise  kiio\vlcd<;e  of  the  antecedents  as  well  as  of  the 
personal  history  of  the  |)atieiit,  the  student  is  now  prepared  to  direct 
his  iiKjuiries  to  tiie  ocular  condjtion  itself.  Me  will  accordiiifily 
iiiiiuire  as  to  the  time  and  manner  of  on.set  of  the  present  attack: 
whether  it  was  accom|)aiiied  hy  pain  or  inflammatory  symptom;-, 
the  de<;ree  to  whicli  vi.sion  was  disturbed,  and  whether  one  eye  or  l)oth 
were  affected,  lie  will  inijuire  into  previous  attacks  of  ocular  in- 
flammation, and  trace  any  relationshi])  with  the  present  outbreak. 
Should  tile  case  be  one  of  refraction  error,  the  previous  wearinjt  of 
ftlasses  and  their  efficacy  in  relieving  the  ocular  symptoms  .should  bo 
recorded,  also  regarding  the  location  and  character  of  any  hea<l  pain 
and  the  influence  of  the  u.se  of  the  eyes  in  reading  upon  it.  If  it  he 
ai)parent  that  a  palsy  of  one  or  more  of  the  extra-oeular  musc!"s  be 
present,  the  nature  of  tiie  double  vision  should  he  elicited.  In  fine,  the 
student  cannot  be  too  searching  nor  too  persistent  in  his((uestioning, 
and  should  exhaust  every  possible  phase  of  tlie  sub.ject  before  aji- 
proachiiig  the  <lirect  and  closer  inspection  of  the  eye  antl  its  a])pen- 
il.lges. 

Direct  Inspection  of  the  Eye  and  Its  Appendages.  For  ti.i^'  ;nir- 
pose  it  is  iieci'ssary  that  the  student  .should  ajiproach  tlie  patient 
sufficiently  dose  to  observe  the  finer  structures  of  theeye  and  to 
permit  of  ;iiiy  manipulation,  either  with  the  liand  or  with  instruments, 
tli.-it  may  be  recpiired:  he  should,  moreover,  refrain  from  handling 
the  eye  any  more  than  is  necessary,  and  eiuleavor  to  gain  as  niucli 
information  iis  is  possible  by  insjiection  with  the  naked  eye, 
without  the  intervention  of  lenses  or  instruments,  for  .such  aids  -ire 
not  always  at  hand,  and,  moreover,  even  the  lightest  touch  is 
often  sullicieiit  to  render  sensitive  eyes  so  irritable  tliat  furtlier  ex- 
amination is  impossible.  In  many  young  children,  ami  in  iiidi- 
vi<luals  who  have  an  intense  intolerance  to  light,  however,  ins])eo- 
tioii  without  haiKlliiig  is  fruitless,  on  account  of  the  tightly  closed 
lids,  .so  that  the  observer  will  be  comix'lled  to  open  them  himself 
before  he  can  obtain  a  view  of  the  eye.     This  is  best  accomplished 


22 


77//-;  Ai'/;. 


in  yoimg  fhildrcii  l)V  tin-  "[M-nitor  soaliiijr  hinisclf  in  such  a  inanncr 
that  thi'  huht  from  a  \viii<ln\v  falls  iipnii  liis  li^ht  or  Mt  sidi',  while 
Ihi-  child's  head  is  held  tiniily  hctwccii  his  knees,  thi>  hody  Ix-iiiji 
supported  ui>oii  the  lap  of  all  atteiidaiil.  who  should  also  grasp  the 
hands,  the  lefis  heiiij:  left  free.  The  head  heiiif;  thus  rendered  iin- 
niobile,  the  surfteoii  can  inspect  the  iiei«hhorinK  [larts  delilx'rately, 
and  cm  examine  the  eye  satisfactorily  by  drawinn  the  lids  slowly 
apjirt,  hy  piessiii);  on  the  inferior  and  suiM-rior  orbital  ridges,  or  by 
inserting  a  Desmarres  lid  elevator  (Fig.  1)  IxMieath  them,  always  exer- 


1 


Flu.  1. 


8= 


IXiiniarres'  Ud  retractor. 


cising  the  greatest  care  to  avoid  pressure  u|)<)n  the  "veball  itself,  for 
fear  of  injuring  the  cornea.  When  there  is  marked  intolerance  to 
light,  a  4  |M'r  cent,  solution  of  muriate  of  cocaine  may  often  l)e  success- 
fully employed  to  allay  irritation,  although  in  some  ca.ses  general 
atuesthetizatioii  by  chlorofonn  may  have  to  be  resorted  to  before  a 
satisfactory  examination  can  be  made.  In  adults  it  is  possible  to 
examine  even  the  most  .sensitive  eyes  by  making  gentle  traction  on 
the  lids,  by  drawing  them  toward  the  inferior  and  sujK'rior  orbital 
ridges,  thereby  avoiding  pressure  upon  the  eyeball  itself. 

The  Lids,  the  character  of  any  changes  which  have  been  noted 
in  the  lids  during  the  general  inspection  should  now  be  studied  more 
carefully,  especial  care  being  devoted  to  the  condition  of  their  mar- 
gins, as  to  misplaced  cilia  or  the  presence  of  i)edicuhe,  and  the  char- 
acter of  any  incrustation  or  swellings. 

Lacrymai  Apparatus.  The  region  of  the  iimer  canthus  should  be 
in.spected  most  rigorously,  any  locali.Tcd  injectiim  of  the  conjunctiva 
or  collection  of  tears  or  mucus  at  that  point  exciting  the  suspicion  of 
obstruction  in  'he  |)roi>ef  canaliza'ion  of  tli<'  secretion  from  the  eye. 
The  iiosition  an  1  patulency  of  th(>  lacrymai  jnmcta  sliould  be  a.scer- 
tained,  and  gen  1(>  ])ressure  made  with  the  ti])  of  the  finger  over  the 
lacrymiil  sac,  with  a  view  to  expressing  any  retained  contents. 

The  Orbit  and  the  Position  of  the  Eyeball  in  It.  I'neiiual  |)rominence 
of  the  globes  may  be  measureil  by  placing  the  straight  edge  of 
a  card  from  the  supra-orbital  ridge  to  the  cheek,  and  comparing 
the  distance  of  the  cornea  from  the  card  on  the  two  sides.  Palpation 
of  the  orbit  should  be  practi.sed  by  passing  the  index  finger  along 
the  bony  margins  of  the  orbit,  the  finger  being  allowed  to  dwell  par- 
ticularly over  the  region  of  the  lacrymai  gland,  to  detect  any  enlarge- 
ment or  uneveime.ss.  Pressure  ov(>r  the  foramina  of  exit  of  the 
rupra-orbita!  air!  infra-orbital  nerves  should  not  \n--  nmitted. 

The  Conjunctiva  and  Its  Cul-de-sacs.  Before  exploring  the  recesses 
of  the  cul-<le-sacs.  the  caruncle  ■■md  the  semilunar  fold  in  the  angle  of 


I.H 


w 


PL  ATI"    I 


Fli,         1  (.,1! 

Fi.|     li      Cih 
F,,l     ^.^      (■..,! 


■ii\mI    (  ■.in,i.--li..ii 

1)1    ( 'I  I'l-ll  1  in  .  il  llf;i!    <;<  Uli  |f--1  itai- 
lun  i.l    AiittM  lor  Cih.tf^    Vcin-i,  Er'i^elernl  Venous  Plexiii^. 


h:.\A.VI\MI'>.\  Of  run  EYK. 


%\ 


ntluis  sliiililil  Iw  cXiitnilH'i 


llic   IIIIH-r  CM 

liiiilirs.     The   ciiiijillictivii 


I  for  sniiill  growths  or  foroiRii 


if  tlic  lids,   iMil/H'tinil  ninjiiiirlini,  slioulil 


tlii'ii  !"•  iiisiM'clfMl,  Mini  Miiy  I'liMiiKi'  ill  its  vasci 


ilaritv  or  in  the  fliariu'tcr 


of  it- 
nittci 


timi.  ami  lln'  prt'sciii-f  of  crai 


ulatiiuis  or  forcijtii  liodics, 


I.     T 


(Ml 


)  fxaiiiiiK-  tlir  coiijuiictiva  <>f  ll"'  rvtrotarsal  jnlds  aiul  the 

•ccssary  to  t'ViTt   the  liiis;  tiiin  Is  n-Milily  aci-oiii- 

f  the  lower  ciii^ It-sac  l)y  tirawiiin  the  lower  liil 


Inle-sacs,  ll    IS   111 


IiII-IkmI  ill  till-  i-ase  ( .  ,       ,  -,     i 

mnllv.lowii  with  the  index  hiijier  of  the  rinht  hand,  while  the  patient 
w  told  to  direct  his  pi/.e  upward.     Ins|)<'ctioii  of  lh<"  U|)|mt  cul-de-sac 

w  lesx  simple,  and  is  iwrfori 1  hy  uraspiiijj  the  edRe  ol  th.e  upjM'r  lid 

.,nd  H  few  cilia  with  the  thuiiil.  and  index  tinker  oi  the  rijilit  hand 


aiH 


1  l.v  deluessiiiK  the  ilp|M'r  edge  of  the  cartilajte  o 


tiiip'i 
a  i>ro 


f  the  lid  with  a 

..f'tl'ie  left  hand,  o'r'with  .-".me  convenient  instrument,  such  as 

\U'.  while  the  patient  looks  steailily  downwar.l.     IK  n'(|U('stinK 


the  i>atient   to  'lirect   his  gazt 


till  further  downward  the  pal|M'hral 


iiortion  o 


if  the  lacrvinal  jrlaiid  may  he  brought  into  view.     The  Uulhitr 
awiinirlirn  is  on liiiarilv  invisible  save  for  the  few  bloodvessels  which 
are  .list libut.'d  throunii  it.    The  color  of  the  sublying  sch-ra  sliou 
i„.    noteil,    and    any     uiuliie    vascularity   ami     prominences    taKcr 

''"iVfl'iii'proceedinjj  further,  it  is  desiral.i.'  that  the  stmh-nt  should 
have  a  clear  idea  of  ''le  vas(Milar  supply  of  the  exterior  ot  the  eye, 
in  <.rder  that  he  niav  ajipn-ciate  the  ditTerent  forms  ot  congestion 
lH.(Miliar  to  the  vessels  of  the  several  tissues,  as  no  other  synii)toiii 
.'ives  -iuiir  indication  of  the  location  of  ocular  lesions. 
"  Bloodvessels  of  the  Exterior  of  the  Eye.  The  vascular  supi.ly  of 
the  e\i(ii.>rof  the  eve  mav  b.'  grouiK'd  for  convenienc-  into  three 
<v<leiii<-  1  The  I'nslrrioi  < 'uniiincliriil  Vtsxeh,  or  the  vessels  proper 
,;,  the  .■onjunctiva.  2.  Th<-  Ankrior  Cilinrn  Vessels.  The.s«-  consist 
of  In)  pcrl'or.Mtiiigarteri.'sa  I  veins,  ami  (/-)  non-iK-rtorating  arteries 
and  veins.  The  p(>rforatii.^  arteries  supply  the  sclerotic,  ins  aiul 
ciliarv  bodv,  th.'ir  veins  receiving  the  blood  ironi  the  canal  ot  Schlemm 


and  the  ciliai 


•V  bodv.     Tl 


ies(>  vess( 


■Is  are 


visible  in  health  as  .several 


iiiiparatively  large  tortuous  vessc 


Is  which  perforate  the  globe  about 


.)  mill 
ve 


"tlie'corneal  limbus.     The  non-iH-rforating  or  epi.sdtMal 

U   which  are  branches  from  the  anterior  filiary  vessels,  are  very 


lil  th 


heir 


)f  closely  set  ves-els  around  the  cornea. 

,,     ;i.   The  Aiiterinr  Coiijiiuctirnl   Vessels 

/."»/;. -p/cj/'/'v  on" tile' Corneal  Border.     The.se  are  the  ves.sels 

ml  immediatelv  adjacent  zone 


iiiimeious  Mild  lorm  a  zone  o 
Thi'V  are  invisible  in  health 


proper  to  the  margin  of  the  cornea  a 


if  coniunctiva.  and  it  is  by  means  ( 


f  these  numerous  minute  branches 


w 


hicl 


1  iire  o 


itTshoots  of  the  anterior  ciliary  vess( 


•Is  tliat  svstoms  1  and 


J  Mllastomo.se 


(Plate  I..  Fig.  1.) 


Conjunct"    1  congestion  is  the  nan 


given  to  indicate  that  f'    :i    ■  s 


cohgestioll    \\ 


lich   is  caused   bv   .an   injection   of   the  j.ostorii 


•tiv;  '   vessels.     The  inie( 


junc 

its  imiii.'i 


tioii  is  most  markeil  at  the  for:   \   .'in 


iiat 


e  liel 


'hboih     d.  where  these  vessels  are 


iiu; 


and  is  less  noticeable  aroum 


id  the  cornea.     The  vessels  being  ? 


24 


TIIK  EYE. 


tl 


111  till'  con 


arc  e 


ijunct 


iva,  iiiav 


1)0  made  to  slide  readily  over  the  filohe,  and 


iisily  emptied  hy  pressiiiji 


on 


the  lid  with  llie  tiiifjer. 


I:i  thi 


form  oieoiifiestioii  the  eoiijunetiva  assiimi 


a  v< 


'llow  or  hriek-red  hue 


specially  in  the  re^rioii  ot  the  inner  eai 


thus,  and  there  is  more  or  le 


lUicopurulent    dischaifii 


Coniunetival    eoiij;estioii   is  diajjiiostie  of 


eonjui 


tivitis.     (IMatel..  Fif^. -'.) 


CUary  or  circumcomeal  congestion  is  the  name  given  to  an  in.i<-( 

^  •'  ...         1  : ,.l,..t<Jt'    •if<\iitiil    t  hi*   ('111 


tion 


which  IS  iiio 


<t  markeil  in  the  zoik 


iminediatelv  around  the  cornea. 


iid   firadually   fad 


t    thi'   periiihery  of   the  filohe.     It   i 


causei 


hy  injection  o 
As  these  are  sitiia 


f  the  anterior  ciliary  am 


i  anterior  conjunctival  vessels. 


place*  1  or  niad( 


ipaiiyiiifr  ihschaip 


ted  beneath  the  conjunctiva 
to  disappear  by  pres.sur 


thev  cannot  he  dis 
the  lid.     There  is  no 


In  this  form  of  coiifiestion  the  circiimeor 


cs  either  a  pinkish  or  a  .sea 


rlet  hue,  while  in  otlier 


ac<'oin 

ileal  re>;ion  assumes  cim.-i  n  ,.....x..-,.  ...  ..  • -  rsi;  ,r,- 

cases  drHM.-s..at.'d  patches  of  a  lilac  or  violaceous  color  ai^i-ear  (  iharv 
i„j,,,,i„„'i„.lica.cs  disea.s..  in  the  cornea,  ins,  or  cihary  '"'Iv-  ^vlie.i 
,1,.  p,.,.,.liar  liia.-colore.l  patclies  are  present,  disease  ot  the  dcper 
Ivini:  tissues,  the  s.^lera,  and  ciliary  body  is  indicated;  and  when 
observe.!  in  connecti..n  with  enlarpMuent  of  the  episcleral  veins,  a 
chronic  hicrease  of  intra-ocular  teiision-filiuicoma— may  be  sus- 
pected. (Plate  I.,  l-ifi.  :].)  .  ,  f  ,  .  ;. 
Mixed  Forms  of  Congestion.  On  account  ot  the  free  anastomosis 
„f  the  three  f;roU!)s  of  ves.sels,  it  frequ.M.tly  hapiH'iis  that  tiiere  is 
in.-nrinfi  „f  the  different  types  of  congestion  into  one  anot  i.'r  It 
shouMbe  borne  in  mind,  how,  .T,  that  while  a  prolonged  cihary 
,..,n.r,.,tion  -raduallv  producs  more  or  less  conjunct iv.d  congestion, 
th,."converse  is  not 'true,  for  a  conjunctivitis  will  not  excit."  a  ciliary 
injection  unless  the  cornea  or  iris  also  is  aflected. 

The  Cornea.  Tlie  shap.",  tlu-  -eneral  curvature  of  th<.  cornea,  and 
the  .position,  extent,  and  d..nsity  of  all  invfiularities  and  opacities  in 
it  sli.H.M  be  stu.lied  on  account  of  the  imp.)rtant  bearing  which  tiiey 
have  upon  the  vision  and  n.fraction  of  the  eye.  lor  tins  purjiose 
two  UM'thods  are  available:  examination  of  the  corneal   ivll-'x  and 

direct  inspection.  ,       ,•  ,       f 

Examination  of  the  Corneal  Reflex.     Wlien   the   lifihl    from  a   win- 
dow i~  pennitted   to  fall  .lirectly  uix.n  the  cornea    and  the  eyes  are 
„,.„!,.   ,,,    follow    th<'   hnger   of    the   surgeon    while  it   is   tnoved    ni 
various  directions,   it   will    !.<•    noticed,  if   there  be  any   irrefiulanty 
„,„,„    ,1„.    .utiace    of    the    c<,rnea,  that    the    imafje  ol    the  vyindow 
Ini-    wluch    is    thrown    upon    it,    inst<'ad    of    beiiifi    reflected    clear 
and  well    defined,    will    be  broken  and    ill  defined  at    these  ponits. 
The  same  principle  is  made  us.'  of  in  th.'  api.li.-ati.m  .)f  the  I  lacido 
disk       iV\»   2)     This    con.sists    of    a    tarjiet    nu    which    are    coii- 
.vntri.'  allernat,'  lilack  an.l  whit.'  circl.'s.  with  a  cntral  p.'rlor:iti..ii 
In    its    emplovm.'nt.  the    pati.-nl  should    b.'  place.l    with    Ins    back 
:,.    ,!.,.   li.ri.t  "tlie   ^utw'on   viewimr   the   ivflectum  .)!    the   inuiiie   ot 
•1„.  einles  np..n  th.'   corn.'a  through    th.'  op.'niiifi   in   the  c.'iitre  ot 
the  ,>'sk.     .\nv  irr.'}:ularitv  .)r  .'xcssive  ditlereiicL'  in  the  curvature 


-••ir.^-'T^-'" 


L 


i:xAMry.iri(>y  of  the  eye. 


25 


n.TicHans  ..f  the  conica  will  ho  inaiiif.'ste.l  hy  a  break  ..r  .li^- 
„,,,,„„   i„  tiw  cirdes.    Th.>  cor,m,l  rejkx  should  always  ho  studio.l 


111  till'  ini 


PlacMo's  disk,  or  keratoscope. 


.,.  pail  of  tho  loutii.o  ..phthalinoscoinc  oxaniinatioii,  the  ohscrvcr 
M.linnin!:  hiinsolf  for  this  purpose  hehiu.l  a...l  to  one  •'^•'li;  <''<"; 
p:,ti..nrs  hea.l.  so  as  to  have  the  patient  s  face  ni  shadow.     The  light 

Fio.  3. 


Corneal  Utuiie. 


IS  then  thrown  upon  the  eve  hv  a  i-laiie  mirror,  and  llu-  shadows  care- 
fnllv  studied   through   a  hole   in  the   mirror.     iVuie   lietmoscopy.) 


5 

I 


^  Tllh:  EYE. 

■n„.  ,„„,  n.c;,.,o  .,.1 ,..].».«-  ;i::j;;',i,:':ri>™,;:;;;:!'X 

„f  th.'  vnvnrix  l)v  iitilizms:  tlu"  ivilrx  tli.tl  it  (ax. 

opi.thaiMx.uiotcr.    ( r*wr pafi'-  n^)  ,      ^^-.^^  „„, „;,u..,l 


Jackson's  liiiuiiular  inannitler. 


;i;'r:::a;'r:;::*n;i:i::«:.;;»y  i.  us,.,u,„,.i,  ,.,i«.n 

spt'cially  coi.j^truct.Ml  for  tliis  purpose. 

Fio.  J. 


OMiiiiie  or  focal  illumination. 


tnra!   }!l<l>n>.>i'il>IH>: 


iscul  10  cucnural.  llic  light    upon  llio  cunu'u.  ^^h^\v  the  (.tlu.r  .. 


t 

used  lo  couci 


i 


KXAMiyATIOX  OF  THE  EYE. 


(>iii]ilt>yf( 


[IS  a  i»:i 


cnifii'i 


thiDudi  which  tlic  ilhiiiiinatfd  surface  ma\ 


lie  -liichi't 


with  t 


1.     iKifl.  5.) 


riic  iwticut  slioiild  l)c  seated  in  a 


lark 


rooiii 


lie  lijrlit  on  t^.e  teiiii.-)nil  side  and  siifjlitly  in  front  of  tlie  phUK 
Tliis  method  is  extremely  vahiahle,  for  l)y  vary 


i|  tiie  patient's  tac'i 


lis:  the  distance! 


1 
(•iian':<-s  in 


illal 


i  tlie  lens  from  tiieeye  it  is  possi 


ilile  tosti.dvnotonly 


tlie  cornea,  Imt  also  tliose  in 


the  anterior  chamWer,  iris,  and 


an( 


I  if  tlie  pupil  l)edila 


ted  and  the  lifjlit  thrown  almost  peri)onilic 


Iv  into  tiie  eye,  chaiifies  ii 


1   the  anterior  layers  of  tlie  vitreous 


iiiav  be  niai 


le  out  as  \v( 


■11. 


I.IIS.<   llj  SllhsldlICi 


in 


the  viirnvdi  vpitlivliiDti  ma 


V  be  demonstrated  by 


instillinfi  a  drop  of  tluorescin  in 
cent.:  carbonate  of  sodium,  ;}.5  per  c( 


to  the  eve  ((iruebler's  tluorescin,  2  per 


■lit.),  the  surface  frosn  which  thf 


rpithelimn 
\vliil<^  the  n 


is   removed  being  stainei 


1  pre* 


•111 


isli  vellow  bv  the  drug. 


St  of  the  membrane  remains  cU 


The 


iitiir)if--f  of  the  cornea  \ 


tested  best  by  gently  touching  it 


with  a  wis])  of  cotton 


if  sensation  be  unimpaired,  the  eye  will  wink 


ri 


•Hexlv:  but  if  the  lids  remain  iinmt 


ibile,  further  investigation  of  the 


sensibihtv  o 


,f  the  skin  of  the  surroundnig  tissue  should  Ik>  tnade  with 


an  a 


he.siometer,  to  determine  the  extent  of  tlie  aiuesthesia 


The  anterior  chamber 


Should  be  examined  in  respect  to  its  depth  and 


contents:  among 


iiig  the  latter  w 


hicli  the  chamber  may  contain  being 


,|„„d,  or  hjiphnnw:  pus,  or  huropijon.  and  foreign  In 


bodie; 


The  Iris.     In  the  exaii 


nil 


iition  of  the  iris 


the  attention  should  be 


lirected  chiefly  to  its  color,  to  the  appearance  ( 


if  its  stroma,  and  espe- 


cia 
iris 


llv  to  the  size,  position 


an< 


1  behavior  of  the  pupil.     The  color  of  the 


du( 


to  tl 


le  auK 


)uiit  and  distribution  of  the  pigment  in  it:  m 


;ilblllisni.  w 


here  there  is  an  absence  ( 


)f  pigi 


lien 


t.  the  iris  is  translucent, 


'I'***'*/       p^^         ton* 

Tlieirisi.    (Kiths.i 

Miwi  ill  iiewlv  born  children  it  is  almost  invariably  of  a  ligiit  grayish 
_  blue  The  "irides  iiiav  ditTer  hi  color  in  the  two  eyes,  chmmalic  asiiw- 
m  m>'lr>r  or  iiarts  of  tli'e  same  iris  may  be  colored  ditTerently,  piebnld 
m       u;>.     Discolorati.m    of    th<>  iris  .sliould  always   .-xcite    suspiciui.    <,t 

inllalliliiatioll  of  melilbriilie. 


:sw«HK-'£ 


■'^if^syfi-mss^-^t^mmmmtsmjnijmDs-j, 


IP 


28 


THE  EYE. 


Wlicii  vicwcil  ilirniijili  a  iiiaiiiiityiii;: 


ass.  witli  tlic  aid  of  ()l)li(iuo 


illiuiiinatioii,  llic  iiis  is  seen 


to  I 


ic  (Miinposci 


)l'  a  sciics  ot  elevations 


(Fiji.  t>)  ;""'  ilepressioii 
vessels,  wliicli    run    rat 


while  the  deijicssions  cor 


s,  the  foiiner  ix'infi  occasioned  by  the  hlood- 

liaily  Irom  the  base  of  the  iris  to  the  pupil: 

res"|iond  to  cryiits  in  the  stroma  of  the  iris. 


and  are  found  chietlv  near  the  pn|)iilary  luargni.  Although  these 
elevations  and  depressions  are  sharj)  and  distuict  in  the  normal  eye. 
they  become  blended  in  intlannnation,  which  constitutes  an  important 
sijin  of  iritis. 

Ciianfies  in  the  i)iane  of  tiie  iris,  tears  in  its  i)upillary  edge  and  base, 
and  any  wavedike  movements  on  its  .surface,  /r/V/<«/('/(c.s/.v,  should  be 
.searclH'd  for  carefully.  Thickening;  and  vascularity  of  the  membrane 
.should  be  remarked  ami  the  character  of  any  nodulation  noted. 

ThePupU.  The  chief  characteristics  of  the  healthy  pupil  are  it.s 
circular  outline  and  its  mobility. 

The  size  of  the  i)ui)il  varies  fjreatly  in  health,  ranging  from  2.44  to 
.').,S-_'  millimetres,  \m\\^  intlueiiced  by  age  a:  !  refraction,  and  is  directly 
dependen,  upon  the  stimulation  of  the  lighi.  acconunodation  and  coii- 
verfient  imp\ilses  which  it  receives.  \Voir',!\v  places  the  average  at 
4.14  millimetres.  As  a  rule,  age  causes  the  pupil  to  grow  smaller,  and 
it  is  also  more  likely  to  be  smaller  in  hypermetropia  than  in  myopia. 
Its  width  mav  be  'a.scertaine<i  by  means  of  the  i)upilloineter,  which 
consists  of  a  scale,  pr(>ferably  of  glass,  graduatcnl  in  circles  ranging  from 
1  to  S  millimetres.     (Fig.  7.)    This  is  held  close  to  the  eye,  and  wliile 


1 


Fir,.  7. 


nirschbvrn's  piiplllometer. 

the  patient  fixes  his  gaze  upon  some  distant  object,  the  circle  should 
Ix'  found  which  corresjionds  with  the  diameter  of  the  pupil.  I'ntil 
the  student  has  ac(iuired  suflicieiit  skill  to  enable  him  to  obtain  tin 
accurate  measurement  of  the  pupil  by  simple  inspection,  some  such 
scale  slxiuld  be  employed  in  ail  {'ases. 

The  pupil  should  be"  nnnxl,  but  this  is  usually  prevented  bv  astig- 
matism, which  gives  it  an  oval  a|ipear;mce:  it  should  also  be  situated 
sliirhtlv  to  the  nasal  sid(>  of  the  centre  of  the  cornea. 

The  sejiaration  of  the  jnipils  from  each  other  varies  with  ag(>  and 

sex  ;iiid  with  the  form  of  the  face:  i"  .adults  it  has  an  nvi ol  58 

mm.,  although  Nagel  places  it  at  i\.\  nun. 


fXAMISATIoy  or  THE  EYE. 


29 


Till'  pupil  is  rarely  dear  hhu-k,  the  antorii)r  surface  of  the  lens  re- 
lli(tiii<;  some  lifjht;  iiuieed,  tins  reflex  is  often  so  marked  in  elderly 
siilijcct.s  that  the  grayish  film  due  to  sclerosis  of  the  lens  is  often  mis- 
taken for  cataract  l)y  the  inex()erienee<l  observer.  If  ol)li(iue  illumi- 
nation he  employed,  however,  the  true  nature  of  the  opacity  in  the 
lens  becomes  maiiifeat. 

Fir..  ». 


Ganglion  trunci  vaiji- 
Suj).  cervical  yanglion- 


\^Cilio-3pinal' 
rt-gion 


Vagits  ,iud  BympatheticX' 
ntt'ves  S- 


2nf,  cervical  ganglion^ 
Aminlii.f  of  VicHs^cna- 
SttUcite  ynr.ijlion~ 
Card''fc  nerves 


Illustrating   the   paths   of   Innervation    of  the   iris.      Constrictors   from   the   corpora   (luartri- 
i,-.iiiinii  hy  the  thirrt  ner\'e.  ciliary  (faiiRlion  and  nerves  to  the  circular  musoles  of  the  iris,    nilatoir 

I; the  hulbanrt  coni  by  anterior  roots  of  the  first  three  thoracic  nerves,  especially  the  second 

■■iiiTii  romniunicanles.  cervical  »yni]«ithetii'  ami  nantjlla,  (iasserian  ganglion,  ophthalmic  branch  ol 
111.'  lilih  nerve,  ciliary  gangliun  and  nerves  radiating  to  muscles  of  iris.    (Waller.) 


Til.'  iris  is  the  diai)hrafrm  of  the  eye,  and  by  its  action  in  intercepting 
iii:ii-^Niial  rays  it  prevents  an  excessive  amount  of  lipht  from  entering 
the  ry.  In  order  that  this  may  be  accoiiii)li.shed  with  great  rap'dity 
mihI  tlie  size  of  the  pupil  instantly  changed,  the  iris  is  provided  with  a 
de!ii':itc  met  1);!!!!^!)!  Wonderfully  adapted  to  the  function  which  it  has 
topeifdini.  This  consists  of  two  antagonistic  factors:  one,  a  constrict- 
ing mechanism,  to  contract  the  pupil ;  the  other,  a  dik.ting  one,  to  dilate 


:«) 


77/7;  EVi:. 


the  iHipil.  Tiic  toiiricr  is  accoiiiplisliiMl  hy  st'mnilatiiui  of  the  oculo- 
iiiotor  nerve  and  (•(.nscimeni  cDniiacti-n  of  tlie  sphinclor  pupilhe,  a 
circular  niiiscle  SUIT. .nil. lin^' the  pupil;  tin-  latter,  l.y  tiie  absence  i.f 
this  stimulation  aii.l  l)V  the  coiilractinji  effect  of  the  cervical  syinpa- 
thetic,  which  sujiplie-^  th.    .lilalor  pupiihe,  the  ineri.lianal  muscular 

lihres'of  the  iris  an.!  ai.'.>  the  hloo.lvessels  of  the  iris,  < traction  of 

these   vessels    causinfi    narrowiiifi  .if   the    iris   aiul  dilatation  of   the 

pujiil. 

The  reaction  of  the  pupil  is  eith.';  irjlcv  action,  in  which  event  the 
impulse  passes  al.irifi  the  o|)tic  nerve,  the  afferent  nerve,  to  the  oculo- 

mot.ir  centre,  ami  aloiifi  th 'uLimotor  nerve,  the  afferent  nerve  to 

the  eye.  throuf;h  the  me.lium  of  tihres  which  connect  the  cor]»ora  <|Ua.l- 
ri"eniina  with  the  nuclei  i>f  the  oculomotor  nerve;  or  it  may  l)e  ((.-«>- 
n7iliil,  in  whii-h  case  the  imjiulses  arc  set  into  action  sinuiltaneously 
with  etlorts  at  accomin.i.lati.m  an.l  converfience.  The  .lejiree  of  the 
puiiillarv  contraction  in  associateil  action  is  always  less  thasi  that 
ohserveil  in  the  reflex  reaction. 

TiiK  iii:i-i.i:x  1{KACTI()\  of  the  juipil  may  he  either  dinrl  or  nmscn- 
siKil.  The  ih'ircl  Hijlil  n'jh-x  is  the  extraction  of  tiie  juipil  which  is 
ohserveil  in  the  eve  when  it  is  exi).ise.l  to  increa.se.l  illumination,  the 
(■Diisfiisiiiil  or  itiilircrl  liiilit  rcjlrx  beinji  that  which  occurs  in  the  pupil 
of  the  other  eye,  foll.iwiii};  e\i)osure  of  one  ey(!  to  lifjht. 

The  direct  ' li'ilit  rvjler  is  hxtcd  hy  alternately  shadinji  an.l  un- 
c.)verinfi  the  eye  in  daylif;ht  with  the  iiand,  or  hy  concentratiiifr 
artificial  li};ht  upon  it,  either  hy  means  of  ..hli.pie  illumiiiati.m  or  t\v 
the  mirror  of  an  ophthalmoscope,  the  fjaxe  of  tlie  patient  iieinj;  iixed 
on  a  .li>tant  .ihic-t.  to  avoiil  any  associated  stinuilus  from  <  ither 
accommodation  or  converjience  stimuli.  It  sometimes  haiipens  that 
after  the  cover  is  removed  from  the  eye  the  hrst  contract i.m  of  the 
jMipil  to  light  is  followed  hy  dihitation.  and  often  an  interval  of 
extreme  contraction,  heing  succee.led  l)y  mo.h'fate  dilatations  and 
contractions  until  the  iMi)il  hec.imes  stationary.  This  condition  is 
terme.l  liippm^.  an.l  is  cxplaine.l  hy  Swanzy  .'is  follows;  V.wh  con- 
traction .if  the  pu|>il,  hy  .liminishiiif;  the  sujiply  of  light  to  the  retina, 
contains  in  itself  the  cause  .if  the  succee.ling  .lilatati.m ;  an.l  for 
the  c.inverse  rea.son,  each  dilatati.in  sots  ag.>ing  the  succeeiling  coii- 
triu'tion,  imtil  at  last  e.|uilihrium  is  attaine.l.  llip)ius  is  seen  in 
cerehro-spinal  sclerosis,  ilisseminated  scler.isis,  neur.isthenia.  hysteria, 
psychical  .listurhanc.'s.  ejiilep.sy.  an.l  acute  meningitis  in  its  e;irly 
stages. 

The  conscnspdl  or  indinrl  jiiqiillar;/  nadion  i."  Ii'slcd  hy  .iliserv- 
ing  the  motions  of  tiio  pupil  in  the  other  eye  while  the  eye  under 
examination  is  heing  alternately  covere.l  and  unc.ivere.l.  This  test 
is  ilepen.ient  anat.iiiiically  u|)on  the  fact  that  fihres  pass  from  the 
retina  .if  each  ev(>  thr.iugh  tiie  chiasm  partly  int.i  the  right  .an.l  partly 
int. I  the  lelt  optic  tract,  an.l  th.'it  t'r.im  these  the  stimulus  is  trans- 
mitte.l  ilirectly  to  h.ith  right  an.l  left  ocul.imotor  nuclei,  each  micleus 
setting  up  a  contraction  .if  the  pupil  of  its  own  si.le. 


t:xAMiyATwy  of  the  eye. 


:J1 


Tlic  (lircM-t  light  reflex  is  tested  for  tlie  purjjose  of  detectiiiii  the 
cxisleiice  of  adhesions  of  the  iris  to  the  capsule  of  the  lens  (posterior 
synechia),  and  to  deteiinine  the  sensitiveness  of  the  retina  and  of  the 
visual  apparatus  ftenerally  to  lifiht.  The  reaction  is  an  exceedingly 
delicate  one,  and  indicates  the  presence  or  ahsence  of  (|uatititative 
perception  to  lijiht.  It  will  presently  he  e.\])iain(>d,  however,  that  the 
iailer  function  may  he  wantitif;  in  certain  diseased  states,  and  yet  the 
pu|iil  reflex  take  place;  or  the  pupil  reflex  may  he  wanting,  and  [xt- 
ccplion  of  lifiht  still  be  present. 

Tlif  (issocifitt'd  rciidion  aj  the  pupil,  or  the  (i(r<iniminkitii>n  and  ruiinr- 
iltiicf  irjh.r.  is  tested  hy  ro(|uestin}i  the  ]>atient  to  look  fixedly  at  an 
nlijcci  iield  in  t.ie  median  line  about  10  cm.  in  front  of  the  face.  The 
ccntraction  of  the  pupil  which  follows  is  due  to  the  intimate  associa- 
tion of  the  central  innervation  of  tite  sphiticter  nuiscle  of  the  iris,  the 
ciliary  i)ody,  and  th>'  internal  rectus  muscles.  While  accommodation 
unassiiciited  with  converfience  will  not  cause  contraction  of  the  pupil, 
reaction  follows  converfience  stimuli  alone. 

In  contradistinction  to  the  contraction  of  the  pupil  when  acted  upon 
by  lii;ht  or  accommodation  or  conver<;ence  stiir  '"  the  pupd  inmri- 
tililif  ilildtes  irlien  itrted  iipi>n  lii/  seuyori/  ytinndi.  'l.hs  the  ])U[)il  which 
is  contracted  diu'inK  sleep  and  deej)  narcosis  dilates  at  the  moment  of 
\vakin<r.  The  pupil  dilates  also  under  nervous  excitement,  such  as 
fear  and  siu'pri.se,  and  also  witli  deep  ins|)irations  and  expirations:  it 
is  dilated  also  during  Imnger  and  in  aiuemia.  Irritatinp;  or  i)inchinji 
the  skin  of  the  neck  is  followed  also  by  pupillary  dilatation  (pain 
reaction).  Moth  |)upils  should  be  e(|uai  in  size,  unc(|ual  pupils  (nnis- 
cco/vV/ 1,  although  freciuently  of  no  import,  lu'ing often  a  grave sym])tom. 
In  testing  the  reflexes,  it  is  essential  to  observe  whether  contraction 
aM<l  dilatation  of  the  pupil  occur  simultaneously  and  to  tiie  same 
degree  in  both  eyes.  As  a  rule,  it  may  be  stated  that  the  least  niov- 
:il)le  pupil  belongs  to  the  atTected  eye. 

.\s  ileepjy  seated  disease  of  the  bniin  and  spinal  cord  freciuently 
manifest  themselves  in  some  disturbance  of  the  pui)il,  it  is  most 
essential  for  the  student  to  understand  fully  its  nervous  connections. 

The  Behavior  of  the  Pupil  in  Disease.  Pathological  processes 
which  affect  the  iris  inanifest  them.selves  either  in  a  contraction  of 
the  pu|)il  (miidsis),  or  in  a  dilatation  of  it  iwiidrinsis).  |{oth  of  these 
differences  in  the  diametiT  of  the  pupil  may  be  the  expression  of 
litlicr  s|ia,sin  or  i)aralysis  of  the  nmsculature  of  the  iris,  or  they  may 
be  the  result  of  some  inflanunatory  condition  of  the  iris  or  within  the 
eyeball,  as.  tor  example,  the  myosis  which  .■iccom|)anies  iritis,  or  the 
Miydriasis  which  is  seen  in  glaucomji. 

Myosis  (contraction  of  the  pupil).  Myosis  may  be  due  either  to 
spasm  of  the  sphincter  puf)ilhe  or  to  au  irritation  of  the  contracting 
centre  111-  nerve  fibres,  .s/w/.v/Zr  mi/osis:  or  it  may  be  the  result  of  par- 
aly>is  (i|  the  dil.iting  hbres  of  the  jnipil  or  of  the  pupil-dilating  centre 
<ir  nerxc  hbres.  pawhjtic  nujosis.  Kitlier  cause  operating  alone  oc- 
casion>  a  moderate  contraction  of  the  pupil;  if  both  are  active,  the 


32 


TIIJ-:  i:yi:. 


I'lipil  IS  (•(iiitiactcd  to  a  |)iiii)<)iiil.     ('out raft ii.n  df  tlic  pupil  follows 

:""»i''':'^' i'"*  Klimulution  of  both  dilatiiij;  aiM  coin  met  iiij;  mccliaii- 

isiiis.     The  most  comiiion  cause  of  coiitractcii  pupil  in  disease  of  the 
eye  is  aillierence  of  the  iris  to  the  lens  capsule. 

Sjuislic  „ni„si.y  is  syinptoinatic  of  intlanunatorv  alTections  of  the 
i)rauiand  its  ineniii>,'es:  it  is  present  in  the  earlv  st:i«i-s  of  intracranial 
tumors  which  involve  the  third  nerve;  it  is  se'en  at  the  bcfiimiiiiji  ,,f 
hysterical  and  epileptic  seizures.  I're.ssure  upon  the  pons  cau.ses 
myosis.  It  results  from  stimulation  of  the  pupillary  contracting 
centre,  and  occurs  in  those  who  sutler  from  tobacco  amblyoiiia  and 
In  those  who  follow  trades  which  demand  lon<;  maintained"  efforts  of 
accmimodation  (wat(  hmakers,  jewelers,  etc.).  If,  in  the  course  of 
a  case  of  cerebral  .li.sea.se,  myosis  jjives  wav  ti>  sudden  dilatation,  the 
im.RiK.sis  becomes  uravo,  the  stapc  of  depression  with  paralysis  of 
the  third  nerve  beiiifr  indicated.  .Myosis  may  be  a  rcHe.x  action  in 
ciliary  neurosis:  it  accoinpaiiii's  m;mv  disea.sed  conditions  of  the  por- 
tion ot  the  eye  supplied  by  the  fifth  nerve.  The  pupil  in  irritation 
myosis  IS  but  htlle  affected  by  reflex  stimuli;  it  is  verv  su.sceptible 
however,  to  drufts.  mydriatics  dilatin^r  it  widelv.and  mvotics  c(.ntrac- 
tiiifi  It  ml  mnximum.  In  contradistinction  to"  this,  the  pupil  in  par- 
alytic niyo.sis  reacts  actively  to  the  ditTerent  reflex  stimuli,  ami  is  but 
little  afiected  by  mydriatics,  althoiifjh  myotics  contract  it  greatly. 

Pariilnlir  mi/osis  occurs  in  spin.al  lesions  above  th(>  dorsal  vertelme 
and  IS  especially  sif;nificant  of  tabes  dorsalis.     In  the  earlv  stages  of 
this  di.sease,  in  which  the  cilio-spinal  centre  or  the  hijiher  n'-gion  of  the 
cord  alone  have  been  atfected.  the  pupil  is  but  moderatelv  contracted, 
and  reacts   to   both   lijjht  and   on   convergence:   later  on,  th"  pupi! 

I>reseiits  the  phei leiia  which    have  ben  characterizeil  as    inii/ll- 

Rohnlson  i„ipU  or  /-cy/cr  iri(lo,,la,i„~i.  v.,  the  pupil  responds  verv 
.-liKhtly  or  not  at  all  to  lifzht,  but  is  .active  in  accommodation  and 
conversreiice.  The  lesi„n  which  produces  the  .Vrfjvll-Hobertson  pupil 
has  been  variously  situated  in  the  fibres  which  pa.ss  from  the  proxi- 
mal en<l  of  the  optic  nerve  to  the  oculomotor  n;.,'lei.  and  to  a  nuclear 
Ic.si.in  pure  and  simple.  Another  pupillary  sijrn  which  is  seen  in 
tabes  dorsalis  is  known  as  iniiUiUrnl  rvjh:r  iridnpliqla.  In  this  con- 
dition one  pui)il  react-;  to  accommodation,  but  not  to  li<;ht,  while  the 
pupil  in  the  fellow  eye  resi)oiids  normally.  It  is  probablv  the  result 
ot  a  lesion  in  the  nucleus  of  the  sphincter  of  the  iris. 

Paralytic  myosis  is  seen  in  jrcneral  paralysis  of  the  insane,  in  mye- 
litis ot  the  cervical  portion  of  the  cord,  in  i)aralv.sis  of  the  cervi'cal 
sympathetic  from  pressure,  in  bulbar  palsy  in  association  with  jiro- 
jrressive  muscular  atrophy,  in  .sclerosis  of  the  brain  and  spinal  cord, 
and  in  some  forms  of  multiple  lu  u."itis. 

Mydriasis  (dilatalioii  of  the  inipil).  This  mav  be  the  result  of 
either  irritation  or  paralysis  of  the  -entre  or  fibres  jrovi'minf:  i)ui)illarv 
.u-tivity. 

Sjm^lic  mi/drinsis  occurs  in  hy])eraiiii.a  .and  irritation  of  the  ccMvical 
portion  of  the  .sympathetic,  in  tumors  of  the  cord  ami  brain  (although 


:v:  \ 


KXAMiyATtoy  OF  Tilt:  evi:. 


33 


r.iii'lvi:  in  tabes  ilm-salis:  in  '■'Ttain  fdriiis  r)f  intestinal  irritation, 
t-|jc(ially  intestinal  tinnms:  in  anu-niia;  in  psycliieal  excitement,  for 
e\:ini]i|e,  fear,  sinprise,  acute  mania,  melanchoiia,  ami  profiressive 
|iaialy>is  of  the  insane.  In  this  latter  disease  the  myilriasis  is  fre- 
i|iiriilly  unilateral  ami  is  assoeiateil  with  inyosis  in  tiie  other  eye. 

In  spastic  mydriasis  the  pupil  is  motlerately  dilated,  contracts 
>lii:liliy  to  li;;ht  and  converjience,  and  does  not  dilate  to  sensory 
-liiiiuli.  .Mydriatics  dilate  the  pupil  <ui  niiuinirini,  hut  myotics  exert 
1ml  little  action  upon  it. 

I'lintlijlic  Hinilriiisi.y,  or,  as  it  is  sometimes  called,  iridojilfiiin,  is 
c.iu-i'd  hy  [laralysis  of  the  fibres  of  the  oculomotor  nerve,  the  liranches 
w  liicli  iiniervate  both  the  intrinsic  muscles  of  the  eye — /.  e.,  f  lie  sphinc- 
Irr  pupilhe  anil  the  ciliary  muscle — beiiifj  usually  affected.  It  may  be 
ilir  result  of  paralysis  '>f  the  nucleus  of  tiiis  nerve  in  the  pons,  or 
truin  failure  of  the  stin  Jus  to  be  conducted  from  tlie  retina  to  that 
ciiitre.  The  pupil  is  n  derately  dilated,  reacting  to  sensory  stiiuuli 
and  to  li<;ht  and  on  converg'-nce,  accordiiiR  to  the  seat  of  the  lesion. 
Thus  if  the  lesion  be  between  the  iris  and  the  pupil-contracting  centre, 
tlirrc  is  no  reaction,  eitlier  direct  or  consensual:  but  if  the  lesion  lie 
Ik  I  ween  the  retina  and  the  pupil-contracting  centre,  the  pupil  will 
ncit  contract  directly  to  light,  although  it  will  consensujilly  and  on 
convergence.  Mydriatics  dilate  the  pupil  ad  timxinnim,  but  myotics 
<'ontiact  it  but  moderately. 

I'aralytic  mydriasis  occurs  in  diseased  |)roces,ses  at  tiie  l)aso  of  the 
br.ain,  involving  the  centre  of  the  third  nerve:  in  affections  of  the  orbit 
which  exert  ])ressure  on  the  ciliary  nerves:  in  cerebral  processes 
attended  with  mark(>d  increase  in  the  i)re.ssure  within  the  skull,  such 
a>  tumors,  hemorrhages,  and  absces.ses,  and  in  the  advanced  stages 
of  thrombosis  of  the  cavernous  sinus;  in  i)rogressive  paralysis:  the 
later  stages  of  meningo-<'ncephali1is,  and  acute  dementia.  .Macewen 
i-  authority  for  the  statement  that  hemorrhage  into  the  centrinn 
o\ale  and  cerebral  ])eduncles  also  produces  mydriasis. 

(llililli(thii<>iil('(/i(t  intcriiii  is  the  name  given  to  tlie  dilatation  or 
|iaiti,il  dilatation  of  the  pupil  associated  with  a  failure  to  contract 
iHKlcr  stimulus:  loss  of  accommodation  accompanies  it.  The  condi- 
liiiii  indicates  a  nuclear  lesion.  Transicnl  mudn'asis  affecting  first 
iiiic  eye  and  then  the  other,  is  generally  regarded  as  prodromal  of 
iii-:inity. 

It  may  be  stateil  as  a  general  rule,  that  dilatation  of  the  pu])il 
wliin  observed  in  connection  with  a  cerebral  lesion  indicates  an  ex- 
irii>ive  lesion  of  th(>  brain;  ind,  when  it  is  of  spinal  origin,  irrita- 
tion lit  the  part  affected.  Mydriasis  is  conunonly  observed  in  glau- 
I'liiiKi.  When  mydriasis  is  due  to  a  failure  in  transmi.ssion  of  the 
liirli!  -linmlus  to  the  pupil-contracting  centre  ami  nerves,  |)upillary 
aiii\iiy  occurs  only  on  convergence.  The  mydriasis  which  accom- 
panies ijptic  .'(trophy  is  the  type  of  this  class. 

Till'  dilatation  of  the  pu])il  which  is  observed  in  complete  blindness 
"iiiiinirosis)  should  not  be  considered  as  a  disorder  in  tlie  mobility  of 

3 


mmmim 


34 


THE  EYE. 


tlio  iris,  hut  should  rather  1m'  n-pmlod  as  a  physioloKicitl  inhibition  of 
th(>  impillary  n-flcx  .liic  to  th«'  witlidrawal  of  tiic  iM-nrption  ot  heht. 
The  Iwitii'iinoiiic  piiiiilliirn  innctiim  sit/n  (Wtrnirkr's).     Hv  a 

of  tl.ix  sipi  it  is  somctiiiK's  possible  to  di-tcriniiH'  ii'  (vrtaiii  cast's  of 
half-bliiidiicss  whctluT  tin-  s.-at  of  the  lesion  is  situ:;ted  anterior  or 
posterior  to  the  (•oii«>ra  .|im.lriKeiniim.  (Fiji.  0.)  This  t»^t  de|K>iids 
upon  the  fact  ihat  the  visual  fibn-s  in  the  optic  nerve  join  the  hbr^s 
of  the  third  nerve,  which  contro'  th:-  sphincter  pupilhe  at  the  corpora 
(luadrineniina.  If  the  lesion  Ix-  iM)sterior  to  this  point  of  junction— i.  e.,  ■ 
back  of  the  coriM'ra,  in  tlu'  oc"ii)ital  rortex-there  will  !«>  no  inter- 
ference with  the  i)upillarv  n-Hex.  Should,  however,  the  lesion  Im» 
situated  anterior  to  the  eorpora,  the  reflex  arc  of  pupillary  activity 
will  he  broken,  and  an  irregularity  in  the  pupillary  contraction  wil 
manifest  itself.  The  hemianopic  pupillary  inaction  test  is  jH-rforined 
Ix-st  bv  placing  the  patient  in  a  <lark  room,  with  a  suiRle  source  of 


Iim«tmtinK  (he  twt  for  hemianopic  pu,.lllary  Inaction  ;  the  lii.w  represent  n  horljonul  plane 
llm.ngh  the  left  eye  an.l  Us  visu«l  tli-l.l  F  O.  fun.lii,  .Kull.  H  M.unl,i  lutea.  A  Naaal 
Imlf  of  the  lleUi.  which  is  Hnwihetlc  in  tenii-.m!  hemiunopsla.  T.  Temi"™!  Imll  ol  retina.  T F. 
Temporal  tiel.l  P.  Pupillary  H,wrti.re.  iMj"  to  u°.  the  equatorial  arc  or  sein.cirilc.  IIU^.  vertical 
,K>1.U  and  line  [«».inK  through  centre  of  eye  t,.  M.  70°  and  iifi.  rays  of  light  striking  the  iaseciUve 
nasal  half  of  the  retina,  proriucing  no  pupilUry  retlex.     (Skuuin.I 

illumination  back  of  him,  *he  eye  not  under  examination  being  closely 
baiiilaged  and  the  patient  being  directed  to  l<H)k  uito  the  distance.  An 
assistant  sht.ulil  then  moderately  illumine  the  eye  by  directing  light 
'ui>on  it  bv  a  plane  mirror,  while  the  examiner  turns  a  narrow  beam 
of  light,  reflecteil  from  the  concave  mirror  of  his  oiihthalmo.seope, 
upon  the  different  parts  of  the  retina,  and  closely  observes  the  effect 
upon  the  movements  of  the  iris. 

The  cerebral  cortex  rejhx  of  the  pupil,  or  Hmth's  rejlex,  is  the  con- 
traction of  the  pupils  in  both  eves  which  occurs  without  change  of 
aeoomiuodatioti  or  rt.iivergf  nee  when  the  sv  ieet,  seated  in  a  dark 
room  directs  his  attention  to  some  Imght  object  within  his  fielil  of 


mF^m. 


wm 


wf^m. 


KXAMfy.lTlnS  OF  THE  EYE. 


.•»6 


vision,  the  amount  of  fontructioii  Ikmiir  proiM)rtionat('  to  tlic  luiiilit- 

riCSS  of  till"  ot)j<'ct. 


Tlif  (irhinihtris  piipiUarij  mirtiini,  wliich  is  used  to  lietcriiiiiic  a 
|i..ssiiiic  paralysis  of  tlic  sphincter  of  the  pupil,  is  a  coiitractioii  of 
tiic  pupil  wliirh  occurs  u|)on  forcci I  closure  of  the  lids.  Clifford,  the 
discdViTir  of  this  reaction,  Wieves  this  contraction  to  he  an  over- 
He  iw  stiiiuilus  which  is  excited  in  the  nuclei  of  the  orbicularis  hhres 
of  the  facial  nerve,  anil  conv  yed  thence  to  the  pupil-coiitractinjj 
centre.  It  is  Ix-lieved  that  when  trigeminal  anasthesia  is  associated 
with  rellex  i)upillaiy  innnolnlity  it  may  1m'  a.scrilM'd  to  a  lesion  of  the 
spinal  root  of  the  fifth  nerve. 

I'lirtuliixivnl  piipillnni  reovtion  refers  to  the  condition  said  to  he 
observed  at  times  in  meningitis,  when  the  pupil  dilates  U!K)n  exposure 
to  lifrht,  and  contracts  upon  its  withdrawal. 

The  Light  Sense.  In  order  to  test  the  power  jK)S.ses.sp(l  by  the 
retina  and  the  visual  centre  of  appreciating  variations  in  the  int«'n- 
sitv  of  the  source  of  illumination,  an  instrument  is  em|>loyed  which 


Phciiometer  of  Kiireter.    (FucHSi 

is  known  as  a  photometer.  (Fip.  10.)  This  consists  of  a  square  box  in 
whii'li  are  placed  black  lines  ecjual  to  certain  standard  letters  when 
seen  at  one-third  of  a  me'  -•  from  the  eye.  These  lines  are  illuniinated 
by  a  standard  candle,  tl;  degree  of  light  l)eing  regulated  by  a  window, 
the  size  of  which  may  be  varied.  The  patient  is  first  made  to  look  into 
the  apparatus  with  the  window  closed.  The  window  is  then  slowly 
opened  and  the  lines  illuminated.  As  socm  as  the  lines  are  recog- 
nized the  size  of  the  opening  re(iuisite  for  this  jnirpose  is  noted,  anil  if 
it  !«■  found  that  -m  oiM-ning  more  than  2  mm.  sciuare  has  been  re<iuired, 
a  subnormal  light  sense  is  jjre.sent.  Before  making  this  te.st,  it  is  neces- 
sary that  the  subject  under  examination  should  remain  in  a  dark  room 
forat  least  ten  minutes,  in  order  to  adapt  the  retina  to  the  absence  of 
light.  The  study  of  the  dimiiiutiim  of  the  light  sense  is  of  great  value 
in  certain  diseases  of  the  retina,  when  lowering  of  its  acuteness  out  of 
proportion  to  the  visual  acuity  is  of  great  significance. 

The  light  sense  of  the  periphery  of   the  retina  may  be  tested  by 
passing  a  candle  flame  affixed  to  the  are  of  a  perimeter  through  the 


fi 


3tf 


THE  t.  YH. 


(lilTlTfllt    IIHTlillMIlS    III 

liluycdiisa  poiiil  nf  ll\:itii'ii. 


fli.Ilt  nf  tlic  <■>•(•,  Willi"'  :i  ^"•••"li'l  <•;> 


UK  III'  is 


J'lWi  rifMnf\isi..ll.i  Ilnldrn'stl'st  for 
tins  ,„„.,,ns....-uiisi.tTin':;Mvrtaiimif:  tli.-  ,H,ii,ts  uii  tli.  I«'«i"";'<'';  •>' 
wllirli 


Wl.ini  :i  >.'Vi..s   nf   t.  st  >^rr^.    i~    |K.nvlV...  .       Vn  drU.-l    .IptUll-all. 

I  .    ntrnu,.,liMt..  an.l  .-iiliiil  /uii..s  ..f  ti..-  h.'l.l.  Ii.  .Miiplnys  a  ran 
,  "  „„,  ,,,,..U  ,„.i,i,  -11  .......  A.U'  a.ul  a  15  iiini.  ;,ua,lia.i    ut  M.t 

)  .  li.vin,'  luui-litths  nf  tlii.int.-nsity  ..f  tlu;  wlut...  on  tlu-  o  lu  • 
\\  iii  ■rim,..,.r  ul'  :;()  .■in.  ra-lius  tli.  Mark  point  and  «ray  ,>^.  .•!.  a.o 
.;  ..  ,  l.v  .1...  noniial  ..y.:  oiilwanl  »:.  .I.%mv-  upward  .«  d.-j:n-.-  , 
■        rd  r.  d<■"••'•<•^  downwanl  :;:.  d.^-nvs.     To  drt-'t  jM-npluTal  di- 

Jid';  lid  a' dark..,-  «.ay  pa..!,  having  ">'--"' "-.""•  "":i";;;,;i^ 
vvliit-  on  ,1,..  otliiT.  i:a.-li  >l.oi.ld  i...  s..,.n  on  tl„.  I7-'"'''''''^  '  /'l: 
l.nvin^r  pnints:  ,.„tward  70  d.-n-.-s,  upward  l.>  d.rn-.'s.  mwa.d  ■>.. 
ilc.Mvis,  and  ilowiiward  .V)dcs;nMS.  ; .  i:.,hl.. 

uf  tension  or  intra-onilar  rcsistam-c  i>  liaiiic 


Tension.  As  tiii'dc^ivi 
111  vary  in  many  discascil 
taiiH'd  ill  every  case. 


eonditions.  it  is  es.sential  tiiat  tins  he  ascer- 


Cliiiieallv  it   is  not   jioss 


sihie  to  a.s('ertain  direetly  the   intra-oeiilar 


Uiiiieaiiv  II    1^  I""   i".^.-..-    -  f  .     , 

„vs>u,v  1  lit  a  sulliei.nllv  aecurate  estimate  may  he  made  of  it  l.> 

'"i.       n^'  t!ie  tension  of  the  eyes  as  felt  with  the  liii«ers  through 

he  ,,.  H.riid.     To  .lo  this,  it  is  hest  to  employ  th.-  two  index  hn^eis 

,,  „  I  ,.,•  tinjiers  heiii«  spread  out  on  the  temple  and  hrow  to  atlonl 

,  h       s  support.     The'  patient  is  direete.l  to  look  down,  ai.l  slight 

J-    e  is  made  on  th.-  plot..-  alternately  with  tlu-  two  tin^.Ts.      1  lie 

..ree  of  tension  d..i.ends    not   only  upon  th.-  mtra-oeiilar  pressure, 


;i;;:  "iKn:;.;;:;;;:.  si,;.;;d  o..  o..  .h..  lempie  an,i  u...  t..  affo,., 
ti 

pre: 

llrio't:: '"r^ilMit ':V;;;a  ■:;.;  th^-elastleity  ..f  tl.  selen-tie,  wlneh 
vi.:' with. :;e,an.l  also  v.:ih  the  in.iiwd..il^  „.  hiipovtaiit,  there- 
fore, in  esthnatin^r  whether  the  tension  ot  the  eye  ^^  t^'f'^^  - 
t,„„  „„,,„al.  always  to  eoinpare  it  with  that  ol  the  tellow  eve,  pn- 
siimin«  th.'it  it  is  unaltered. 

The  (litTerellt  dejlives  of  tension  aiv  noted  as  tollows: 

T  \    Normal  tension. 

T  full    Sli<'htlv  more  than  the  aveia,'.;e  normal  tension 

t'        i      \"-li"iit  hut  decided  inerease  ahove  the  normal  tension. 

t'.  -2.  More'marked  iiu-rease  of  tension,  hut  where  the  fiiifiers  eau 
still  sli'ditlv  impress  the  jilohe.  .  , 

T.  :{.  ■increase  of  t.Misioii  so  marke<l  tint  no  impivss  can  he 
niade  ;'n  the  jrlohe. 

Diminished  tension  in  the  same  way  is  recople.l  as 

^  Several  dilivrent'  instruments  have  Ixm-,,  invented  for  recordin- Hie 
U'.isi.m  of  the  eye,  call.'d  hmnmetcr.-^.  None  ol  them  is  ot  .sulticient 
practical  u.se  to  need  description  hen 


if  three  dejirees: 
the 


KXAMtXATlOX  OF  TlIK  EYE. 


a? 


THE  0PHTHALM08C0PB. 


llir  ^tiiiicht  haviiiK  ai'.iuaiiitcd  himself  with  the  appfaraiici-  of  the 
1  as  iinicli  nf  the  interior  as  may  In-  Icarnci!  l)y 


Atclllil'  <' 


if  thi' 


eve  am 


|;,i,i:il  ilhimiiialinii    is  iniw  prcpami  l.>  (•cimplclc  liic  I'xamiiiatii 


III. 


,\    v\\ 


iliiriii;;  miiiutfiy  tiir  inicrior  nf  tlu'  v\ 


Dm  ai'iiiiiiit  i)f  cciiam  optical  lesion 


ich  an  examination  rannot 


I,.  l,y  the  nakeil  eve,  and  the  student  will  have  to  eall  to  his 

,1  -I  deviee  whieli  will  .ivereome  these  and  remove  the  hiiideraneew 
ppose  his  view  hito  the  eye.     Aithoiij;!:  liie  prineiples  of  siieh 


ulilcll  o 
:;    dr\ici 


su^Ijtesteil  and  near 


v  attained  l)v  a  mimher  of  early 


>iii'iitisis.  the  honor  of  perfeetm):  an 

irii'iit  lielollils  to 


1  elalHUatiii''  them  into  an  instni- 


,////,.// 


IIIIISCIIJM'   111 


llelmholl/,.    This  distinfinished  physicist  invented  th» 
1S.")1,  and  l)V  this  instrument  solved  the  prohlem  of 


-.miiiltaiieoii 

.■illhoii 


v  ilhiminaliii"'  and  viewinc  the  interior 


i.f  the 


eve 


^h  the  iiistriimeiit  employed  by  him  was  crude  and  inetlicieiit 
iny  wavs.  it  comprised  allOf  the  optical  principles  of  the  later- 
iplithalmosco|M'. 

his  instrument  immediately  opi'iied  a  new  held 


The  discoverv  ot    t 


Mill  on 


Iv  ii 


the  studv  of  ophthalmolofiy 


hut  in  that  of  clinical  medi- 


well.    Conditions  w 


iT   the 


names  of  amaurosis   aiu 


hich  were  ilescrihed  by  the  older  writers 
1  l)lack  cataract,  terms  used   to 


li'-iLrnM 


te  all  forms  of  blindness  the  cause  of  which  was  not  apparent 
,f    the    aiterior   segment  of   the    eye,  wore 


an    examination    o 


veil  into  vari( 


)Us  diseases  of 


the  opt 


ic  nerve 


retina,  am",  choroid. 


Ii  WM-  fniiutl,  furthermore 


that  svstemic  disorders  <|uite  remote  from 


Ihr  v\v 


sue 


as  a 


tTections  of  th<"  kidney 


iieart,  and  brain,  often  pre- 


I  tl'"ir  !ir>t  'uamies 


•ount  no  routine  examiii 


nil-  :hm 
lie  lim 


iKir  i<  a  ciinician  ju 


itations  in  the  hidden  tunics  of  the  eye.     I'pon 
ation  of  the  i^\i^  can  k'  considered  to 


iiiilil 
ii'iiii'ni 


IICIAI 


perlv  performe.1  until  the  ophthalmoscoiM'  has  Im'cii  emi)loye(l 

(•linician   justified   in   rendering  a  diajinosis  in  many  ca.ses 

is    aware    of    the    intra-ocular    condition.     It    should    be 

br'i-.'d  that    bv  no  other  means  is  it  iiossib'e  U>  sec  a  living 


■ad  and  to  study  the  complete  vas( 


ular  cycle  in  an  orpaii,  of 


llie  elitl'ance  o 


if  its  arterial  and  the  exit  of  its  venous  blood. 


I.ike  most  instruments  of  a  similar  nature,  its  use  presupposes 
:,  rrtain  ainoimt  of  prai'tice,  and  the  student  will  succeed  m  anpur- 
inu'  :iliililv  to  us(>  the  ophthalmoscope  only  after  the  exercise  of 
I  Mn-i.|rnil')le  patience  ami  emleavor.  One  api)roachinL' its  study  should 
iiHi  .  ;imIv  b(>  discourajied,  nor  should  he  expect  to  become  expert  in 
IN  M-.'  ill  a  few  weeks'  time:  he  should  sedulou.sly  cultivate  every 


'|i]i'itiii!iit 


y  that   jireseiits  itself  to  e\;imin( 


tli(>  interiors  of  healthy 


ir  It  IS  only  by  a 
il  ri.ndiliiilis  mav  be  recoirnized 


kiiowleil<;e  of  the  phvsiolojiical  that  patholo;ri 


.\rtilicial  eve: 


.ire  iif  drciiled  Value  when  it  is  imiiossible  to  obtain  na 


such  as  1 
tural 


'ernn  s. 


eves 


for 


1  J |.-i,iil  |,rni.'i|ilosiiiV(ilveil  In  .jplnhrtlmoM-ni.y,  thf  llu'i.ry  of  ihe  ophthnlmnwoiif.  mid  the 

•  let.  rin:^  iiiun  nf  ihf  ri'fmotiun  of  the  eye  by  it  will  bt  coiisiik-iv.l  in  tliu  I'hapter  on  Kelraclion. 


•M 


Tin:  EYi:. 


stiiily,  «>r  a  r:il)l>il's  eve  may  l)c  utilizi'.l.  In  on'  t  tliat  tlic  stuilciit 
niay'lM'  lau'ilil  accunicv,  and  Miay  ai>|>ivciatc  fully  the  iiaimv  of  tiic 
ciia'iijli's  whicli  the  o|>liilialinosco|M'  reveals  In  liiiii.  it  is  a(lvisal)le  li>r 
liiii  '^..sketcii  what  ill'  sees;  for  while  but  few  persons  possess  sntli- 
cient  skill  to  make  an  artistic  .Irawinu'  of  the  tindin-is  of  tlic  oplithal- 
nioseope.  nearlv  everyone  may  proihiee  a  schematic  rei)resentation 
(if  I  hem.  especially  it"  lie  employs  a  sketch-liook  sudi  as  has  been 
(levisecl  i)V  Haali. 

The  writer  knows  of  no  nhjectioii  to  the  student's  inakinj;  his  tirst 
trials  with  the  oi)hlhahnoscope  upon  eyes  the  pupils  of  which  iiave 
heeii  arliliciallvdilate,!.  The  employment  of  the  instrument  isfjivatly 
facilitated  thereby,  and  the  fact  that  he  has  once  seen  the  fundus  will 
enable  the  beLdiiiier  to  proceed  with  more  conlideiice  upon  eyes  the 
pii|iil--of  which  are  undilated  than  he  wiio  has  never  experienced 
tile  sensation  of  aetuallv  viewin-i  the  head  of  the  optic  nerve  and  the 
retinal  ve-^sels.  To  avoid  any  possible  accident  resulting'  from  the 
emplovmriit  of  nivdriaiics,  individuals  under  forty  years  of  ap' 
slK.ul.i  be  i-hoseii,  and  eyes  which  are  free  from  external  sifiiis  ot 
ilise;i-e  llomatropiiie  in  weak  solution  if  irrs.  ad.  f.-.j  i  is  a  con- 
venient druf;  to  employ  for  this  purpose,  as  it  proiluces  a  dilatation 
of  the  pupil  in  thirty  nVmutes.  and  its  effects  are  very  evanescent,  and 
may  be  rendered  -till  more  so  by  the  instillation  of  a_i'ew  ilrops  of  a 
solution  of  eserine  loerine  suljili..  ^M•.  >s;  a^i.  <lest..  f ."ij )  at  the  com- 
pletion of  the  examination. 

.Mtliouirh  not  es-eiilial.  unless  tile  student  have  markedly  ilefective 
eves,  it  i-  di'-irable,  to  avoid  errors  in  the  estimation  of  the  refraction 
ami  to  nbiain  the  clearest  imaiie  of  the  fundus  possil)le_.  that  he  have 
the  refi.-ictioii  of  his  (iwii  eye<  estimated  and  <'orrected.  if  neeils  be,  by 
<rlasses  before  attemptin<z  ophthalmoscopic  work. 
^  Method  of  Ophthalmoscopic  Examination.  |.\ote.  Since  the  prin- 
ciple- which  irovein  ophih.aliiioscupy  .are  not  described  until  the 
next  ch.-ipter.  it  will  be  supposed,  to  avoid  ambiL'uity,  that  both  the 
eye-  of  thi'  -urireoii  and  those  of  the  patient  are  oi  normal  refraction.] 
The  Instniment,  The  most  i— lailial  pari  of  .an  ophthalmoscoix' is 
;i  mirror  with  a  centra!  perforation,  as  it  is  necess.ary  that  tiie  lijiiit 
dmuld  lie  rellected  into  the  eye  ;m.l  an  opportunity  afforded  the 
.ili-ei-ver  to  ^r.iin  a  view  of  it<  interior  .it  the  same  time.  There  should 
he  iwii  miiini-  on  every  instrument:  a  plane  one  to  detect  opacities 
ill  the  media  and  sliLdit' chamrcs  in  the  I'olor  of  the  eye--rroun''  and 
a  r.  me.aveoiiedf  ;il)out  :|l»(Mn.  focal  di-tance.  for  ofdin.ary  exaie  ion. 
In  addition  iu  the  mirrors,  everv  ophthalniosi'ope  -honld  be  ji.  vided 
uiih  ;i  series  of  lenses  to  neiitrali/e  the  refraction  of  the  eye.  in  order 
to  (li)taiii  a  -harp  and  distinct  view  of  the  det.iils  of  the  back,irro\i:iil 
of  e\-e-  of  .almormal  refraction. 

W  bile  there  are  a  host  of  ophthalmoscopes  employed  throughout 
till'  wc'iiii,  liie  most  |iopiiiar  in  llie  i'niled  Sl.iie-  and  the  I  nited 
Kimrdoin  are  the  l.firini:  .and  the  Morton  o|ihtlialmoscopes.  resp<'c- 
tivelv,     Uoth  of  these  instruments  exhibit  to  a   m.ar' cil  defrfce  the 


W" 


npmnsMiil 


j:.\.iMis.iri(>y  of  nit:  eye. 


39 


ni,,st  I'ssciitial  t'ciituivs  in  :in  ophlhaliiioscopc.  viz.:  larficiicss  of  field 
,,l  view.  iini|)cr  iliuiniiiatioii.  and  the  aliility  to  hriiis  a  variety  of 
IriiH's  licforc  tin-  sijtiitdiolc  in  tlic  miiTor,  witlioiit  tlic  necessity  of 
iviHdvin;  the  instriiitient  from  tlie  eye.  When  propi-iiy  nianufac- 
i,,,...,i      m,   ,■  wl"  these  instnnneiils  should  la.-^t  the  averaj;e  ophthal- 

II, u,  ...i-;  a  lifeii.;,"  ,       ,      ■ 

'  ,  :  „-lii'i  iij,l,n ,  Iniosropc.  As  shown  in  Imj;.  11.  the  Loiinj; 
,,.,!  I.;,  ,|,,sc.i|..'  i:  providetl  with  a  coneave  mirror,  parallelojiram 
ill  .  ,  .with  ,1  .-entral  perforation  from  ;{\  to  I  mm.  in  diain- 
,1,1  The  mim..  is  so  hinif;  upon  the  frame  that  it  may  he  tilted 
■_'()  ,|ei;rees  to  the  rigiit  or  to  the  left.     For  the  purpose  of  focusing 


i,,»ring's  ctphtlialnioscnpe. 


!;,■     r 

■    !,■     1- 

I'l    |M| 

nhirl 

!,'ll-i 

I'aiii; 
C.I   :: 
Tl 


ivs  upon   ihe  fundus  in  the  i-vent   tliat   the  format  ion  (>f  the 

~  almiiinial,  and  secomlarily  to  oi)tain  the  dejiree  of  refraction 

..1  the  eve.  the  instrumenf  is  provided  with  a  series  of  lenses 

V  \»'  rotated  hehind   tiie  sijiht-hole  in  the  mirror.     These 


I   i!ia\ 


^  iiv  .'ontained  uiion  a  full  disk  and  a  (|uadrant  of  a  disk,  and 
iiniii  the  weakest  convex  and  concave  spiierical  lenses  to  those 

-Mviiirili  suflicieiit  to  iieutrali/e  the  lii^hest  ocular  defects. 

.    \ln,i,„i  Ophtltnhiioscoiif.     (Fifi.   !■-'.)     In  this  in.struiuent   the 

-  !v  —t  in  a  <-v!i!!d,.r  in  the  form  of  ail  en-lless  chain,  and  are  pro- 
li'll'i  i.v  M  siroiifi'drivinfi-wheel.  The  instrument  is  jirovided  with 
tluv,   miners— one  plane  and  two  concave,  one  of  10  inches  focus  and 


pflf 


m 


40 


a  sniMllrr  mw  n\  ., 


Tin:  i.Yi:. 


illl'lli'^    |(ICU~ 


Tlir  t 


wo  lust,  wliu'ii  ar 


'(•  si't  hack  to 


ick  ill  Hill'  iiKiunliim  an 


I  arc  fcvcrsihlc,  ar 


niil  iviiiioscoiiv:  tlic  siiiallci-  concave  on( 

htliali 


('  for  iiiilircct  examination 
is  for  the  direct  iiietliod. 
has  been  introduced  by 


Oiiite  receiillv  a  stationary  o,  .  ,        i  i       • 

•nionirnFi-.'i:ii.\vliicli.altlion};li  too  larp'  to  i.e  .iianipuiate.l  l.ytnc 
iiaiid  and  roii-.r>|uenllv  valueless  in  ordinary  rout,,w  work,  altords 
an  un(M|ualled  opportunil v  of  viewing  the  fundus  williout  annoyiiif,' 


Till'  Miirl.iii  ■.iilillinlniMSCopc. 

reflexes  un<li'rl)rilliant  illuminalion  and  iiiudi  nia'Jinilicalion.  ami  wjth- 
,,ui  the  necessitv  of  relaxation  of  the  observer's  a<-conniiodatioii. 
\\\  an  arranjieiiMMit  of  pri-ins  it  is  possible  for  tlie  teacher  to  a.ljust 
tile  instrument  lor  the  student,  and  to  ilemonstrale  the  clianires  in 
(!,(,  I'.n.Jij-  bv  viewinir  them  simultaneously  witii  hiiii. 

Examination  by  Transmitted  Light.  Before  proceediiu:  to  the  ex- 
amination of  the  det.ails  of  the  backiriound  of  the  eye  by  either 
tiie.liivct   or  the  indirect  metiioil.the  student  should  hrsl  acciuaint 


mmii 


/.'.Y.i.u/.\.i7/o.v  or  rill-:  i:yi-: 


41 


iM'ir  with  as  niucli  as  may  lio  loanicil  l)y  simply  thrnwinj;  llic 
ii  of  tlic  oplitlialiiinscopip  miiror  iiiti)  tiip  oyo  at  a  distance 
iidiii  ;}()  t(i  40  cm.     l'(ir  the  |iriiiicr  pcilDrmaiicc  of  tliis  test,  as 

Fl(i.  in 


The  ThonuT  (*i.hthKliiH>sr<>iH\ 

i  :i~  I'll'  ilic  mi'llidiis  of  oplillialmiiscopic  cNaminatioii  to  lie  prcs- 

^'\   ii;i  iiiiniicl.  tiip  |iati('iit  sliodld  1)('  scalcii  in  a  darkened  rodin, 

'   I  liiilit  pliiccd  a  little  l)eliind  tlir  head  and  to  the  side  of  the  eye 

1  \:iiiiinalion  and  njion  a  line  with  the  ear.     .\n  .\rgand  limner 


IhciiHiociMlt  cuil  lor  i'iihIhntiiH»i'"l'.v, 

■•:i;|t!<tyri|,  or  a  <-!nsely   woveii   i!u-aiidf.--i-('nt    ("oil   (l-'i-r.  14) 

":  ;i  lirackel  which  should  lie  lapatile  of  heiii}!  moved  in  ail  direc- 

\ii  old-fM<hioiied  oil  lamp  wilh  a  broad  llame  jrives  an  excellent 


wnc ;. ..' v^*.'a  *«  -.^ji 


fwrnSSATJ-viTir  TS>i...-.-J^.<.'^?iL'';  :•'-.- -^ 


42 


/■///•;  K17v. 


li.rht  and  (lavliRht  mav  Iv  (■ihi.1...vc(1  hv  p.Minitting  the  rays  to  f;am 
rulraiur  into"  tlic  room  tliroufjli  a  narrow  slit  ni  a  l)lnul  or  stmttcr. 
Sui.li<'lit  i<  to  l>c  prclVrrcl  when  it  is  .Icsiral)!."  to  study  clianpcs  n. 
tlic  tundus  as  ncariv  as  possil.lr  in  their  natural  color,  as  m  ana^nna. 
If  the  patient  he  l)odri.l.l<Mi.  it  is  lr('.|ucntly  necessary  to  resort  to  a 
cmdle  as  a  source  of  illumination,  and  the  ..l.server  may  he  compell.'.l 
to  make  the  examination  in  a  constrained  posture.  Such  ('xannna- 
li„„s  an-  ai)t   to  he  uns  -tory.   l)ut   the  student  should  never 

desi.t  nor  allow  himse''  -  --me  discourajred  until  he  has  satished 
himself  that  he  has  ace.  ..,  .i>he.l  all  that  was  possible  uiu ler  the  cir- 
cumstances, la  the  ])erformance  of  all  onlinary  tests  \yith  the  oi. h- 
thalmoscoix',  the  observer  should  b."  on  a  slifilitly  higher  level  than  the 
P'lti.'nt  and  both  he  and  the  jiatient  should  be  comfortably  seated: 
the  cu.s'tom  which  prevails  in  ;oine  Jilaces  of  the  surgeon  standmfl 
and  bendinji  over  the  patient's  ey  is  ,leprecated  as  timdinf;  to 
favor  hurried  an.l  sup.Tticial  examinations.  In  exaimmns  chihh'en  s 
eves  the  p.ilience  and  iiifrenuity  ..f  the  observer  will  often  lie  taxed 
l„.f,,re  a  -atisfactorv  view  of  the  fundus  can  be  obtained,  aii.l  a  third 
...rsnii  is  often  ne("essary  to  attract  the  tiaz(>  of  the  child  trom  the 
liirror  towanl  some  distant  object.  .,     ,     , 

In  examination  with  transmitted  lif;ht,the  student,  with  the  larfje 
eoncave  mirror  of  the  ophthalmoscope  held  clo.se  to  his  eye,  throws 
the  li^rhl  upon  the  eye  under  .ibservation.  the  patient  bein.sj;  instructed 
to  direct  his  <:a/.e  in  front  of  him.  ,      ,  ,     ,  ,■ 

\  faint  pinkisli-re.1  glow  will  be  seen  to  replace  tlu-  blackness  ol 
,1„.  pupil.     This  is  know,    as  the  iimJns  rvjUx,  and  is  occ.-isioned  by 
the  reileciion  of  liuht  from  some  i)art  of  the  illuimnated  interior  ot 
th,.  eve      With  the  'iuht  from  the  mirror  still  concentrated  u|)on  the 
pupil'   the  student  should  now  tilt  the  mirn.r  in  difTerent  directions 
'md  WW  the  .•hanicter  an<l  the  direction  of  the  movements  of  the 
shadow  which  will  be  seen  to  travel  ovr  the  eye,  thus  obtammj;  an 
idea  of  the  refraction.     The  jiatient  may  then  be  re,|ueste<l  to  rotate 
his  eve  through  the  different  meridians,  and  follownifi  this  the  student 
.houid  move  his  own  head  fn.m  side  to  side  an<l  back  and  torti,  the 
better  to  obtain  the  ivllex  from  all  parts  of  the  eye.     The  mobility  o 
ihe  iris  <liouldbe  tested  bv  throwhifi  the  li^'ht  upon  the  pupil,  and 
the  perceptive  power  of   the  entire  retina  ascertame.l  by  redectmj; 
the  li'dit  from  different  angles  upon  all  l>arts  of  that  membrane. 

\\\\\\'  use  of  the  mirror  it  is  also  jx.ssible  to  determine  ///<■  jixntion 
noiul  This  is  done  bv  observin.-;  the  coriK'al  retlex.  This  method, 
;,tt..nlion  to  which  was  called  by  I'riestley  Smith,  is  practise.l  ni  the 
lollowin-  wav  the  patient  is  told  to  look  at  the  mirror;  the  hfiht  is 
tlu'n  thrown"ui)ononeof  the  i)atienfs  eyes,  am!  the  exact  position  of 
the  lifjht  reflex  upon  the  surface  of  the  cornea  noted;  the  student 
then  quicklv  turns  the  lisiht  to  tlii'  other  eye  and  compares  the  .osi- 
tioii  of  the'corneai  li^dit  re(1e\  in  the  two  eyes,  'ilir  corneal  <  Hex 
L',-nerallv  api.ears  a  little  nearer  the  inner  than  the  outer  clue  ot  the 
piijiil    as  the  visual  axis  usually  lies  to  the  i...ier  side  of  the  axis  ot 


T^rssr. 


-  sc-"S^'?=^iij«aB*-' ■ 


i:x.iMiyAriox  of  the  kye. 


43 


ihc  ciinica.  If  hdtli  cyos  ho  properly  iliroctod,  tlio  position  of  the 
(■(MIii'mI  rcH(>x  will  he  syiiinictriciil  in  the  two  eyes;  but  if  one  eye 
ilrviatcs,  tlic  reflex  will  he  ilisplaced.  I.i  this  way  imperfect  fixation 
ill  >trahisnuis  w'"'  he  readily  detected. 

H\-  transmitted  li^lit  alone,  the  presence  of  npncUies  in  the  mediu 
may  lie  diagnosed;  these  appearing  like  dark  shadows  in  the  red 
iKickjirouiiil,  because  the  rays  of  lifi;ht  as  they  return  from  the  oye- 
^'nuuid  are  arrested  by  the  ojjaiiue  spots  in  the  media,  just  as  all 
(iliiicts  which  do  not  transmit  light  api)ear  dark  when  seen  in  front 
(if  a  luminous  surface.  .\s  th(>y  often  are  seen  best  with  feeble 
illniiiinatioM,  it  is  well  to  substitute  the  |)lane  mirror  for  the  concave 
ill  searching  for  them.  With  a  view  to  examining  the  media  more 
closely,  and  to  ascertain  more  definitely  the  character  and  position  of 
any  opacities,  the  student  should  now  rotate  a  high  convex  spheri  al 
liiis  berorc  the  sight-hole  in  the  o|)hthalmoscope  and  approach  the 
.  \r  until  he  is  witliin  the  focal  distance  of  the  lens.     For  this  purpo.se, 

Flo.  15. 


l>iaj;iiosis  of  the  site  of  iiti  (»|iurity  from  [laratlactU'  ilisplticenipnt.     iFl'CHs.^ 


iIm'  Moiidu  ophthalmoscope  i<  priividc<|  with  a  lens  of  ,")  cm.  focal 
Iriiirtii  !  -jn  D.I,  the  I.oring  with  one  of  ().2.')  cm.  (-  Ki  D.).  I'nder 
ihi-  high  niagnihcation  any  foreign  body  or  opacity  which  may  have 
iidii  (ivcrlookcd  usui'lly  becomes  visible.  To  determine  the  exact 
'■H-Miiiin  of  opacities  is  often  diflicult,  and  careful  observation  is  re- 
.  ;iirii  to  state  iletinitely  whether  they  be  in  the  cornea,  in  the  anterior 
I "iii'iii  (if  the  lens,  in  the  posterior  portion  of  the  lens,  or  in  tlie  an- 
I  liiii-  pdrliiii  of  tin  vitreous.  It  may,  however,  be  stated  as  a 
■.'1 '  '  Till  rule,  that  stationary  opacities  are  in  the  cornea  and  lens,  and 
i!i.!i  nj.acities  in  the  vitreous,  although  ;it  times  fixed,  are  usually 
ll'.-.'iiiL'.  It  is  fretiuently  possible  al.so  to  determine  tlu'  location  of  an 
w]iiiii\  by  comi)aring  its  i)osition  with  other  structures  in  the  eye  in 
i!i<'  -  iiic  iil.'iiie,  as,  for  example,  the  conjunctiva  and  the  limbusin  cases 
'if  iijiK  iiy  of  the  cornea,  and  the  iris  with  the  anterior  part  of  the  lens. 
\  \.  I \  ■icr-iirate.  and  at  the  same  time  a  very  simj>le  mode  of  loca- 
tiiii:  till  position  of  an  o|)acity  is  by  mean.s  of  the  jHiralloctic displace- 
im  III  iif  the  of    -ty  with  reference  to  the  margin  of  the  pupil.     Iri 


44 


77/ A.'  KiK 


I'lfT.   I.),  1,  2.  .i.  4   n'prcsciit  I'diir  n|i;ii|iic  [loints  in    tlic  (.|ilic;il  ;i\i^ 
"I    the  vvi;  sitimtcil   in    the  .•<,nic;i.   u|),,i,   i!,,.  aiitcridr  (•.•i|.sul(.  nf 
the  let's,  at  tlic  |)(,>trn,,r  p,,!,.  ,,f  il„.  l,.|,s,  and  in  the  anterior  part  of 
tlie  vitreous,  resp,Tlively.      W  lien  tiie  ol.server  is  stationed  at   U    all 
•  •ur  ponits  will  I,,,  nierfred,  and  he  will  see  l,i,t  one.     Should,  h.nve'ver 
'"'  '.'"'^'W*  '*•   "'•'"  ""•  l"'^iti<>ii  nf  these  p„ints  in  relation  to  the 
I>iipil  will  he  ch.uijred.     Thus.  2  will  remain  fi\e,|.  while  1  a|)proaches 
tlie  upper.  an<l  ;{  and  4  the  low.'r  part  of  the  pupil.  4  the  more  so 
In  the  appheation  of  this  test,  tin-  observer  notes  the  position  ,  f  the 
oi):ieity  hy  lookiii};  direetly  into  the  eve  aloiij;  its  optieal  axis      He 
now  slowly  moves  his  h.-ad  to  one  side.    If  the  .sp(,t  remains  inunol.ile 
It  IS  situated  m   the  plane  of  the  pupil.      If  it  moves  in  a  direetion' 
"i'Posed    to    that   of    th.'    observers    eve,    the    opaeitv    is    .situated 
anterK.r  to  the  pupillary  plane.     If  the  motion  is  in  tiie  .same  direc- 
I'on    then  the  opacity  is  situated  in  the  deeper  part  of  the  lens  or 
ni  tile  .anterior  portion  of  the  vitreous. 

Havinjr  e(.mpleted   this  |mliiniiiarv  .studv  of   the  media  wMh  the 
mirror  and  by  tlie  u.se  of  the  liijih  inafinifviiif;  lens,  the  student  should 
now  rotate  the  disk  upon  the  ophthalmoscope  until  the  si^^ht-hole  of 
the  instrument  is  onee  iiiotv  unob.structed  bv  a  lens,  and  should  tli<-n 
proceed  to  ;m  examination  of  the  eye-frround  itself.     For  this  purpose 
he  has  the  choice  of  two  metliod.s.  the  direct  and  the  indirect  •  tlioudi 
•he  befimiier  will  do  well  to  familiarize  himself  with  both  in  all  e-ises 
Indirect  Method.     In  the   ai)i)lication    of  this  method,  the  studimt 
stations  huns..|t  m  a  po.sition  corresponding  exactiv  to  that  assumed 
III  the  test  by  transmitted  li;;ht,  at  a  distance  of  about  :i()  cm     and 
throws  the   HRht   into  the  eye  under  examiiiati,)n   bv   the  concave 
!iurr.,r  of  th(>  ophth.almoscope.     A.s  has  just  lieen  de.s'cribed,  the  red 
reflex  <•!  the  lundus  will  at  once  become  visible;  but  unless  the  eve  bo 
iijlhly  nearsiKlit.'d,  nothiii}:  more  will   be  ob,s,>rved  unless  ji  nmvex 
lens  of    about    o    cm.  locus  l)e   iiiterpos(>(l  before  the  eve  and  held 
at  Its  focal  distance.      If  |h,s  be  done,  an  inverte.l  imajre'  of  the  eve- 
jiround    IS  obtained,  which    will  be   seen  between    the  lens  and   the 
slu.lent  s  eye.     Some  difficulty  is  usually  found  bv  the  bejiiimer  in 
.■H-eomphshmfr  this,  on  account  of  reHectior.s  from  the  surface  of  the 
lens  and  the  cornea,  and  his  tendeticv  to  accommodate  either  for  the 
ey.'  or  the  auxiliary  lens.  The  refl.Ttions  mav  be  overcome  bv  -entiv 
tiltins  the  lens  from  side   to  side,  by  bearinjr  in  mind  al.so'that  the 
nnajie  o|   the  fundus  is  ,an  aerial  .me,  au.l  bv  inakinjr  an  attempt  to 
ad,iust  the  eyes,  both  bemjr  kept  (.pen,  upon  a  point  between  his  own 
e.ve  and   the  lens;  the  latter  dilhculty  may  be  dispelled  also  and  he 
will  avoid  the  natural  tendency  to  accommodation.    In  •■xaminin-'  the 
eye.  the  student  should  apply  his  rijtht  eve  to  the  si<:htd.ole  in  the 
niMTor.  the  msfrum.Mit   b..inf;  -nisped  bv  the   ri;;ht    han.l  while  the 
auxiliary  lens  ,s  hel.l  in   the  left.      It  is  advi.sabl..  t<.  steadv  the  hand 
which  holds  the  MUMh.irv  lens  by  resfn-  the  tij.  of  the  little  or  rinj: 
tinirerui.on  the  patient's  brow,  and  to  utilize  one  of  these  finders  to 
rai.se  the  upper  lid  wh.'ii   it   is  desirai)le  to  examine  the  lower  pan 


^ff 


hXAMf.XATIOy  OF  THE  EYE. 


46 


..1  ihr  (vc,  or  if  tlic  lid  is  covcfinj;  tiic  pupil,  ;is  is  frctiuciitly  the 
r;i-c  ill  iiill;iiii(Ml  eyes. 

If  ihc  ri<;lit  eve  is  iiiKJcr  cxaininatioii,  in  order  to  hriiij;  tiic  iicad 
,.|  the  optic  nerve  into  view  the  patient  siiould  he  toltl  to  diri'ct  iiis 
;;:i/.c  at  the  raised  little  finj;er  of  the  observer^  ri>;ht  hand  as  it  grasps 
ihf  lip  of  the  handle  of  the  ophthalmoscope.  When  tiie  left  eve  is 
l.(  iiiii  exaiiiiiied,  he  should  look  at  thi   observer's  left  ear. 

riie  indirect  inetho<l  is  to  be  [)referrod  wlion  it  is  desirable  to  obtain 
a  irnieral  view  of  the  fundus  ami  in  eys  with  hazv  media  or  in  hifih 
myopia,  as  the  image  obtained  by  it  is  more  luminous  than  that  froni 


Fill.  10. 


The  inilireot  methmlnf  o|ihibaluicwo|>ic  cxiimination. 

'I";  'linTi  niethoil.  By  this  method  the  image  of  the  fumlus  is  mag- 
"iii''l  about  five  diameters,  ten  diameters  le.'is  than  bv  the  direct 
""  iliod,  but  greater  magnifieatioi,  mav  be  obtained  o"^f  the  aerial 
iin:.-r  hy  rotating  a  -r  S  4  I),  lens  before  the  sight-hole  of  the  ophthal- 
i!iii-r(i|-iic  mirror. 

It  .-liuuid  i„.  remembered  that  the  image  in  the  indirect  method  is 
■  tn  inverted  ,,n(>,  mid  that,  t.-erefore.  the  u])i)er  part  of  the  image  cor- 
|'-p"ndstothe  lower  part  of  the  eye-ground,  ami  the  right  .side  of  the 
'•'■'■"■■    '"   t':,-  left   uf    the    eye-ground.     It    is   e.vlremelv  useful    in 

'A-niiinmg  patients  in  a  reeuml t  posture,  ami  is  very  Valuable  in 

'■\:iiMiiiiiig  the  eyes  of  children,  as  it  is  often  impossible  to  obtain  a 


46 


THE  EYE. 


view  (if  the  fundiis  in  this  class  of  ciiscs  l)y  tho  direct  method,  on 
account  of  tiic  iiiipossihility  of  i<cc|>in>;  thcin  iiiiict. 

On  account  of  its  fircalcr  niapiifyinj;  power,  tlie  direct  nietho<i  is 
to  he  preferred  for  the  recognition  of  tine  'etails  in  tlie  fun(his,  and 
it  possesses  the  fnrtlier  advantafre  ovi-r  the  indirect  in  tiiat  it  i^  pos- 
sihle  to  estimate  tlie  refraction  of  the  eye  by  it. 

The  Direot  Method.  In  the  application  of  this  method  tlie  student 
approaches  as  closely  to  the  face  of  the  patient  as  is  possible  until  the 
ophthalmoscoix-  is  broufiht  within  one  inch  of  the  patient's  eye.  The 
instrument  .should  l)e  gnus|H'd  with  the  ri^ht  hand  when  the  ripht 


Fio.  17. 


The  direct  method  of  ophtbalmoBCopic  examination . 

eye  is  Ix'ing  examined;  but  when  the  left  eye  is  under  examination, 
tiie  hand  as  well  as  the  position  of  the  light  should  be  ehanjied. 
The  student  should  aim  to  keep  the  pupil  steadily  illuminated,  and 
should  endeavor  to  keep  the  .Miiall  circular  shadow  which  occupies 
the  ('(Mitre  of  the  jjlare  thrown  by  the  mirror,  and  which  represents 
the  sifiht-hole  of  the  ophthalmoscope,  directly  in  the  centre  of  the 
piijiil.  This  he  will  timl  greatly  facilitated  by  the  practice  he  has 
aci|uired  in  the  observation  of  the  eye  by  transmitted  light  and 
in  \\\v  indin-i't  nu-thoi!.  The  red  refi'X  of  the  fundus  ^'-r-uld  at 
once  become  plainly  visible;  but,  as  a  rule,  nothing  more,  the  details 
of  the  fundus  being  still  hidden  from  view.     This  may  be  due  to 


on 

1  is 
mil 


cut 
the 
I'hc 
gilt 


ion, 

and 
pies 
fnts 
the 
has 
and 
!  at 
tails 
f  to 


PLATE    II. 


Nor'mal  Eye-gr'ound  (Aver'age  Tint). 


Normal  Eye-ground  (Br-unetle). 


m^mmmm^mmm^mmmmmmit^m^^ 


EXAMlSATloy  OF  THE  EYE. 


47 


ictlrciiiins  I'ldiii  the  ciPiiica  aiul  lens,  which  ',i-  osiHrially  ili.sturhiiig 
ill  iliiisc  witli  ilfi<|ily  iii^inctitiMl  iriilrs  ami  siii::ll  pupils,  or  to  an 
;iiiivc  accomriKHlatioii  in  cither  the  surncon's  or  the  patient's  eye. 
Tci  ilccreasc  these  rcHcctions.  the  niirmr  shmilil  lie  nidved  aiiiiost  iin- 
|,rr  iilii)ly  friiiii  side  to  side  until  a  spot  is  t'oiiiid  where  the  rellcctions 
-dill  to  disapi)car.  i'or  optical  reasons  which  will  he  e\plainc<l  in 
the  next  cliapter,  it  is  necessary,  iti  ordi-r  to  see  the  details  of  the 
HKidiis  clearly,  that  the  acconnnodation  in  hoth  the  observed  and  the 
(ii-civind  eye  should  Im-  relaxed.  This  is  accomplished  in  the  patient's 
v\r  liv  liaviii":  hitn  look  into  the  distance  in  a  (iarkene<l  room.  I'rac- 
lice  alone,  however,  will  enahle  the  student  to  lose  the  desire  to 
iii'coMiiiHidale.  which  has  heeii  iiatural  to  him  in  re<;:)rdin<;  all  near 
iilijects  hitherto,  and  to  view  the  interior  of  the  eye  situated  hut  an 
inch  or  so  from  him  as  thoupii  it  were  a  far-away  object.  He  will 
tiiiil  that  relaxation  of  the  accommodation  will  be  facilitateil  greatly 
hv  keeping  both  eyes  ojK'n,  and  this  should  be  practised  durinfi  the 
(■utile  test,  for  while  the  imaftes  formed  upon  the  miemployed  eye 
will  at  liist  be  confusinji.  he  will  soon  accustom  him.self  to  ipnore 
tlit'in. 

Tiie  student  should  now  searcli  for  the  head  of  the  o|)tic  nerve,  as 
ihi-  is  the  most  prominent  feature  in  the  fundu,«.  To  bring  tliis  into 
\ir\v.  he  should  request  the  patient  to  din'ct  his  gaze  sliglitly  toward 
tlir  Icit  when  the  ripht  eye  is  being  examined,  and  virr  virsn  for  the 
Irit  eye.  If  he  now  looks  closely,  he  will  observe  that  the  glare  from 
ihc  fundus  is  not  imiformly  red,  bu*  that  it  contains  a  disk  of  color 
wliiili  is  yellowish  white.  This  whitish  reflex  shouhl  be  kept  stoatlily 
ill  \ir\v,and  as  his  accommodation  relaxes  he  will  Hnd  that  the  whitish 
ili-k  resolves  itself  into  an  oval  body  yellowish  white  in  color,  forming 
a  tiv.Mg  contrast  to  the  reddish  color  of  its  surr>)iindings.  This  is 
the  head  I'f  tile  optic  nerve.  If  the  nerve  does  not  come  into  view, 
one  111'  the  retinal  vessels  frecjueiitly  will,  and  this  should  bo  followed 
up  until  the  nerve  is  reached,  the  avenue  of  entrance  and  exit  of  the 
I'  'iiril  circulation. 

l.il   no  one  fancy,  however,  that  the  interior  of  the  eye  reveals 

'-r!l  at  the  first  attempt  of  the  beginner,  nor  let  him  be  discouraged 

'hat  account,  for  usually  much  [HTsistence  and  no  little  pains  will 

i'  luaiided  of  him  bcfcre  he  accomplishes  his  purpose.     It  is  not 

lilc  at  first  for  the  student  to  try  to  discover  tlu^  lens  in  the 

I  iliiioscope  with  which  he  .sees  the  details  of  the  fundus  best,  for 

'Illy  possible  after  much  practice  and  after  he  has  learned  to 

lii-   accommodation    thoroughly.     For   determination   of   the 

i  ill  by  the  dir'M't  method,  ritir  page  118. 

"".:■  Normal  Eye-ground.     (I'late    II.)     On    account    of  the    many 

!  h-  iii  the  normal  eye-ground,  the  beginner  is  urged  to  famil- 

'  iiiiself  with  the  appearance  of  many  fundi  which  are  known 

•  althy,  to    prevent    confounding   f)hy.siological  chafigcs  with 

i  .      '  iiical  ones.    He  will  find  the  study  of  children's  eyes  especially 

'  |iled  for  this  purpose,  as  their  pupils  are  likely  to  be  larger 


4H 


77//.  A'KK 


.„„1  ,1,,.  rHi-Tli!.};  t.MMliM  rlranT  il.ai.  in  ..M.t  im-.i-I.-.  nnd.  ;i<  m  mlr 

. .  s:;!:,;;';n;:Aiiiin.iy ...  .i...  1,^..,...  .....in.. ...  ••--;,-";;";, 


Ilic  .vli.i;!!  vi's^cU  talMM-ili^'  i.o.n  |l. 


;i;:;,-y^--;r';;;-;ttj;;;':;.:;:t''i:;;:H  '';;: 

,1„.  .AT      iFis:.  IS.)    Tl.is  ,-..1.  is  ..s..ally  .......ri-sLai..-!.  I'Ut    x...... 


l'h)»ioliiKi.'..l  .■xiuniiiHticiii.     (S/.M.i.) 


,.,,a.lv  i..  si..>  a...l  l...si.i,.„  :,<  w-ll  as  i„  (.nnlm..mt..m.     If  ...a>       ; 
r,-    small  .l.-nJi....  .na.ki.,j:  .I..'  'uU-anrr  ...  .In-  l.lno.lv..s.<..l>     ., 

;:;;!,;  s,u.i,i...i  ui.i.  „ayisi.-bhu.k  s,....s,  .i...  p......s  ..1  .■.■.,..„.•.. 

"M;i;::nJ;';hr,iisi<  is  i,>  .van-v  i,...  i.:^ .......  i..  .na..,......- 1.  m^^. 

.,ui,  ■  la,,r;  l.v  .lu>  ai.vH  „.Hh...l.a...l  as    .  .s  tl...  .-..Iv  p..r....    .. 

,  lus  Nri.i.-li  has  a  fix.Ml  for.,.,  it  is  ..sr.l  :.s  a  la...l...:..k  t.,  ......   rhv 

".....•  1-si.io..  of  ..l.a..j..s  i..   .!,.■  h..wl..s    as    ....•  ..xamp  •'.  .' 

,  „.     1  a,.,  is'  ..0....1  as  l,..i.„'  !..  .1..'  .Hi.K.  two  ,l.sk  .l.a.......-s  al.u.. 


ll...Mlisk 


,i:;):!rt-- 


n..ss:    .!...  i.,...M-.,.ost.  a  wl.i.isi,  nvv\.    Ihr  .cicrninn,,.  ='"  '      "    "     - 

„p„„  .hi.  a  ,)ifr....M.t.Ml   .-i..;:,   (/"■  <-l">r'>"l"l   '""'•  ^'^  ^'■•'"   '"   "" 


AAM.W/Xir/O.V  iiF  THE  KYK. 


49 


,.,.,ial.:mviii>:  illuslr.'ition  (FiR.  l!t),  which  w  taken  fr.mi  Fiichs.    The 
(Irial    rinn  i'   the  rt'suli  of  a  larger  (iiH-iiiiin  in  tiie    liiuroid    tliaii 


txa.  13. 


?M  '''"> ' 


a  Ha   H   sf  ''   ^*^       t'  "' 

ll™.|  c.f  !(»■  nplic  nerve.    A.  Ophlhalni<»o<.|.ic  view.    S..me«  hut  to  Ihe  inner  sirte  of  the  centr.^  of 

!l,.  i«|.ill»ilie  mitral  urlery  risen  frDin  tielnw.  and  to  the  temi.iral  »l.le  ..I  it  risen  tlie  cemnil  vem. 

1.,  ilie  leiiii-.rttl  side  of  tlie  latter  Ilex  the  Miiall  i.liyslolosii.il  Meavation  with  t-ray  sti|.|)lini!  of  the 

UiHiiia  inhro^.    The  i«pilla  is  eiielrcleil  by  the  llKht  Mleral  rln«  (lietween  r  and  it)  and  the  dark 

.  I,i.r..i.|ui  riiiK  at '/     ;(.  I.ongitu.linal  section  through  the  head  of  the  o|.i.e  nerve.    MuKiiitied  U  x  1. 

I  ',.•  'ruiik  of  Ihe  ni  rve  np  to  the  lamina  orlbr<iBa  of  medtillated  nerve  fibres,  n.    The  tlear  Inter- 

„r,  -  ,.,   wi.iratinK  iliein  eorresi<,nd  to  the  sepu  eoiiii«i!.ed  of  connective  li.sue.   The  nerve  trunk 

.•lu.U.i.il  liv  the  sliealh  of  pla  mater,  p.  the  nrachnnid  sheath,  ar.  and  the  sheath  of  dura  inaler. 

.'..     Tliere  H  a  free  iniersi«ce  remaininK  Iwtneeii  the  sheaths,  consisting  of  the  subdural  siwre.  nt. 

,.,l  Ihe  suhurai-hnoid  s|«ce,  m.    Iloth  si«ceii  have  a  blind  endini?  in  the  sclera  ai  e.    The  sheath  of 

•  liri,  1. later  |«.«ses  into  the  eitemal  layers,  m.  of  the  sclera,  the  sheath  of  pia  mater  into  the  internal 

.    rv.  *,,  which  latter  extend  as  the  lamina  cribiwa  transversely  across  the  course  of  the  optic 

■     .-.    The  nerve  is  represiMiled  iu  front  of  the  lamina  as  of  liRht  color,  bi-cause  here  it  consists  of 

tiiedullatcd  and  lience  transparent  nerve  fibres.    The  optic  nerve  spreads  not  in«in  the  retina,  r, 

.^.  li  a  «i,v  that  at  its  centre  there  is  pniduce.1  a  funnel-Bhapc<l  depres.«ion.  the  vascular  lunuel, 

-  :i  .iliose  I'liuer  wall  the  central  artery,  a.  and  the  centml  vein,  r,  ascend.    The  choroid,  ch.  shows 

»  ir„-ver«e  section  of  its  numerous  bloodvess.>ls,  and  toward  the  retina  a  dark  line,  the  pigment 

,  i  !  Inliiim :  ne-;  the  margin  of  Ihe  foramen  for  the  optic  nerve  and  corresponding  to  the  situation 

•    i.e  thornldal  ring  the  ch..r.)id  Is  im.r.-  darkly  plgmente.1.    ri  isa  |-»terior  short  cihary  artery 

:     i  n-M  h,  s  the  .■horold  lliroiigh  the  sclera.    The  i,»terior  portion  of  the  scleral  .anal  forms  a 

..    .lin ,  t.^l  backwar.1.  Ihe  anterior  i«rtion  a  funnel  dirvite<l  forward.    The  wall  ot  the  anterlo: 

.  1  wh.Mi  seen  in  front  ap^ars  to  have  Ihe  extent.  c(i,  and  corrc«iK)nds  to  the  scleral  ring  vis'ule 

"I  {illmhnoscoiie.    (FtCHs  ) 


•riera.to  iM-riiiit  of  the  entrance  of  the  ojitic  nerve  into  ihe  (-yo, 
■i'iise(|uence  of  which  u  portion  uf  the  aclera  is  exposcil.     The 

4 


50 


THE  EYK. 


choroidal  rinp  is  formod  by  tiic  iicapiiifi  iij)  uf  pifjiuciit  where  the 
clioroid  adjoins  tiie  optic  nerve. 

Thv  rcssel.s  of  the  retina  (Fip.  20)  consist  of  a  main  arterial  and  a 
venous  stem,  the  central  artery  and  vein  of  tlie  retina,  which  divide, 
directly  after  they  have  emerged  from  the  misal  side  of  the  excavation 
upon  the  head  of  the  nerve,  into  two  main  branches,  the  superior  and 
iid'erior.  These  further  subdivide  s(>veral  disk  diameters  distant  from 
the  disk  into  the  sujM'rior  and  inferior  temjjoral  and  the  nasal  l;ranches, 
respectively,  Mid  still  further  subdivide  into  smaller  branches:  these 
branches  nevei  anastomose.  (Vide  page  41c8.)  The  macular  region 
is  sui)plie(l  bj  small  twigs  from  the  superior  anil  hiferior  temporal 
branches,  anil  often  by  two  small  twigs  directly  off  the  parent  stem 

Flo.  .». 


IMstrihnllon  of  retinal  vnwclii.    (Jirhkr.) 


on  the  disk,  the  su[X'rior  anil  inferior  macular  arteries;  larger  vas- 
cular stems  never  invade  its  territory.  The  arteries  are  .smaller  and 
straighter  than  the  veins,  and  are  yellowish  red.  while  the  veins  are 
purjjlish.  Moth  have  a  light  streak  along  the  centre  of  each,  which  is 
fainter  upon  the  veins,  the  rejles  streak.  The  veins  usually  accom- 
pany the  arteries,  ;iiid  have  tlie  s;tme  distribution  and  name.  It  is 
usu.il  for  a  distinct  pulse  to  occur  in  the  veins  upon  the  '>ead  of  the 
nerve.  Puls.ation  in  the  arteries,  however,  is  always  pathological. 
The  retinal  vessels  fre(|iiently  present  great  variations,  botli  in  distribu- 
tion and  characteristics,  and  the  observer  will  often  be  jiuzzled  to 
decide  whether  such  variations  fall  within  physiological  limits.  The 
two  most  striking  variations  are  an  arterv,  which  is  occasionallv  .seen. 


KXAMISATIoy  (>!•'  THE  EYE. 


61 


iind  wliicli  iiriscs  in  tin-  clidroid  iuitl  runs  iiiwanl  toward  the  disk,  tlicii 
i:ikiiij:  a  jii'iicral  direction  toward  tlio  niaciilii,  and  a  cilio-ntinal  rrsxcl. 
il'ii;.  L'l.l  Oiitiai-iiliiinj  rvssd  is  tiic  iiaiiio  ftivcu  to  a  I)rancli  of  tin- 
ciiitral  vein  or  artery  which  disapjjears  at  tiie  edfje  of  the  (hsiv. 

'{"lie  student  should  ac(iuire  tiie  hal)it  of  ohserving  tiie  retinal 
I  ill  Mid  vessels  with  {jreat  care,  for  their  condition  is  fre(|uentiy  indic- 
:iiive  of  tlie  condition  of  the  bloodvessels  elsewhere  throughout 
till' system:  and  on  account  of  the  ability  actually  to  view  the  blood 
cnluMin  itself,  an  exceptional  ojjportunity  is  afflmled  him  of  diag- 
iiiisini;  patholoijical  conditions  of  the  blood. 

The  reddi^li  a])pearanee  of  the  fundus  surrounding  the  optic  nerve 
is  due  chieliy  to  the  blood  in  the  choroidal  capillaries,  although  the 
ictiiial  circulaticm  is  also  a  slight  factor.  (>f  more  influence  in  affeet- 
iiiij  the  general  coloration  of  the  fundus  is  the  pigment  hi  the  retina, 
Mccording  as  it  is  present  in  greater  or  lesser  (luantity.  Thus  in 
liruiiettes,  in  whom  there  i.s  an  abuiulance  of  pigment,  the  "general  tone 

Fio.  21. 


'  ihiHriiinnl  artery.  From  the  outer  nnd  Icmer  margin  of  the  [wpilln  rims  a  cilio-retinal  artery, 
<i.  iiii.kuiK  u  hooli-llke  iCTii,  In  this  case  it  Is  larger  than  nsiinl.  because  it  is  desUned  to  replace 
ilK^  iiiiiii,  Mifero-exlenial  (inferior  temporal  branch)  of  the  central  artery,  which  branch  is  wantlnit 

ll-'lcHs.l  •' 


i-  deep  red  or  evil  slate  color  in  pronounced  cases.  In  blondes  it 
1-  "ticii  a  delicate  pink,  and,  owing  to  the  absence  of  pigment  in  the 
I'lin.i  ;ind  choroid,  the  entire  circulation  of  the  choroid,  whic!)  is 
'I'lile  obsciire  in  brunette  eyes,  is  laid  bare  to  the  gaze.  Alohn'.wt 
I'li-eiils  this  to  an  extreme  degree,  the  red  choroithil  vess«>ls  Ix-iiig 
-I  in  to  course  over  the  white  background  that  is  formed  by  ;he  sclera. 
I  1^'.  -'-'.I  .Vlthough  the  retina  in  health  is  transparent  attimes,  e.spe- 
'  i:illy  ,11  ciiilih-en,  it  is  so  rich  in  connective  tissue  that  a  striated, 
i:i...vish  .ippi-aiance  is  given  to  the  fundus,  especiallv  in  the  neigh- 
'"■'■  i""d  ol  the  disk.  These  irjlrxcs  fr(M|uentlv  accompanv  the  ves.s<>ls, 
^'lid  :'ie  sii  i.roininent  that  they  give  the  retina  a  watered-silk  apiM-ar- 
•'I"'  liiey  are  usually  more  marked  around  the  vellow  spot  and 
'"■'M-inii  the  h;il()  which  surrounds  that  area. 

A  number  of  small  shining  bright  dots  are  sometimes  seen  in  the 
renn.M  .•nitenur  to  the  retinal  vess.  !s:  thev  were  calle  !  bv  Marru-Cunn 
who  lust  descrilM-d  them,  '-crvrk  dots."    They  are  only  visible  bv  the 


w 


go  THE  EYE. 

«liroct  niptliod,  aiul  aro  not  oasily  socii.    Thoir  nature  is  not  known; 
they   may  occur    in  si'vcra!   nieiulK-rs  of   a   family,  ami   are  often 

hereditary.  r   ,  •  i 

The  macula,  the  region  of  greatest  imp«irtance  of  the  retma,  reveals 
itself  only  after  some  difficulty  upon  the  part  of  the  oi)htha!mologist, 
as  it  has  no  characteristic  suliicicntly  striking  to  delineate  it.  It  is  an 
oval  area,  with  the  long  axis  horizontal,  is  more  ileeply  pigmented 
than  the  surrounding  fundus,  and  is  avascular.  From  its  centre  a 
bright  reflex  is  emitted,  tkc  lorea  centralis. 


Fio.  22. 


^^M' 


Ophthalmoiicopir  reprosonliition  of  the  eye-grouiiil  of  an  albino.    (Jaeo«b.) 

To  examine  this  region  when  the  i)upil  is  undilated,  the  ophthal- 
moscope siiould  l)e  slowly  luovetl  upward  and  inward,  while  the 
observer  brings  his  line  i)fvi.sion  to  a  i)ointalK)ut  two  to  two-and-a- 

When  the  pupil  is  dilated, 

'ient  gaze  directly  into  the 

The  iH-riplnri/  of  the  eyc^ 

and  in  order  that  no  part  of 

lo  follow  each  l)ranch  of  the 


half  ilisk  diameters  outward  froiii  the  i 
the  macula  may  be  seen  by  havin 
sight-hole  of  the  oplithalmoscojiii 
ground  should  also  be  carefully  st 
it  may  escajie,  it  is  well  for  the  st 


central  arterv  of  the  retina  as  far  iorward  as  is  po.ssi 


ble. 


CHAPTER    II. 

THE  PHYSIOLOGY  OF  VISION. 

By  WILLIAM  NORWOOD  SUTER,  M.D. 

Vision  is  the  mental  interpretation  of  an  impulse  conducted  from 
the  rods  and  cones  of  the  retina  through  the  optic  nerves  and  tracis 
to  the  visiml  (ireax  of  the  brain.  These  areius  are  situated  in  the  cuneal 
and  occipital  lobes  at  the  internal  and  posterior  region  of  each  hemi- 
si)here.  As  to  the  manner  in  which  the  physical  impulse  is  trans- 
fi.rnieci  into  vision,  we  have  no  knowledge,  as  we  have  not  of  any 
other  kind  of  ixTception. 

The  visual  impulse  normally  results  from  the  action  of  light  on  the 
rods  and  cone;:,.  This  action  "is,  in  part  at  least,  chemical,  the  visual 
jmrplc  of  the  retina  being  changeil  into  a  colorless  substance. 

Artificial  (electrical)  stinmlation  of  the  optic  nerve  or  of  the  visual 
ureas  cau.ses  only  the  sensation  of  light  (illumination)  as  distinguisheil 
tioiii  darkness.  For  the  distinction  of  objects  by  the  vi.sual  sense,  it 
is  icmisite  that  the  object  l)e  reproduced  in  an  image  on  the  retina, 
tliu>  stimulating  only  such  rods  and  cones  as  are  covered  by  the  image. 
Ill  tliis  wav  a  mental  picture  is  realized  corresponding  to  the  image 
dcliiieiitedOn  the  retina.  Thus  the  (juestion  of  the  physiology  of 
vision  resolves  itself  largely  into  an  investigation  of  the  laws  of  light, 
ill  adaptation  to  which  the  eye  is  constructed. 


OPTICS. 

Light  is  a  form  of  energy  capable  of  giving  rise  to  vision,  but 
.  ripablc,  also,  under  suitable  conditions,  of  being  transformed  into 
it  her  kind  of  energy. 

iliat  branch  of  science  which  treats  of  the  laws  of  light  is  called 

•  '/■/((.    Optics  deals  not  only  with  light  in  its  relation  to  the  organ 
t  I  vision:  it  investigates  the  laws  which  govern  light-<>iurgy,  irre- 

i .  iiixc  of  the  eye— the  organ  by  which  alone  the  jjhenoinena  of  light 
:ii"  liKiiiit'csteil  to  our  consciousness.  It  behooves  us  to  consider  here, 
In,  Ai  \ri',  only  so  iiiucli  of  the  sul)j('ct  of  (i|)tics  as  will  afford  a  correct 
MU'li  !-taiiding  of  the  formation  of  the  retinal  image. 

A  l.iidy  whose  constitution  is  such  as  to  produce  light-energy — to 

•  iiiit  r.izlit— is  said  to  l)e  self-luminous.     Such  a  Ixuly  emits  light  in 
:ill  diivciions  ;ind  in  rhythmical  impulses  or  waves. 

Siiur  we  cannot  conceive  that  light  or  any  other  form  of  energy 
iiia\  tiiiveise  space  without  the  intervention  of  a  medium,  it  is  neces- 

(53) 


^1! 


54 


THE  EYE. 


sarv  to  assume  tlic  cxistoncc  ..f  an  all-porvading  substance,  called 
cthvr,  l)V  means  of  which  lifiht-vibnitions  are  transnntted 

The  velocity  of  liflht  thioufih  si)ace  is,  as  demonstrated  by  astro- 
nomical observations,  about  :i(M),(KK).(MH)  metres  (1,S(),(X)0  miles)  per 

"'"  A'luminous  bodv  does  not  ordinarily  emit  a  single  wave,  but  a  num- 
ber of  waves  of  different  lenfjth  and  rapidity  of  vi'  -♦ion.  ( )»  y  those 
wives  within  certain  limits  of  periodicity  (from  :V.H  million  milli.ms  to 
7(W  million  millions  of  vibrations  [.er  second)  affect  the  eye  as  vismii. 

Color  deiiends  upon  the  wave-lenj;th  and  rapidity  of  vit)ration  Uie 
wave  of  greatest  ieiifith  and  least  rapidity  fjives  rise  to  the  sensation 
„f  red;  that  of  least  length  and  greatest  rapidity  pves  tiie  sensation 
of  violet.  Between  these  limits  are  comprised  all  light-waves,  which 
produce  the  colors  of  the  rainl)ow  or  .v/>«  ■rum.  ( )rdinary  white  liglit 
is  conipose.1  of  all  these  wav.-s  actin";  upon  th<-  retina  m  unison. 

It  is  not  definitelv  known  how  color-sensations  are  i)ro.luced:  Ini 
acconliiif,'  to  the  Yoiinjt-Helmholtz  theory  (th'  .ommonly  accepted 


i  it 


»  I 


one)  there  are  three  sets  of  rods  and  cones,  ejicli  set  benift  affected  by 
waves  of  certain  Imgths  only.  The.se  jtroups  of  waves  (■orrespond  t<) 
th<.  three  prima,.  col..rs,  red,  green,  and  blue.  Hy  the  combmed 
effect  in  varying  proportion  upon  the  retina  of  these  three  elements 
all  color-sensations  are  produced. 

A  substanc.-  whi<-h  p.-rmits  the  pa.ssage  of  iipht  is  calle.l  a  mednm 
or  a  transparent  body.  ( )ne  which  does  not  permit  the  pa.s.safte  of  light 
is  said  to  be  fipnf/Kc.  ._  ^    ,   ,i      i   •  ,    .!>„ 

\Vh..n  light  meets  an  opa.iue  bo.ly.  it  is  either  rfjlvclvd  back  into  he 
me,lium  from  whi.'h  it  <ame,  or  it  is  «/..ser^<'./-converted  into  other 

form  of  energv.  .      .  , 

If  the  medium  surrounding  a  lummous  point  is  homogeneous,  th. 

light  emitted  from  this  point  will  travel  equally  in  all  .lirecti.nis  and 

the  wave-front  will  be  si)herical.     (Fig.  2.3.) 

\  small  portion  of  this  wav:-  Hi  O  B),  such  as  might  enter  an  eye, 

is  called  a   ;»<>/(r(7,     \n  inimitesimal    pencil  is  call.-,!  a  rnij.     \Um. 

mathemati.ally.  a  ray  is  a  straight  line  {B  O)  iH'rpendicular  to    tlu; 

wave-front. 


■HTfcrr 


THE  I'll Y.SIO LOGY  OF  VISION. 


55 


li!  the  study  of  optics  it  is  often  convoiiipnt  to  ropml  light  as  com- 
imixmI  of  rays"  ])ro('c('( ling  in  cvory  direction  from  a  luminous  i)oint; 
and  we  may  with  propriety  make  this  assumption,  provided  we  do  so 
with  the  understanding  that  it  d<x>s  not  represent  the  tiue  mode  of 

kvery  |".int  of  a  luminous  l)ody  emits  light,  hence  there  proceeds 
ln.nial)("lv  of  api)recial)le  size  a  great  numher  of  waves  whose  i)aths 
(loss  each  "other  in  various  directions.  We  must  a.ssume,  tlierefore, 
that  many  waves  may  traverse  the  same  medium  at  the  same  time, 
each  wave-disturhance  being  sujM'rpo.sed  upon  that  of  the  other,  a 
i.rinciplc  with  which  we  are  familiar  in  the  su])eri)osition  of  motions. 

Formation  of  Images.  In  order  that  an  ohject  may  be  reproduced 
ill  an  image,  it  is  essential  that  light  from  any  point  of  the  ohject  shall 
n  ach  a  corresponding  point  on  the  intercepting  screen,  and  that  light 
iiuiii  all  other  parts  of  the  ohject  shall  \n'  excluded  from  this  pomt. 
'I'lic  simplest  way  in  which  this  can  be  accomjjlished  is  illustrateil  in 
lilt.  24.    .S  .S  n-prestMits  an  opa(iue  diaphragm  in  which  there  is  a 


iiiimitc  opening,  O.  Light  from  .4  parses  through  the  opening  and 
tails  ii|.oii  the  screen  at  .1,.  Light  from  other  parts  of  .1  B  cannot 
ivacii  .1,.  Hence  at  A,  the  luminous  pohit  .1  is  reproduced:  so  for 
ryrry  other  point  of  A  U,  and  .1,  «,  is  an  inverted  image  oi  A  li. 
i'lic 'objection  to  this  device  is  that  the  opening  nuist  be  so  nunute 
-  to  allow  the  passage  of  a  single  ray,  or  at  least  of  a  very  small 
!  .11,11  from  each  point  of  the  object;  onseciuently  the  image  is  very 
!rrl)iv  illuminated. 

Refraction.  In  the  eye  and  in  other  optical  apparatus  greater 
'  uiiiinatioii  is  secured  and  the  apparatus  made  more  sensitive  by  rc- 
M  M  tion  of  the  per-cils.  Hy  this  means,  larger  pencils  are  concentrated 
'  •  :i  |ioiiit  ill  the  image. 

i'  i-  louiid  that  the  velocity  of  light  is  less  in  dense  than  in  rare 
Ml'.  I  iiices.  The  effect  which  this  retardation  lias  upon  rays  is  illus- 
!i:.i.>l  III  Fig.  25.  in  which  BOB  represents  a  section  of  a  spherical 
\\a\i'  iiii'ctinir  a  denser  medium  in  the  plaiu  S  S.  That  part  of  the 
\v:ivr  uliich  travels  along  O  A  meets  the  surface  sooner  than  that 
\\  liii  li  t  ravels  along  0  B;  hence  when  the  former  traverses  the  distance 


56 


THE  EYE. 


\  H  in  tUr  .lonse  Miediu.n,  th.-  latter  travprs(>9  the  Rreatpr  distance 
)i  S  .:>  tt.j  r..i  luciiu.u.  In  this  way  the  wav(>-  n.nt  is  flatteno.l  so 
that  the  centre  of  the  wave  is  now  situated  at  /.'  *  H  S  being  the 
wave-front,  the  ravs  are  represented  by  lines  drawn  pen)endicular  to 
the  -irc  .S  //  .s-  as  /  .S  and  /  //.  The  .lirection  of  all  the  rays  is 
chanp  1  except  that  of  0  A,  which  is  ,K.riH.ndicular  to  the  surface. 
\il  other  ravs  are  said  to  l)e  refracted.  The  degree  of  refraction  de- 
l,ends  upon  "the  obliquity  with  which  the  rays  meet  the  surface  and 


FIO.  25. 


the  relative  retardation  of  light  by  the  second  medium.  The  latter  is 
called  the  relative  refractive  index  for  the  two  sul)stances.  W  hen  the 
first  medium  is  a  vacuum  (ether)  the  relative  inilex  becomes  the  abso- 
lute index  The  velocitv  o.'  light  in  vacuo  being  reg.-rded  as  unity, 
the  absolute  index  of  'water  is  1.33,  that  of  spectac  e  gla.ss  is 
about  1.52,  and  that  of  air  is  1.0003,  and,  being  so  nearly  identical 
with  that  of  ether,  it  is  regarded  as  unity. 


FIG.  26. 


J__- 


Refraction  at  Curved  Surfaces.  What  has  bwn  illustrated  as  occur- 
ring 'It  a  plane  surface  occurs  similarly  at  a  curved  surface,  rig.  -ib 
illustrates  the  passage  of  a  wave  from  a  rarer  to  a  denser  medium  at 
■i  convex  surface.  In  this  ca,se  the  flattening  of  the  wave  is  greater 
than  it  would  l>e  as  afl"ecte<l  by  a  i)lane  surface;  but,  as  with  the  plane 
surface,  the  pencil  is  still  .livergent  after  the  refraction.  \\  ith  grc-ater 
convexitv  or  refra.-tive  index  tlx'  flattening  may  Iw  such  that  the  wave 
is  plane  after  refraction,  as  illustrated  in  Fig.  27:  tlie  refracted  rays 
are  p.'irallel. 

I  we  assume  f.r  .be  p.-esent  that  the  refracted  wavelront  1.  spherical,  anrt  that  ">e  refracte.!  rejf 
all  ,,roce.Hl  from  the  »me  loint,  /.•  we  shall  learn  later  that  tbla  a«umptlon  1-  ,..rm.,«lble  only  wbtn 
a  Miiall  i.irlliin  or  iwncil  of  the  wave  Is  eoniildered. 


T^BT^f^^f 


THE  PHYSIOLOGY  OF  VISIoy. 


57 


Tliiidly,  ns  illustratod  in  Fig.  2S,  the  retardation  may  U'  so  groat 
tliMi  after  n'trartion  the  rays  converge  to  a  jK)int,  /,  which  is  tlie  jocus 
(if  the  rt'fractctl  pencil.  This  focus  is  ilhnninated  by  all  the  rp.ys  of 
the  pencil  SOS;  it  is  consequently  a  bright  point  corres|]on(ling  to 
tiie  l.rifiht  i)oint  O,  from  which  the  jiencil  procmls.  /  is  the  image  of 
i).  and  the  two  points  are  called  amjwjdle  foci  with  respect  to  each 

"tlier. 

In  Fig.  2()  light  from  O  api^-ars  after  refraction  to  cf)me  from  /  ; 
I)  and  /  are,  as  in  Fig.  28,  conjugate  foci,  but  in  this  ca.se  /  is  not  an 

Flo.  27. 


illuminated  point.  It  is  calle<l  an  imaginary  or  rirhial  focus,  in  contra- 
distinction to  the  real  focus  /  in  Fig.  28. 

The  distances  0  A  and  /  .4  are  called  conjugate  focal  diManees  ; 
the  line  O  /,  on  which  the  distances  are  measured,  is  called  the  axix. 

In  I'ig.  27  the  rays  are  parallel  to  the  axis  after  refraction,  that  is, 
niMtlieniaticallv  they  intersect  the  a.xis  at  infinity.  The  point  F,  so 
situated  that  the  rays  are  parallel  after  refraction,  is  called  the  prin- 
rljuil  focus. 

Relative  Positions  of  Conjugate  Foci.  If  we  examine  mathemati- 
cally the  relation  between  ct)njugate  foci,  we  find  that  when  0  is 


O'  :rr-i^ 


-ii'Kii.d  nearer  the  refracting  surface  than  the  principal  focus  the 
I'liijusate  focus  /  is  virtual;  it  lies  on  the  same  side  of  the  surface  as 
".  '    Fit;.  2f>.) 

W  ill  n  O  is  more  remot(>  from  the  surface  than  the  principal  focus, 

III.   I juiiate  /  lies  on  the  opposite  side  of  the  .surface,  and  is  real. 

'  1-  isr.  '-'s. ) 

.\-  t!;.-  jiuitit  O  ifccdc^  from  the  rurfare  the  conjugate  on  the  oppo- 
>iii'  -Idi  apiiroaches  the  surface,  and  whr-i  the  distance  O  .1  liecomes 
inliniu ,  that  is,  when  the  incident  wave  iM-onu.s  planv  (the  rays 


!  1! 


tft' 


'  ■  i 


^     V. 


5M 


THE  EYE- 


F  J  2S..  V      .-l/is  .!u.  ../lr/,-r  ,;nn..i,.al  focus      U^t^s  p.'".'.-.!...,  ..vn. 

h  ";  nt.T  or  ,„i.H-i,.al  torus  an-  lurall.^l  «//..  ,vtra,-t.on.  an,l  rays  x    rh 

a'v  i-aralk-l  Ijore  rcfrac-ti....  convrfi..  to  tl..  ,.ost.-nor  prnH..i.al  locus. 

Fli..  J'J- 


O- 


Fourtlily, 
the  wavi'  is 
In  this  case 
till' surface. 


the  point  O  inav  lie  to  tl.e  ripht  <.f  the  surface,  that  is. 
alrea'lv  converfrinji  to  this  virtual  focus  hi'tore  retraction. 
/  lies  on  the  same  side  of  the  surface  as  (>  an.l  nearer  to 
(Fitl.;5<t.) 


Flu.  30. 


CoUective  Refraction.    lu  the  con.htion  illustrate.!  m  l-i^-.  2b   he 

,liv..rg.>nce  of  the  i>encil  is  .li.nini.sh.M  by  the  retraction;  in  that  i  us- 

Xru^\  in  Fip.27the  .livrgeiur  is  neutralized;  m  the  con.lition  illus- 

r    M    in  Fis  2S  the  .livergence  is  ...on-  than  neutrah.e.l.  the  wave  is 

ren  lerea  couverpent,  an.l  in  th,-  fourth  cn.liti.m  tlu-  c.-nvrpence  of 

.  nlrea.iv  convorgiuK  ,K-ncil  is  increas...!.  H.-mr  the  n;fracti on 
Ihi.'!.  ..ccurs  when  light  passes  from  a  rarer  to  a  .lenser  me.hum  at  a 
convex -surface  is  n)//cdn'c.)rr(»/(rm/p«/.  ,  ..  ,     .      ,        •„ 

is  evi.le.U  that  we  may  n-verse  the  course  of  hpht  in  these  illus- 
trati..ns  that  is.  wo  mav  rcKanl  /  as  th."  focus  before  ivtraction,  an.l  O 
a.  th."  conjugate  after  refra.-tioii.  H<-nc."  th.'s,>  .hapams  serve  e.,ually 
w,.ll  t..  illustrate  refraction  which  takes  pla.'.;  when  ifiht  passes  from 
a  ,l.'ns,.r  to  a  rarer  medium  at  a  c.ncave  surface.  Such  refraction  is 
therefore  c.illective.  . 

Dispersive  Refraction.  It  w..ul.l  be  superfluous  t..  illustrate 
h.Tc  the  r.-fracti..n  which  occurs  wh.-n  lifjht  pa.s.ses  fr..m  a  rarer  t.i  a 
denser  m.'.lium  at  a  concave  surfac.'.  ..r.  its  e<iuivalent,  that  at  a  con- 

1  An  e.«.,..i..u  u,  thb  .n..e>ir. .  il  ^  whci  the  in,i,k-n.  .v*v.  1.  .Ifre.tP.-l  towarrt  the  centre  of  ,h...r. 
f«ce  all  the  r»y«  iheti  bems  pcr,«nmcular  to  the  surfc™  there  «1U  be  no  refm.tion  ;  and  (i)  «  hen 
[he  wave  ,  conve,KM.^  to  a  ,H,lnt  ..  the  le.l ...  C.  that  Is  to  a  ,«int  nearer  the  snrfaee  than  the  centre, 
In  Jhioh  cl"he  mvergen ce  of  the  pencil  will  be'  i„crea.^-eou<lltions  which  do  not  art*  la  ocular 
refrRctlon. 


TIIK  rilYSKtLOOYOF  VlSl'iS. 


v,.x  <urfaco  whon  liplit  passos  fro...  a  .lo.i.or  to  a  rarer  n.rd.u...  It 
i<  •n.i.aivi.t  that  tl.c  ctTcH  of  such  r.-f.a<'tio..  is  opposite  to  that  \vh.H. 
1,;;  „.,.,.  illustrat.Ml,  that  is,  the  .liverpM.ee  ot  the  pe..e,l  w.l  l.e 
i„..rease.l  l.v  s„ei.  refn.ctio,,.  This  .s  ea ile.l  ,/,../>.r>Mr  ref,-aet.o. 
\  ,„.|,.'il  of'licht  .liv...-«inK  from  a  poii.t.  I.e...^  re...l.Te.l  st.ll  ...or. 
;iiv,..-e..t  l.y  .Uspersive  .vfraetio...  ea..  ..ever  1«'  .....ted  l.y  s.ieh  ...  a 

''''rdmation  of  Images  by  CoUective  Refraction.  The  i,;.n,a.io„  of 
i,„;,...s  l.v  .vfra-'tio..  is  ilh.st.ate.l  i..  F.^  M.  All  .'ays  ot  the  pe„e.l 
.livn-siii.K  f.oi..  O,  a.v  eo..ee..trate.l  at  the  eo.ij.istate  foei.s  ,.  No 
H„  ?.-om  other  pa.ts  ..f  the  ..l.jeet  O  O,  ea..  .vaeh  /hut  eae  h  po.u 
lyiMfi  iH-twe.'..  (>  and  O,  has  a  eor.-espo..<lmt:  eo.ijufiate  ly...j:  l.etwee..  / 
iunfl,:  heiiee  /  /,  is  the  ii.iafre  of  <>  <h-  .  , 

We  have  lea.-..e.l  that  i..  eulleetive  .vl.-aet.o..  the.e  xv.ll  he  a  real 
,„,.us  .-ouiu^ate  to  a..y  poiut  (O,)  ^vhe.,  this  p.n..t  .s  lurther  Iron,  . he 
MMfaee  tha..  the  iirst  p.-i..eipal  foeus:    .e„ee  ihe.v  w.     he  a  rea    an. 
,„  i„ve.-te.l  i.nage  of  O  O,  xvhe,..-ver  the  .hsta..ee  .1  O  (or    1,  O  ,  h 
(,  <\  a.i.l  /  /,  are  .-eally  ir.'s  of  eireles  whose  ra.lii  are  C  O  au.l  C  /) 
is  fireater  thai,  the  principal  focal  .listai.ce  -I  F. 

Flu.  81. 


Cardinal  Points.  It  is  appanM.t  that  any  ray,  as  O,  /„  wh..-h  passes 
llnou-h  the  centre  of  curvature  of  th.-  refraetinn  s.irlace  u...lerpo.'S  no 
ref.a.^ion.  Fro...  this  p.-ope.-ty  the  point  T  is  ealle.  the  mulnl  ,m„it: 
an.l  a.iv  .-av  (O,  /,)  J.assinn  th.-ounh  this  point  is  called  a  «'<-;'»<l';p- 
axis,  in"  c.mt.-adisti.ictio.i  to  the  pi-i...ary  or  pn>ict,>nl  axis  ()  I  I  le 
point  ,1.  where  the  surface  h.tersects  the  pri.icii.a'  axis,  is  called  He 
nrlm-iixil  mint.  These  two-the  nodal  and  pri..cipal  iM.n.is-t..getlier 
with  the  two  prh.cipal  foci  constitute  the  carduml  imints  of  the  re- 

'"'ir.  as  has  h(.en  done  in  the  fipure.  the  diagra...  Ih>  so  drawn  that  the 
incid.M.t  rav  O,  '%  ;in<l  th.>  refracted  ray  N  /„  are  each  parallel  to 
the  axis  O"/,  it  is  evident  that  in  so  doi..K  we  have  a  ineai.s  ol 
deteniiiniii!;  the  i.osition  of  the  pri..cipal  foci  F  a..d  /•  .  I  onversely, 
if  we  know  the  positio.i  of  these  foci  a..d  of  the  other  two  cardinal 
points,  we  may  hv  the  same  geometrical  construction  ascertain  the 
l.ositinn  and  the  size  of  the  in.age  (/  I,)  of  an  ohject.  O  O,. 

The  Aphakic  Eye.  Since  it  is  requisite  ior  vision  that  a  real  ....age 
of  t!..'  "l.jeet  viewed  he  funned  on  the  retina,  it  is  apparent  that  the 
eve  must  he  .so  c.nstiucted  as  to  co.istitute  a  coUect.ye  refractive 
apparatus     The  si..iplest  .levice  of  this  kind  is  that  of  a  single  surlace. 


60 


TiiK  f:yK 


,1„.  con»-a.  tl...  aMn.'"Us  humor,  aiul  th        r  ' » '^      _'  ','  ^, :    -.^  „,^ 

SU.-U  au  oy..  I.rovi.10,1  |t  has  ^;''  "■'»''    «*';•,;        „,  „(  a.la  .tin« 
luents  of  .mtun-  .•xcpt  "i  cue  n-s,M.ct        has    o  in.  a 

the  ..pposi  <•  sule  of  '''"^  ^  [  •;  '    ;^,^  '  ,,,.  ,„r,„,v  ,hat  .listant  ol,  eets 
surfaces,  both  centre<l  on  the  same  axis. 


\' 


I...sarec,asslHMaooorain.t..th^j7-foun^^^ 
,„,l..s  to  the  ax,s  of  the  [>'  '";^^' ^^^.,"1^.,  "[,  a  o  -linarical  lenses,  that 

!;:tSar:i;s::S:^^::t;':nhet.on.^ 

.0  the  fornea  the  lo«  er  Index  of  the  .queou.. 


THU  J'llYSlOLOHY  OF  VISIOX. 


(U 


,tho  principal  mcridiam),  but  tlio  curvature  is  Rroater  in  ono  than  in 

tlic  othrr  meridian.'  ,      »        „     ,.„,. 

L,-i.^-s  are  rlassitied  also  in  res|)ert  of  curvature,  a«:  1,  /j/amw-""'  ••r.. 

•2.  (.(-coHrfj;  3  and  4,  c««mr/>-tv»irej;  5,  plmw-concare;  an.l  «>,  Oi- 

'"TrtifiiiufieS's  are  made  usually  of  Rla-ss  and  are  surn.un.led  by 

.,ir  and  since  the  refractne  index  of  glass  is  greater  than  that  ot  air, 

i,  i".  apparen-  that  plano-...nvex  and  bi-e..nvex  lenses  ar."  c<.llective 

„  .H-ti  'n  that  plano-concave  and  i.i-concave  lenses  are  disinrsive,  and 

..a  ..  cavo-convex  lens..s  an-  collective  (.%  Fip.  32>  or  d.s,K.rs.ve 
!  I- .:}•.')  acconlinK  as  th,-  convex  or  the  concave  refraction  .s 
..n-iter ■=  In  the  former  case  the  concavo-convex  lens  is  called  a  con- 
'rniinumfnisrus,  and  in  the  latter  a  divcrrjin,!  meniscus.  Meni..ci  are 
(••lilcd  also /xri>(»/)/c  lens«'s.  .    -n     .     .    i  •„ 

•  T,,,.  funnation  of  a  re.al  image  by  a  collective  lens  ,s  illustrate.l  in 
l-i,r  ;«  As  in  collective  refraction  by  a  single  surlace,  a  real  image 
i<?:.,M.i-d  when  the  hrst  conjugal.,  focal  distance  is  greater  than  .e 
;„.incii.al  focal  distance.     As  the  .listance  ot  the  object  mcreas<.s  the 


conjugate  focus  moves  nearer  to  the  lens    and  when  the  object  is 
!inmted  so  far  that  the  rays  may  1h^  regan led  as  parallel,  the  image 
w  n  \,c  formed  at  the  posterior  focus,  F'.     When  the  rays  are  a  rea.ly 
V   .«       before  ent'ering  the  lens,  the  image  will  lie  between  the  lens 
!  nltl  e  posterior  prin.-ip.al  f.-cus.     \Vh,>n  the  object  is  situated  at    he 
,  ,.     r'focus  I'X-  rays  will  be  parallel  after  passing  through    he 
.„.,  and  no  inu.ge  will  be  formed.     When  the  object  is  wi  hm    he 
.„„crior  principal  focus,  the  rays  after  passing  through  the  lens  suW 
a,,,«.ar  to  come  from  a  virtual  focus-the  image  mil  Ik-  virtual. 
'  Sine.,  a  .lis,K>rsive  l.'ns  increases  the  ,li^,  rgenc.-  ..f  ixmcil.s   ,t  is  ap- 
pan.ntthat  a  real  imasre  can  be  forme.l  after   ref,act...n  by  such  . 
.',.„<  „Mlv  when  the  rays  have  n-ceivd,  by  previ,.us  .,r  -"l)s(..iu  .a 
,.„!l....tiv..  n.fraction.  a  convergenc.>  greater  than  the  .hv<;rgent  act  <^ 
of  th..  .lis,H-rsiv..  lens.     The  a.-tion  of  a  .li<l)ersive  lens  is  >""«  ;•''•" 
1-i.r  :u      Havs  pr..<v...ling  from  a  point  (K  app.ar  aft<-r  n'fract  on  by 
,he  lens  to  come  from  /.     When  the  distance  C  0  may  be  r..garded  as 

the  case  of  concave  lenses 


w 


rrl 


■nit:  KYF 


:x 


I  |)»'l.iri'  !•  iractii'ii. 
Tlii'MMtHinr  prinripal  fm-iis  is  /■'  ,Ih  iiin.l  th.>  I-  f-r  .:->-  "licl.  ar.. 
,|inct(Ml  tuwanl  Orn  poiui  l-f-rr  r.-fr!i(!i..i.  at      raraii.  i  a.f.  >•  rclrar 


iiiiiiiiif,  /  cuiiicMi-'  with  / '.  \vlii>li  i-  thf 

sinr-il  is  tl...  virtual  ;  ..us  fur  ray- «l.i.h  arc  p^"     MMnnT.  ira.-ti.-i, 


tloll. 


n-  at. 


Cardinal  i  aiuts  ;n  Lens-refraction  !'i  rrlr,,  i.  i.  i  sih,K  iffac 
ravs  passi!.;;  (hmut-'li  ;l.o  cciurc  nf  rvaturr  ii,.;.  i-z.)  noivti  no. 
•m'.l,  as  \\v  .ivt!  l.v  :.mI  the  ccnli  \  .urvaiun."  i^  >n  this  ..  .)U:. 
calhMl  till-  I  'xlal  p<u.  t  II  ihc  n]\uu\  >  iitrc  itu' 
tlicri'  arc  tvo  rcfrtctious.  the  t>pti(;ai  f<  -m-  luu  '  1'- 
asrcpinlsa.  vray  p>--iui;  ihroufihit  tli'  "fn.  "  n 
nuist  I)  I'xai  :ly  couutrractctl  hy  that  at 
O,  r  /,  (l!'_'  ;>:!),  pussiuy;  throu^ih  thi'  <>p 
-•liaii^c  ill  (i  ivctinii,  l)Ut  a  latiTal  dispiaci  '  .ar.  ■■ 

III--  i>f  t!M"  Ictis. 

I'll. Tf  arc  two  no.!'.!  pi  lilt--  111  lirst  >  '\)  ni.  i^^ 
prim  i  il  axi>  lowar  .vliicii  '  •  iin  !  rays  an  .iir^'tt-.:  Ih'! 
ti,  III   the  scci.li.,  one  '  V)  is  I         I'oiiit    1       u  wii     ll 

appra,  tl.  proceed  alter  pMactinii. 

Aiiv  iri.iai  ray,  as  ",  /  .  is  a  seroi-iary  ,:      .  ami  as  il 
of  tlielciis  l)oc()ii"ics  iusijinil  I  -it  in  coniparLsti       'tii  tlie 
th    Moilalravapproxiiuatt     I  -irai^l     hi   •.     l- 'i'\>    '" 
points  arc  nier^ed  in  :-.  shiii v  nodal  -oil      emncidii 
ceiitl-e.      Hence  wlieil  the        nklicss  ,.f  \'w  lelis  is  . 
artificial  lcnsc>  u-d  in  o]       lalinol  :y),  the  r«n///e 
in  numl.-r:  the  I'       !  pnii.     or  tii-- optica       ntre)   .uu     .. 
ci])al  fi'i'. 

Tile  principal  f 
whicii  in  iliis  n-' 
tlie  two  prinei|)a: 
ness  of  the  leii 
wlietliiT  one  nl 
ray- 

Numeration  of     enses.    1 


a^ 


t  is  .li 
a|.    ■ 
■  ■  -■iin 
llier  ol 


iiice  111       Ici 

■ii;.'|.il  -.. 
Iirsi  -ii'fae 

iiidei : 
ilh  th' 


i  llie 

ic- 

-r     ays 

I         icl<r.es.s 

'  »nces, 

111    lal 

„p.       \ 

ivA   (:        -t 

:ire  th    'C 

,,•  l\v.>  |ir    i- 

iiieasu!'        roll!  '       nodal  point 

1  th         .  and,  :.-  so  measured, 

I,  fi,      lisreirardini:  tlie  thick- 

,,.   .i^,,      fraeti.Hi     must   'le  tiie  same, 

•  t       sii'iaces  In      vIhi-.      to  incident 


iicipal  focid  •: 


r  the  local 
/,7»/?r^^f "a'lciis,  1      isuresit-ii.    u'tiM'  jiower,  ,u,i-  heinc;  in- 

versely proportion  ..  tlie  lueal  leii-iii.  Tlie  ui  ..■  nieasurcinent 
in  iiphthahuoloirv  i-  ue  </-e/,  Tliis  rciircsents  il,e  p-wer  of  a  Cns 
havi!;tr  .,  fdca!  !e!!ff!L:  of  nnc  n  -e.  A  ieiis  haviii;:  a  focal  length  ot 
.ill.  lalf  metre  i-  'tv  ice  -  -tr^  as  tiie  nnit-lens.  and  conse.|ueiit!y 
has  ,  p„\vcr  I  ••  t\^         .pt'  :  a  i''"^  liavin-;  a  focal  h^iifrth  of  two 


Titf:  "/ir"«/".'."''' >'  "/■■  visius. 


w.\ 


„„  ,  n-  \\xx^  a  powor       O.:.  1  •  .  .'t.        (V.Hoctiv.-  l.-nsrs  ar*-  .|riu.|fMl  l,y 
,,,..  ,.lus  (      )  -ijIM,  a.,  hiisi  -IMV.     ....-  In  tl..-  nimus  (-)  s.^'n. 

The  Crystalline  Lens.    Hi-  is  ..  In    "nv.'X  1oiisc..iii|)<)hm1  ,,  hl.nll.i. 
Mni.tui..    in-nM>        in    l.M„.ly   t.,war.l  tin-  .•.•ntn-  or  nu.-U-u.,  t  ..■ 
v|,nlc  l-iii"  .'iirliw.    :  ill  :•  tr;iiis|.aiviit  caiwil.'  niul  Misi«'ii.lc.!  »).v  I  i<' 
,„.,..„-.  .rv'lidanx'ir    '..•tw.'c     tl.c  a.|U-.iu.  l.m.i..r  aimTiurly  ai.l  tl- 
vitrcm    1h«Iv  |-<-'     .-••ly        .  I..-  n-frartiv.-   in-l.-x  ut    '"■  •■';>>i='' " 
„.,i-<:i-    1  whoii'    -ll,.t;,>in..!nit  nfrocln.   ,m/.u   -is  alMmt  1  »..>    wl 
,1,.,,  ,,    tl„.  ;,.|U.-n.w  an.!  vitrcHis  is  al.oiit  1  .:!;!7.     Siiicr  tli.^  ui.l.'N 
,1,;.  I,         ivx  cr'    tail:.'  !.-ns  is  j:r-;,'.T  lliaii  that  of  the  sun..im.lin!i 
•  ,„.;■,    tliis    , MIS  i;  list         .fl  a  (•(.licet  ivc  action  IIIM.M  tlir  ray-      •  t'-rht 
pass   tim.ujrli    i.  al'   r   iitiviiift    uii<lcr<;..iic    rdiaction     ,'     the 


1'.  'X 


c  cornea 


1  r.  I 


ractioii    he  anterior 


Incus  is  al>nnt  2:?  mm.  from 


'  tha 
Ireu' 


•iicr  tl 


and  since  ol)ji 
n  'his,  it  I'lillow- 


viewi 


,1  liv  the  eve  lUv  at  a  yrcaler  .lis 


tlie  rav~  from  :'ii\-  point 


.1  th 


(ject 


•onverfimK  t" 
^talline  lens, 
i  of  tlie  lei. 
,11.. 


|e  lieliin.l  the  coritca 


leV  won! 


Jiiy;:' 
converjieno 

,  that    the  ray.- 
ihout  the  lens. 


IS  mere; 


when  they 
hv  the  col 


are 


1. 


ijlht 


Compou       Optical  Systems 


Several   rifrnctii 


l"   SU!    ,ice: 


focn 


cenlieil 


:i  coninii 


xis,  and  separated  l)y  intervals, 


tl' 


I'  eve, 


institute  a  conitHiunc 


I  optieal  system.    I'  was 


tlie  v:',riolls  ,surl:iccs 
1  Krst  deiuon- 


slrated  hv  the  inallicniat    itin  ('tan- 


that 


<tem  IS  e\ 


;icth 


ana 


lop 


)!i-^  to  a  simp 


SVs 


M,  e\ce| 


I  that  the  an',  t'lur  and  posterior 


iical  (hstanres  are  iik-m-^ 


Irom  a  sm 


iniici  I 


tlucl 


jHtl  jxiiiil"  Sep: 
lints,  haviii 
(Fi«.  IW) 


I  interva 
^igniti 


trl' 


it.   but   from  tirn 


>\\\i\ 


laiiy 
tlie  noi 


•re  are  hni 
ts  of  a 


loin 


lens 


n  the  eve,  the  final       'dium  differ 


in  index  from  the  first 
tl;e  [iriiicipa!  ]>oint>^, 
roii'paraltle  to  a  sinjrle 
The  Schematic  Eye. 

refract  i 


points  do  not  eoiii<'id(  in  position 


with 


in  a 


Ion: 


111 


th 


•t  tl 


le  eve  is 


aturi'<.  indice: 


ve  media  of  the  ht 


ind  positions 
tel\ 


tlie 


■ve  hrive  heen  very  accurately  iiivcs- 


tlL':itei 


1.     The  following  tahle  presen 


tstl 


le  average  values  w 


hi.'h  1 


lave 


■11  determinei 


I  for  tlie  normal  adult  eye. 


CURV.vn-KES. 


.Anterior  siirfiifc  111 'he ciirneH 

1  isttrinrsurfHi'col  the  cornea 

'.•ilerior  si.rfHC!  of  the  !>-■"«  ilurini;  r.  Uxntion  ..r  the  cMnry  nmwle 
Posterior  ."UffAceol' the  lens         ...  ,        .  ■ 

Cornea,  1.377 ■  .  .  .  ■ 

.\iiiieoiiH,  l.'.vyi ■  '  ■  ' 

l.onn.  l,l;V< '  •  •  ■ 

Vitreous,  1.337 


lo.O 


Thirkiirn*. 


4.0 


t  In  the  old  .v.len,  of  cnnu-ration  the  ,n,l,-tr,„  ^^:»  taken  as  the  no.t  ..f  me«.urement.     A.  let.-e, 

...      .,.„..;  .....^,  ..f  ..., „  ,„<.!, .....  «.!.i.>ni  o.^.,l  ,„  o.,l,ihalinol..Ky.  e.c  weaker  lenses  in  roni- 

nn'"  ..Jh«"r«lUoteex,,r,.-*.linrraelio„H.    Thnsalensoll  L    having' «  l.*all.n^lf.,ll.,rtyE..K,,.i. 
„,,-,cM«oul,i  l.eclcnot.-l .  ■.  the  frH.,-H>,.  > .     a  let.so".  I.,  won'.!  l«cxprcs*.l  by  thefract...u  '  »„cic. 


g^  THE  EYE. 

Bv  apnlvinp  the  formula  ..f  fiauss  t-  those  .lata  the  followi„ff  are 
,le«hHr.l  as  the  eanUnal  p-ints  cf  the  average  normal  eye: 

F>„tprind^l  point  (U) i.g  m™.  behind  anterior  ...rf.ce  of  c,m,». 

Second  prliicl|i«l  piiint  (H'l -]•■ 

First  ni)dal  point  (N I -  i    ■■ 

Second  nodal  point  (N') '■      .,    ,„,„„„  „f, he  cornea 

Anterior  principal  foe.  «(r|.        •       •       '       '  .    ,,ehlnd  anterior  surface  of  cornea. 

Pi«teriorprinci|>Hl  focus  (F)        .       .       .  -' 

\  .liaprainniatie  eye  e..nstruete.l  in  aeeor.l.mee  %vith  the.^  ■   ueas- 
ureiuents  is  ealle.l  a  sclieinatif  eye.     (!ig.  3o.j 

Fio.  8'.. 


fi 


The  Reduced  Eye.    It 


two  pniiciii 


am 


I  Ix'l 


wee 'II 


efllect  this  iiitevv 


„ ,ti('e(l  that  the  interval  between  the 

tlie  two  noda".  i>nhits  is  only  0.:^  •  mi. .  if  we 
1,,.  1,.-,.  iiriiwiiiMl  .-Hid  th.'  !«■()  nodal 


will  lie  no 


il  anil  nieifre  the  two  principal  and  th 


lOlll 


ts  into  a  siiifile  priiieip 


1  and  a  silisie  nodal  point,  the  refraetivt 


HVct  of  the  eye  is  in  all  ivspei'l 


siiita 
noin 


i)le  cnrvatiiie.  the  surface  in 


tsare  merged,  and  the  indices  being 


. ..   ilar  to  that  of  a  single  surface  of 
tersecthig  the  axis  where  the  princi])! 


smi 


tl 


>f  the  first  (air)  anil 


final  medium  (vitreous),  respet 


the  ri'ihind  cm 


Th 


.,,,„>tivelv.      Suchasul)stituti.in  is  called 
lucc.leve  is  useful  for  the  stu.ly  of  refraction, 


esp 


ally  for  experimental  demon 


tration.    The  index  of  water  is  very 


arlv  tlii>  same 


as  that  of  the  vitreous 


heiie 


■  we  inav  make  an  arti- 


ficial eve  for  demon 


^tration  hv  filling  a  suit 


:ihl(>  receptacle  with  water. 


the  cornea  being  npresentei 


I  i)v  a  verv  thin  spherical  segment  of  gla,s.s 


aiK 


1  the  posterior  face  of  the  receptat 


■le  having  a  ground-glass  face  on 


which  images  are  projectei 


represen 


itation  of  the  retina  am 


Tl 


ic  curv 


tancesarea 

the  refractive  mei 


ature  of  the  artiticiai  cornea  s 
pproximately  iMjual  to  those  ( 


I;  or,  for  the  study  of  the  fundus,  a  painted 

\  bloodvessels  may  b'  substituted. 

liiould  be  such  that  the  focal  tlis- 


if  the  normal  eye. 


If  water  is 


liu'm  the  radius  of  curvature  should  be  about .")  nmi. 
The'i.<.sterior  focal  distance  of  the  schematic  eye  w 


Emmetropia.    The  posterior  local  ti..  ......  . 

M.mroximatelv)  21  mm.,  and  the  second  principal  point,  from  which 

SSu'ei;  measured:  lies  about  2  mm.  behind  %■  anterior  suriace 

of  th    CM  r  le-i-  hence  the  posterior  f.ieiis  of  the  eye  lies  2:5  mm,  iM-himl 

thet    ealsuliit:  thai  is,  parallel  rays  will  be  brought  to  a  f^.cus 

at  this  distance  from  the  cornea.     If  the  retina  coincides  in  position 

with  this  focus,  the  <-ye  is  a.lapted  to  receive  a  clear  impression  of  a 

is  lint  ohiert.    When  tlii^  n!,.!ion  exists,  the  condition  is  ea  le<l  cm- 

;    ;:  L.  S'his  is  the  itleal  or  normal  state  of  ivfraction;  but  as   ins 

relation  depends  upon  the  curvatuit'  of  the  vuri(.u.s  surfaces  as  well  aa 


ri/A'  I'liYsioiou y  OF  risioy. 


65 


„  tlu.  .i7(>  of  the  evcliall,  it  is  not  to  »k'  cxi^cctcd  tlial  it  uniformly 

:;::';"  i    l  '  l  hv  ..-.;.     m  fact,  stn,.tly  .p-akin,,  ..n.n.Kropm 

. .    „;  .X     .   l.ut  it  is  only  wh<-n  thr  variation  fron,  tii<;  stan-lard  is 

i        .  .^^  in  1     in«  disturLance  (visual  or  n..rvov.s,  that  the  con- 

;,■!•;;,„  is  to  L  n-anUM  as  ahnonual;  any  deviation  lion,  emmctropia 

"  AbrnZrChave.  for  the  sake  of  simplicity,  implied  tluU  all  the 

rMvs  of  •!  refracte.1  pencil  meet  the  axis  in  a  common  point- the  focus 

To  fulfil  this  con.Ution,  there  must  l.e  a  suitahl.>  diminution  of  curya- 

uith  increase  of  distan.r  from  the  axis,  for  m  si.hencal  refraction 

;,  ii    lend  ravs  are  proportionally  too  strongly  deviat..,  so  that 

,1;;.^  iZs.-ct  th'e  axis'nearer  the  surface  than  .lo  the  central  rays. 

This  is  called  xitluriad  abirratwn. 

'Hu-  rVfractiiR  surfacs  of  the  eye,  while  more  nearly  resembling 

ir,      id,    surfac(-s    differ  at  the  axial  portions  only  sliphtly  froin 

:!l;iX!l  li£^^.  and  are  regarded  a«  silch  in  all  calculations  in  the 

''tn^^r^^'li  i^  necessaiT,  i"  .-Ut  to  pronire  a  sKajp 
■u'^hs-  splu-rical  refraction,  that  all  but  the  more  cen  ral  rays  be 
X ch  de.   from  the  refracting  media.    This  is  accomphshe.l  in  art.hcial 
y  V  means  of  an  opaque  diaphragm  having  a  circular  ope^mng 

oVth.'  .leslred  size,  through  which  the  central  rays  are  -"'"""ed  to  the 
n-fr  ict ing  nu-dia.     In  th<>  .-ye  peripheral  rays  are  .-xcluded  by  the  m. 
e  ce    ral  ravs  being  admitted  through  its   central  aperture-  fee 
,,,7- vich  varies  in  size  acc<.rding  Xn  necessity.     In  bright  lUu- 
,i„      le  pu,.il  b<-comes  very  small,  thus  ad.ling  to  the  sharpness 
I   'n.„nal  image  and  preventing  the  .lazzhng  of  the  retina  which 
w.    11  occur  from  The  excess  of  light.     In  feeble  illumination  he  pupil 
dilates,  so  that,  if  possible,  sufficient  light  may  be  aflorded  for  the 
iirniMT  stimulation  of  the  retina.  ...         •      i 

'oLomltic  Aberration.    Hesi.les  spherical  abermtmn   there  is  abo 
,l,n,ma;ic  or  color  alM-rrati-.n,  which  is  .lue  to  the  fact  that  tl""!  'P  ^e 
I   1,    iMtion  ..f  light  vari<-s  with  the  wave-U-ngth  or  color  violet  Ik>  ng 
,i    ;  e  s    efracte.1.    It  may  Ix- experimentally  demonstrated 

,1," t  ;lr  alH.rrati..n  occurs  in  refraction  by  the  eye,  but  it  is  too  slight 
1(1  lie  noticeable  in  onUnarv  vision. 

ncrea  e  of  Aberration  with  Increase  of  Sixe  of  Object.  Aberration 

i.   °"ter  according  as  th.-  secondary  axes  an-  tlu-  m.>r.-  ren.o  e 

n,n    the  i.rincii.al  axis      Hence  it  is  evi.lent  that  there  is  a  linut 

,  Iv  t    t        i  '  of  aportun.  (the  pupiH.  but  also  to  the  size  of  the 

„.,.     vhich  will  affont  a  dear  image:  the  ohj.rl  ,„u.t  nhcay.  he  .,ml 

Zl,.rison  vilh  the  }orol  .listances.     It  is  thn.ugh  the  peculiar  co- 

structilm  of  the  n-tina  that  we  are  enabled    ..see  large  objects  ^^lth 

,.l,,,„ess      It  is  onlv  the  central  porti.m  ot  tins  organ,    he  macula 

La  Ivinc  near  the  prin.'ipal  axis,  that  is  sufficiently  sensitive  to  con- 

vev  a  wISl  detined  iinpn'ss'on  to  the  brain.     The  macula  lutea  covers 

.„.,-„vtd  nn'M  about  2  .nm.  in  th..  h..rizontal  and  1  nmi.  m  the^ertlPa 

di..meter.  but  not  even  all  <.r  the  gn-afr  i-art  of  tliis  area  is  concerned 


f 


6tf 


rilK  EVE. 


in  .liroot  virion;  tho  form  centralis,  upon  which  must  fall  tho  inuiKc  of 
"  .rH  ,j^.  •   -U  tin.-th-  s.......  is  .  .ninut..  .lopn.ssiou  n..:.r  tl-  -"tro  o 

1„  n.J.la      "'lu.s  .mlv  that  part  ..f  tho  n-twial  unap-  whu-h  is  nu.s 
u  rSus,>.l  is  utili...!  iu\/-r.d  vision.    Tho  less  oloarly  fonno. 

^;  Ion  of  tho  in>a.o  .lopioto.i  upon  ti.o  loss  — ^x ij-y';;/^,;; ,  J 

rotina  is  howovor,  of  f^roat  s.tv.co  hi  oniarfiuiR  tho  ho  d  ot  iwlncl 
vi  im  \nv  ol.joH  ..r  part  of  an  ol.joot  lyinf;  in  this  ho  .1  of  .n.l.stn.ct 
vls!!!n'  if  h  Jxoiis  attention,  is  brought  ahnost  i..stantly  l,y  the  nms- 
cular  apDaratus  of  tho  v\i'  into  tho  Ihio  of  dnoot  visimi 

F^i   ion  of  the  Choroidal  and  Retinal  Pigment     Tho  -'  --;  ^^f 
„hoto..raphio  oa.nora  islino.l  with  l.lack  sul.stanoo.l.y  >'f  "^'f  ^^'"^ 
,ht  .vHoot<..l  fron,  tho  piato  is  al.sorl>o.l;  othorw.so   >>•;";--«-; 
,r.ns  fron.  tho  interior  of  tho  oaniora  tho  plato  would  h      "octod  b^ 
this  unfoouso,!  hfjht.  and  tho  in.ago  would  bo  n.arro.l.  tl^  ovc  this 

function  is  p..rfornH.d  bv  tho  pipnont  of  tho  cW.  .1  and  ^''♦l"'\,  =, 
Mental  Projection  and  Rectification  of  the  Retinal  Image.    It  is 
apluZt  tbat  tho  in.ase  as  fonned  on  tho  retina  is  an  rnverted  nuago. 

Fio.  3fi. 


u..vortholoss,  objects  app.>ar  in  their  true  relations  as  porce.ved  In    ho 

visual  .o„se.     The  roctitication  ..f  tlu-  i.nase  .s  porlonnod  by  the  nnnd, 

possiblv  as  tho  result  of  ox,HMionce,  in  that  -i-  rotn.al  nnafio  Use     .s 

!„  „uuufost...l  to  consciousness,  but  the  ox      aal  pro.,..ct.on  of  this 

i,nage-lhat  is,  u-e  do  not  see  the  irmuie  on  the  retina:  we  seetheot>jed. 

Srdinj:  the  two  nodal  i.oints  as  u.erp..l  in  a  sn.jile  pon.t   the  ray 

r  s  raifilU  lino  passing  through   the  nodal  pou.t  and  connoctnig  any 

point    .Fan  object  with  tho  corresponding  pon.t  of    ho  unago  n.arks 

h    din.ction  of  tho  external  point.    (Fig.  3(1,)     H  .s  because  tlus  hue 

,„,!  onlv  this  lino,  represents,  in  nonnal  v.sum.  the  true  .Un-'.on  o 

:,nobj.."ct   that    the    n.in.l   has  learned  (through  assoc.ati.m   n     the 

visual  sons.-  with  otlu  r  senses)  to  i>roject  images  along  the  nodal  Imos. 

and  this  even  when,  thn.ugh  artificial  or  pathological  conditions,  those 

lines  do  not  indicate  the  true  direction. 

Tho  estimation  of  th.-  p..silion-the  .listance-..f  an  object  is,  like- 
wise not  th.-  result  of  anv  distinctive  ch.arac*<>  . ;  of  the  image,  but 
is  a  inontal  product  <-ftecte,l  by  the  associatio  ■  .:  .-r  senses  and  by 
the  working  of  tho  two  eyes  in  unison. 


THE  PHYSWhOUY  Of  VlUloS. 


67 


ACCOMMODATION. 

u-..  Invo  •illudo.l  to  tho  fact  that  the  eyo  possos^-s  the  moans  of 

''''Z}^':^^^^^^^  -ti„u;  tho  rays  hoh^^  int.r- 
•'"  M  hv  to  retina  bol<  re  reaching  thoir  focu.,  th(-  inmgo  as  .lo|ncto.l 
'■'''•  r!tinM  uml.1  bo  bhirro.1  In  or.lor  to  aff.ml  a  clear  un.iR.- 
.„,„,„    ho  retina  n^^ou      l.o  ^'";[;  , ,     ,^„  i„,rease  of  convexity 

'■'''"'. eofn  V    ueinm  mh.pt  the  eye  for  .Ustinctnoss  of  nnapo. 

nnpulso  iM-caiiso  ol  the  nieniai  <u  i  transmitted 

al)l.'  of  unih'ruoinp;  change  of  shape. 


-(irv  ligament,     (rig.  .»<.)  .«i,„«r>jtnr    irriilur  nortion 

tl„.  nUnni  '""-/'•  '■o'-i^'^  "f  *-?  i:::;:!  tin?  1  0  l.  m'  'u  face  of 

„,av  1.0  aos.Tibo,l  as  a  r.ng-sha,Mvl  "'"^   ^^ j,'      f.  \\'V  s,.con.l  orlongi- 

,1.0-solora  just  behind  tho  -fr.^rn.^X^-^^;;^l^^^^_^^  Jr^^^ 

n,dn>al  portion  '^.'-''-I'-f'' 7^"''  ;";.^,;;'  '  XrhVwv       the  o.,uatonal 
the  circular  portion,  and  which  exton.l  poMeno.ix 


GS 


nm  EYE. 


it 


rcfiinn  of  the  cyoball,  whoro  they  an-  insortod  into  tlio  ohoroidal  coat. 
In  the  normal  cy'  t'"'  fiiTular  filircs  prcdoininatc  over  tlu-  lonRitudinal 
ones  in  tiic  proportion  of  about  ten  to  one. 

.Vs-vuininf;  tiic  sclcro-form-iil  attai'iiincnt  to  1)0  tlio  fixed  jxiint  in  tlie 
!nu.><eular  action,  it  is  ai)parent  that  contraction  of  tlie  nion^  powerful 
circular  fibres  iiuist  diminish  the  diameter  of  the  ciliary  rinp,  while 
contraction  of  the  less  potent  ineridianal  portion  of  the  muscle  will,  at 
mast,  produce  a  slight  tension  upon  the  choroid. 

When  the  ciliary  muscle  is  uncontracted,  the  anterior  suspensory 
ligament  is  held  tightly  stretched,  the  posterior  jjortion  beuig  much 
less  so.  (Fig.  M,  1 .)  The  stn-tching  of  the  anterior  ligament  causes 
a  flattening  of  this  surface  of  the  lens;  but  when,  by  contraction  of  the 
muscle,  the  anterior  ligament  is  relaxed,  the  anterior  portion  of  the 


Flo.  37. 


lens  is  allowed  to  bulge  forward  (Fig.  37,  2),  so  that  the  convexity  of 
this  surface  is  increase<l.  In  maxhnum  relaxation  of  the  ligament  the 
form  of  the  two  lens-.surfaces  is  practically  the  same,  the  radius  of 
curvature  being  about  5.5  mm.  in  the  young  adult:  for  the  posterior 
ligament  also  undergoes  a  slight  n-laxation,  the  radius  of  curvature 
of  this  surface  iM-ing  reduceil  from  6  to  5.5  mm. 

Tscheming's  Theory.  Certain  physiologi.-its,  most  prominent  of 
whom  is  Tscherning,  believe  that  the  theory  advanced  by  llelmholtz 
does  not  afford  the  true  explanation  of  accommodation.  They  believe 
that  contraction  of  the  ciliary  nuiscle  produces,  by  means  of  the  longi- 
tudinal filires,  an  incn-asc  of  tctisioii  of  tin-  ^usirtnisory  ligament,  and 
that  by  this  ten.sion  the  curvature  of  the  ajiices  of  the  lens-surfaces 
is  incrt'ascd  with  a  dimimition  of  ourvatun"  at  the  j)eripheral  jxjrtions. 


TIIJ-:  rnY.si')LO(i  r  of  visiox. 


G!) 


■     1       ..V,nn,r,>  i^  nhv«ic.illy  possible  culy  in  the  event  of  the  nuclens 

T' ii :/  i^  -.1^1    -I  -^il'  tlu'  cortex  is  fluid  or  gelatinous    Th.s  .. 

:;   flu/    n.l   i      of  tl.e  hunuin  lens  in  ehiUl'uooa  an.l  early  a.  ult  1. f e 

"    1  '    , .  tvhich  aeeon.nuHlation  is  nu.st  active:  henee  U  wouM 

t    i       is  "xplauation  is  less  plausible  than  that  o   H(-hnholtz 

Meiiemen^o  Acco^^  Acconnn.Hlation  ,s  n.easuml  by 

,1     l^n  TSvvhen  placed  in  fn.nt  ..f  a.ul  as  near  ius  po^s.l,  e  t..  the 

V.'.  u  ul.    li  V     >  san.e  focusing  power  as  the  acconnnodat.on  cN-r- 

1,;„  tlir  >.mK     «''■>-   '  I      I  J  ,,„  „.|,|,.l,  a„  eye  can 

' '"'"■ "  ,  :'■    '    u,,»   .  M   a    nl     l„.  a  ......,n,.l,.liv,-  |«.vv,.r-th,. 

acconinioilate,  tne  iins  t^  ""'^•"' ,  ,f  ,    /)  :^  n.)-,  metre  in 

,„    ,ll„„k.  „l  acco„wmlation-oi  the  eye.      If  L  0  i.  O..o 
l,.ngth,  the  acconnuoaative  power  is  4  I).,  etc. 


Variation  of  Accommodation  with  Ai;e.    Since  acconnnodative 
hardened  wjth ;"7«;- "^f  j^,^/^    ^i^l^ In  enunetropic eye  can 

,s;;;;;;^;ow;^a.;;^i;ou;l-r  of  Seventy  or™ 

ha.  Iu...n  reached  acconnnodation  is  n..  h.nger  P'^'-'We- 

The  following  table  (Don.lers)  gives  the  acconnnodatne  pow.  r  at 
intcA-als  of  live  years; 


11 


10 
14 


-.0 
lU 


;io 


X>        41) 
5.'>       4.0 


4r> 
X5 


8..'.     175 


l'4l 
1 


(,:,      70 
uVj    O.i'. 


75 
00 


Presbyopia.     In  ordinary  near  work  .ich  as  rvjuhnj.  theobjoct  of 
vision  is  usually  at  a  distance  of  about       f  ;       /""^Pf  ^^  ,„„.,  fi„e 
the  eve,  or  even  nean>r  in  the  case  ofNcrv  small  prim  . 
work:    In  order  to  adjust  the  eye  for  tins  /l'^/'^"'';,;/^  .'^j//^-'^    'his 

;;i::;;:;iE";:;Sz,z:i^™rgS^ 


TIIK  KYE. 


;il)out  two-thirds  of  the  total  iimphtiido  is  available,  and  with  ud- 
vaiieiiiR  years  a  still  smaller  proiM.rtioiican  he  utilized.  If  one  attempts 
to  engage  in  iHvir  work  without  this  reserve  arcommodat ion,  the  eyes 
six-edily  tire,  vision  l)eeomes  blurred,  and  pain  in  the  eves,  sometiiiies 
aecomi)anied  by  headaclie,  develops,  so  that  the  work 'must  l)e  aban- 
doned. After  a  short  [MTiod  of  rest  work  may  a^ain  be  resumed,  with 
more  or  less  ])romi)t  return  f)f  the  aforenientioned  symptoms.  If 
near  work  l)e  jH'rsist(>d  in  under  such  eireumstanees,  "the  .«ynii)toms 
will  in  time  become  very  distressing,  and  to  those  already  noted  may 
be  added  extreme  hy[)ersensitivenes.s  to  light,  and  conjunctival  con- 
gestion and  inflannnati(m,  which  fre(|uently  ensue. 

In  order  that  one  may  be  able  to  use  continuou.siy  '.\  I),  of  accom- 
modation he  must  have  a  total  amplitude  of  4.5  D."  When  from  in- 
crease of  age  the  crystalline  lens  has  become  so  hardened  that  the 
amplitude  falls  below  this  amount  (corresjjonding  to  vision  at  22  cm., 
or  !)  inch(>s),  the  condition  is  called  imshijopia  (old  sight).  Reference 
to  the  table  above  given  shows  that  the  presbyopic  state  is  reached 
when  the  fortieth  year  of  life  is  passed;  practically  the  condition  is 
usually  manifested  between  the  ages  of  forty-three  and  forty-five 
years.  It  is  <)ft(>n  nearer  the  latter  age  when  relief  is  sought,  though 
the  exact  time  varies  according  to  the  physical  condition,  to  the  char- 
acter of  work  pursued,  and  es(>ecially  to  th(>  refractive  Lstateof  the  eye. 
The  jihysiological  condition  of  presbyopia  should  not  be  confouiuled 
with  hyiK'ropia,  which  may  give  ri.se  to  similar  symptnm.s.  A  person 
having  ;}  D.  of  hyi)<To|)ia  will  re(]uire  (as  W(>  shall  learn  in  Chapter 
III.)  this  amount  of  accommodation  for  distant  visicm;  at  thirtv-five 
years  of  age  the  amplitude  is  5.5  D.,  and  if  .'j  D.  of  this  must  be"  used 
to  focus  parallel  rays  on  the  retina,  only  2.5  D.  will  be  available  for  the 
additional  focusing  re(iuired  in  near  work.  This  amount  being  insuffi- 
cient, near  work  becomes  burdensome,  hut  this  is  not  presl»/oim;  the 
inconvenience  arises  not  becau.se  the  accommodation '  is  weak, 
but  becau.<e  an  abnormally  high  amount  is  re<iuired.  With  the 
aid  of  a  convex  lens  correcting  the  hy[)eropia  the  svmptoms  dis- 
appear, to  reappear,  however,  about  the  age  of  fortv-five,  when  an 
.iilditional  convex  lens  will  be  re(iuired  to  take  the  place  of  the  failing 
accommodation,  that  is,  to  overcome  the  pmsbyopia.  On  the  other 
hand,  a  person  who  has  .'5  I),  of  myopia  will  never  develop  presbyopic 
symptoms,  because  he  can  focus  rays  coining  from  an  object  i)laced 
at  the  reading  distance  without  any  accommodation.  Such  a  iK'rs(m 
will,  liowever,  become  i)resbvopic  (his  accommodation  will  fall  below 
4.5  D.)  at  the  usual  age,  and  if  he  wears  glasses  correcting  the  myopia, 
he  will  have  to  remove  these  in  order  to  read  fine  i)rint. 

Alth.High  presbyopia  is  a  i)hysiological  condition,  in  that  all  eyes 
are  sui)ject  to  it,  it  would  nevertheless  entail  most  serious  conseciuences 
among  civiiixed  race^i  if  if  .,vcn>  nc-t  that  artificial  condition.^  of  life 
hav(>  brought  al.-^o  artificial  means  of  relief  in  the  substitution  of  a 
gla.s.s  lens  for  the  lo.ss  of  accommodative  action  of  the  crystalline  lens 
of  the  eve. 


TirK  PHYSIOLOGY  OF  VIS/S 


71 


I'lu.  following  table  give?  the  probable  strength  oi  l.ii.v  ner.  ssary  in 
■,l,.r  In  enable  the  {)resby()i)e  to  engage  coniforlably  in  i.'.  c  »vork: 


r* 


I 


2.75 


60 

3  2:> 


70 
3.3 


So 


Tor  reading  a  glass  of  3  D.,  or,  at  most,  3.5  D.,  is  suffirient,  even 
V  h.n  the  acconiinodative  power  =.  entirely  lost ;  hence  the  rule 
u<uallv  given  that  1  1).  siiouh!  .e.l  for  every  live  years  is  not 

,p„li.-able  after  tiftv-five  years.  vidental.^.  that  the  strength  of 

i,'n^  must  vary  acroVding  to  th.-  c  ,a.  -  r  of  the  work ,  it  may  be  neces- 
.uv  in  eertain  handierafts  to  use  u  lens  of  4  I).,  but  a  lens  of  this 
.'tn'iigth  and  even  one  of  3.5  I),  would  cause  objects  situated  at  a 
distance  (^f  one-half  metre  or  more  to  be  blurred,  and  for  work  which 
,„u^t  U'  performed  at  such  distance  a  lens  of  2  1).  would  bt>  reciuired 
when  all  acconunodative  power  is  lost. 

It  is  al.so  ar)parent  that  in  ametropia  the  pn'sbyopic  lens  nmst  be 
:„1,|.mI  to  or  subtracted  from  that  correcting  the  ametropia  according 
lis  tills  is  hyjwropia  or  myopia. 

VISUAL  ACOTTT. 

The  size  of  the  image  as  formed  on  the  retina  varies  according 
to  th.-  distance  of  the  object.     Thus  if  O  0  (Fig.  3!t)  represents  the 


no.  39. 


li,„,ir  dimension  of  an  object,  the  image  of  this  dimension  will  be 
nM.ivsented  bv  /  /.  or  /,  /„  according  to  the  situation  of  the  object. 
Conversely,  an  object,  0,  0„  Kig.  40,  will  form  on  the  retina  an  image 
ni  tlic  same  size  as  that  of  the  object,  0  O. 

no.  40. 


The  Visual  Angle.    The  angle  0  X  0  (e<iual  to  /  .V  /)  is  cM 

i;r  visiud  angle  The  >=!na!!est  .angle  which  two  points  (as  i)  and  O) 
M,MV  subten.l  at  the  nodal  point  of  the  eye,  while  they  a^e  distin- 
L'uished  as  separate,  is  called  the  minimum  visual  angle  "  - 

mini  visual  angle  measures 


The  mini- 
the  ristw/  acuteveKs  of  the  eye.     It  has 


^^ 


.  (^  ! 


72 


Tin:  EYE. 


Ik'oii  found  by  cxixriinnit  that  un.lcrsuitahloilhitnitiationtho  smallest 
iUiRk.  under  which  two  white  lines  separited  hv  a  black  interval  am 
H>  distinjruished  as  .separate  is  for  the  n(.nnal  human  eve  .sliKhtlv 
less  than  imc  iiiiiiiilc.  ' 

Test-letters  for  Measuring  Visual  Acuity.  Making  use  of  the 
foreRonifi  cxiK-rnneMlal  determination,  Snellen  constructed  u  series 
of  test-letters  so  arran-ied  that  when  placed  at  the  proiH-r  distance 
each  stroke  of  each  letter  would  subtend  an  angle  of  one  minute  at 
the  no,ial  pomt  of  the  eye.  This  is  illustrated  in  Kijr.  41  When 
placed  at  a  distanc  of  :H)  metres  from  the  eye,  each  side  of  the.s(,uare 

rta.  41. 


would  subtend  an  angle  of  five  minutes  at  the  iiod.il  jioint  and  each 
stroke  of  the  letter  v-uld  subtend  an  angle  of  on<>  mituite.  In  testing 
visual  acuteness,  U  •  onvenient  to  have  letters  of  various  sizes  the 
distance  at  wliK^h  ti.  subtend  the  one-minute  angle  In-ing  noted  on 
the  card.     (Fig.  42.) 

Method  of  Conducting  the  Test.  The  test  is  usuallv  conducted 
with  the  letters  placed  at  a  distance  of  fi  metres.  If  at  ihis  distance 
:hi  eye  ran  dislingui.4,  tho.>e  t<-tleis  which  subtend  the  one-minute 
angle,  the  visual  acuity  is  normal.  It  is  expresse.l  bv  the  .-(luation 
V  =  (i()  or  V  =  1.  Jiut  if  at  this  distance  the  eve  can  distinguish 
no  smaller  letters  than  those  which  subtend  the  one-miimte  angle  at 


^m 


TIIK  PllYSIOLOIiY  OF  VISlOX 


73 


r>  iiii'tivs  tlic  visual  iicuitv  is  only  ono-half  as  gn'at  as  it  should  1m>: 
il'  i<  i\|)ri'ssoa  1)V  till"  ciiiatiou  \'  =  «)  12.  In  nencml.  the  visual 
Miiitv  is  cxpirssfil  by  a  fraction,  the  iniiiicrator  of  which  is  the  dis- 
tiiKv  at  which  tho  test  is  coutlurtoil,  and  the  denominator  is  tin- 
,iistancc  at  which  tho  smallest  distinRuishahle  letters  subtend  the  oiii'- 
iiiimiteanple. 

Via.  4J. 


Tlioriiigton  bracket  with  test  letters. 

Visual  Acuity  Exceeding  the  Standard.  Partly  Ucause  of  th 
laniiliaritv  with  the  al|)halK>tiral  characters  and  partly  because  t he 
^i.indnnl  adopted  bv  Snellen  (one  minute)  is  slijrhtly  lar-er  than  the 
ini.muum  visual  anple  in  young  persons,  it  fre<iuently  ha|)pens  that 
Miialier  letters  can  be  read  than  those  indicated  for  normal  vision. 
ri,„<  \-  =  (14  or  V  =  6  3  mav  lie  recorded.  In  old  persons  vision 
cNc-edhip  (iti  is  not  connnon,  because  of  diminution  of  transparency 

Estimation  of  the  Refractive  Condition  and  of  the  Accommodative 

Power  by  Means  of  Test-letters.    Since  an  eye  must  have  its  maxi- 

nial  seeinji  power  when  the  imap"  is  properly  focused  on  the  retma 

we  have  in  the  t.>st-letters  a  means  of  determining  whether  or  not 

tl„.  ..mmetropie  condition  is  present.     If  the  visual  power  is  incn-as«'d 

l,v  placing  a  convex  lens  before  tho  eye,  we  know  th;  '  without  this 

Irns  the  focus  falls  behind   the  retina  (hyporopi:       if  tlie  visual 

|M,wer   is  increased   by  a    concave   lens,  the   focus  without  the  lens 

M,ust  fall  in  front  of  the  retina,  either  from  excess  of  curvature  or  of 

i,„glh  of  eveball  (mvopiai.  or  from  undue  actmn  (spasm)  of  the 

a<Tommodation:  finally,  if  the  maximal  visual  pow.-r  is  obtaine.   with 

il...  aid  of  a  cvlindrieai  lens,  tho  eye  is,  without  the  lens,  adjusted  to 

the  object  in  the  meridian  of  the  axis  of  the  cylinder,  and  hyix-roi-ic 


74 


Tin:  KYh:. 


or  myopic  (iistipuatic)  in  the  moridian  at  rijilit  unglw  to  this,  accor.l- 
iiiK  as  a  convex  or  concave  evlinder  is  re<iuireil. 

Havinn  .leteniiine.!  wili»  tli.-  distant  test-letters  liie  refraetiv.-  con- 
dition and  tiie  visual  acuity  of  an  eye.  it  is  ix.ssil.le,  l)y  means  of  small 
letters  constructed  upon  the  same  i)lan,  to  measun-  the  accoimntxla- 
tive  power.  I'lacing  Ix't'ore  the  eye  the  lens  which  affords  the  con- 
dition of  emmetn.pia,  and  noting  the  visual  acuity,  the  same  acuity 
should  l.e  obtained  in  near  vision  so  long  as  the  acconun. .dative  i)ower 
is  sullicient  to  adjust  the  eye  for  the  distance  at  which  the  tyiH's  are 
held. 

DURATION  OP  THE  VISUAL  SENSATION. 

The  leiipth  of  time  required  for  light  to  produce  stimulation  of  the 
retina  is  jjracticallv  instantaneous;  the  shortest  flash  of  light  that  can 
he  produced  exjK'rimentallv  is  seen  by  the  eye  as  iH-rfcctly  as  a  nuich 
longer  Hash.  Moreover,  linwever  brief  the  in-riod  of  stimulation,  the 
visual  impression  always  jx-rsists  for  an  apjireciable  interval  (about 
one-eighth  of  a  second')  after  withdrawal  of  the  .stimulus.  Thus  a 
.series  of  rapid  stimulations  apjiears  as  a  continuous  stimulation -the 
s)>okes  of  a  rapi.lly  revolving  wheel  api)ear  to  cover  every  part  of 
tlie  area  of  the  circle. 

BINOCULAR  VISION. 

This  .subject  will  be  considered  in  another  chapter.  It  -.uflic  <'s  to 
sav  here  that  in  normal  vision  the  muscular  movements  of  the  eyes 
ari'  so  associated  as  alwavs  to  bring  the  image  of  an  object  (in  direct 
vision)  upon  the  fovea  centralis  of  each  eye.  When  this  is  aceom- 
plished  a  single  mental  impression  is  received— slightly  more  mten.so 
and  with  better  appreciation  of  form  and  perspective  than  is  obtained 
from  one  eye  acting  alone. 


■S^ 


■wwwwrtP 


CIlAriKR    III. 

UEFRACTIVK  KUUOUS  IN  OENKH.Vl. 

Hy   ALKXANDKH  DIANK,  M.D. 

EMMETROPIA  AND  THE  VAEIETIB8  OF  AMETROPIA 

U„KN  ravs  con.inR  fn.in  a  .listant  objert-rays.  that  is.  vsluoh  are 

'" -n"  ';'  ,'il',.i  nm'lio  just  at  tho  iH.st.-ru.r  f..c-us  ,.f  the  eye.    The  eye 
:;::,'.;,;;  ol-ieets,  fomnn.  a  shur,,  i>nape  u^m  t^u.  -  -;^^  •.  ^  .^ 

S.S  t:::::z::si'::  =ri^;^^^.  ^^  ^ays .,.. 

its  retina,  is  railed  em m€<ro/»2a  (L.).     (t»g- •*•»•) 

Fio.  «. 


,f  ,„«  ,.,int  f.'»  the  fundus  i,  illuminated*,  that  it  .end.  <^ujra>,^^^^^  ^^^^,  ^^_  ,.^ 

<  y ..  Hia-p  ,««lng  back  .gain  thn.i«h  Up     ryrt.l.ine  leu.  and  cornea. 

opposed  to  ommetropia  is  the  couaition  i^'»X  ej^"  amX'e^^e 
whi 'll  the  retina  is  not  at  tlu-  ,>ostenor  ocus  of  the    >^' ^J'\;'  f    -, 
..„se,uently  is  not  adjus,.<l   -  t«u^  X>nt'.^'^SXd^tive 
ikf  a  caiiu-ia  OUT  of  lofU.s,  an<l  canmu,  i.-il.,         ..        .  ..hierts 

,.,Ton  or  l.y  the  aid  of  a  .lass,  fonn  ^^\^:^:;l:^'^^!Sn. 
up„n  its  retina.     Ametropia  comprises  the  \  armas  errors  «/     / 
wlii.li  arc  myopia,  hyiK-ropia  antl  astigmatism.  ^^^  ^ 


70 


Tin:  f.Yh:. 


Myopia  iMv.),  or  iitnrsiiihUihuss,  \>  \\v.\\  ctuiilili  m  ill  wliicli  tlic 
n-liiia  lic^  lit'liiml  the  iHistninr  Incus  ..i  \\v  eye  I'lic  eye  tlicii  if* 
likr  a  caiiH-ni  wiiicli  is  nit  of  Incus  Imhwiusc  its  rcciviiif?  plalc  is  tiH. 
far  hack  dl' its  lens.     (I'ijj.  J4.» 


/> 


u 

Tli>;inyn|.io.vi'  cr,  l."i«  rfpresenting  the  mrni>«  hihI  rry«t«lliiii' leu- n(  the  eve  r.>llwtivi-ly, 
>;  Ihe  |.rimi|«l  f.K'U"  i.f  (' C,  .ir  of  Ihu  lye,  lyltiu  In  frolllof  Ihe  retiim  V  .V.  Ki>«  tin..natliiK  fn.m 
»dl»l«i!t  cbjict,  <>  aiKl  hiTioe  |«™IUI  LxiDuaiioth.-r  (l»kiig  Itwomr-'  l>  C.  P  I'l  wh.ii  Ihtj-  rwiih 
Ibci'^o.  iiif  Mm-  i«.1  by  (Tnt  f  In  iMiit  of  the  PctinR.  The  lye  l».  tl.er.r..re.  ii..t  «.tiii»t.-.l  f..r  " 
Tln-(.m."int  by  which  It  In  out  nf  l,xii»-/  (  .  the  ilUwnce  botwwii  /■«n-,  V  -me«i.urt>^,  Iboainaiiiil 
oriiiyo|.lrt. 

Hyperopia, or// ///M^rwWr»i/</Vj  (H.),aisi>  callcii  jursiijlilalm  ■<  xvlonij- 
siiihlt tl fii.^s.  is  that  coiuiitioii  in  wliicii  tiic  retina  lies  in  front  of  the 
|x)sterior  focus  of  llie  eye.  The  eye  tlieri  is  hke  a  camera  vvhicli^is 
out  of  focus  JH-caus*' its  receiving  >late  is  too  close  to  its  lens.   ili^.  I.).i 

Fig.  45. 


Thf  uypeniplc  eye  CC.  lem  repn-sentitiif  the;  cornea  and  orystalline  lens  ccilli'ctivily.  F.  the 
I.nii<-ii«il  l"<-ii-  iif  r  f,  or  of  llie  eye,  ti.hiri(l  the  retina  .V  .V.  Ray?  emanalliiK  from  a  ■liMaiit  object. 
O.  an'l  hence  iwmlU-l  looiic  auoUier  heloreftrikinif  the  eye  (tukiiiit.  Ihenlore.  the  course  /)  C,  D  Ci. 
,vill,  after  refraction  throUKh  V  C,  )»■  converised  t.)»arO  >'.  They  will  hence  slrilie  Ihe  relina  U'fore 
they  come  to  a  f.M'Us.  The  eye  i»,  therefore,  not  ailjusted  for  ().  Tlie  aiuonnl  by  which  it  is  ont  of 
l,«.aji_i  f.,  the  amoiinl  of  Its  hyperopla-l"  nicaBured  by  the  distance  between  .V  .V  ami  F. 

Astigmatism  (As.)  is  that  condition  in  which  tin  several  meridians 
of  till-  e\c  ilitTer  from  each  other  in  refraction,  so  that  larh  will  focus 
parallel  rays  at  a  different  jioint.  Instead,  thei  .  of  there  being  one 
principal  fociiH  for  all  meridians  alike,  as  in  myopia  or  hyiK'ropia, 
there  are  a  numlier  of  foci,  ono  for  each  meridian,  ami  tin  ~e  foci  lie 
one  liehind  the  other.  If  the  focu.-^  for  any  on."  meridian  I,,  j^peiis  iu 
lie  upon  the  retina,  that  meridian  will  he  emmetropic,  while  all  the 
other  meridians  will  he  myopic  or  hyperopic,  Wecause  their  foci  are 
in  front  of  the  retina  or  iM'hind  it.     If  the  retina  lies  hi  fron!  of  all 


%m 


iih:n!.i<Tiyi:  i-:i:iioi!s  i.\  uiskum. 


n 


mi,  iill  ili«-  iiH-ridiiUis  will 
!i,rs ;  :mil  if  the  ri'iinii  li••^  I' 

,^[\\  \h-  MlVLpic.  I»lt  W'll"'  """■'•  ' 

Accommodation.  A*  we  lui\ 
uh,.  wishes  to  f"'<'i>'*  f<""  '»  """"■ 
that  is.  I'V  iiirn'usiiiK  thi'  c.iivfN 


liyiMTopli-,   l>llt    solllf    :!inrc    lllOIl 

ml  all  th<!  fori,  ull  Wv  mcri.lian.s 

11  DtluTs.     (FiR.  52.! 
M'*n\  in  ('hii|)tt'r  H.,  an  eiiuiiftrojjn 
lijt-rt   iliK's  s(i  l>y  acfoiii'iKHliitiMR, 

V  (.f  his  crvstalliiu-  U'ms,  ami  thim 


r:i;;;i,':;s  .-J...  i....,  .i. ..  (n^.  4,.)  -nns .....  a  --.  j^-.  n^. 


„,  ,,  i,,,  fru.n  /'  such  a  .lirecti....  that  the  .-y  (  can  forus  them 
,  T,  ti.  •!  V  V  If  th.-  cvr  ('  i<  onii.ictn.in.- .'«  lias  hc-n  iiia.le 
'?:";;;■!-/  ;  :  i  i^  i^  a.lju-.M  f..r  ,.arall..l  rays  .1  nu«t 
;:;.K;  ;;';:';hat  .liv,-r.e  fr,..i  /•  ,;ar.U.;.  to  o-.  ^uiother.  Hut  ..^^o 
this.  .1  must    have 


,Ui.    I  must   nave  a  f..cal  length..    .1  I'.     Hh.o  the  a,mh.,n,l<^ 
,;./;  r. 7,rr..,«/.<  the  ,vr„mm,.Uitire  effort  that  the  ei,e   makes  „  r.iu>4- 
,       VJn    on.    near    ,^nnt    must    have    a    joa,!    length    e,,oot    to   the 

ZZo    !hot  «</./   Iro.    the  eye.     This  amounts  .,,su>-.nK 

„.at  when  a  patient  a,l,asts  fora  pomt    ^'^^^]'';;if;^^^''^^;Z 
„l,ls  to  his  ,.ve  l)V  aeeoiimio'lative  effort  a  10"  (     D.)  l«n>.  wno 
;:;itl  ■  f!!r  half  that  .listanee.  he  a.Ms  a  U-ns  twice  as  strong:.  e,e. 

Flu    if, 


r  >  .V 


,  ....,,    .,,«r..U.l  r.y,.  m.y  be  ..IJu^e..  for  ^^« "   "'  '  i;',.^,  ^^  °C  ]      Thl,  len.  mu.t  have 
•i.Kth      ,1  R  fiirlbmoiiiy  will  a  n)»li<!        »    .lai  uiv^rig^  ■  r" 

:,  air''.lon  .ha.  .he  len,  C  wlU  >-  w  e  ,o  ru.  •     =  hem  u,«n  .he  re,l..a  >  .N. 

..         f  ..  „     ,„,,,   ,,  wi.itive  nrocoss  i.^  verv  helpful  in 

This  comriition  of  the     vo-   iixiatn.    pro...  iiUif^eil 

,.nn-i.l...iiiK  the  eorn-ction  ot  relractnv  errors.     It  is  so  f-^r    ™  ;' 

„:\;l,  J„.ay,  if  we  wish,  actually  repla^.e  <'>'•  ;;-<-;-;  f^^^ 

,,,.•,.!=  ..f  iu-t  such  an  v.uxiliary  lens,  an.l  thus  a-ljust  the  o>.  t.  r  i  y 

:  ■•        IZ  point.    Thus,  suppose  we  paraly^e  the  a-onunoj^anon 

,   .   .l-telv  in  an  e.nnietrope  with  atropn'-c,  so  that  h.s  cvc  un.u  lo; 

,. :,i  'see  aistinetlv  at  .listanee  only.     Tli.-n    by  placnip  a  .  D   (8  ) 

l,.„s    l„.rorr   his  eye,  wo  at  once    a.ljust   las  **'«'^^  f;^,".f^'J,., 

r,„„,  l,i,M,  .•ui.l  enable  him  torea.l  at  that  -hstance,  just  a.  if  h.  ^^<n. 

;-in<'aii.   ,   ivaletit  amount  of  ac.oinnuxlation 

Vrsin  u.  Ametropia.      Difl^Bion   Images.     An    '"f  7''^^;'  J. """ ^ 

nle  alwavs      .s  in   .Hffusion  images.     To  un.lersta ml   ^^»  '*     'lu. 

Llu^Jh...-  only  to  con«i.ler  what  happens  when  tb.>  ray^ema- 

KUins  from  a  distant  point,  .1  (Fi^-.  47),  strike  an  eye  ^^>'    '    f";  ^J 

..ea.  amount  of  astig.liatisni.     These  ray.,  unpmgmg  u,H.n  the  cor 


7H 


TIIK  KYE. 


II 


Ilea,  arc  coiivcrgod,  tlicn  pass  tliroufrli  the  jmpil  and,  striking  tlic  lens, 
an*  coiivcrjicil  still  niorc.  so  as  finally  to  unite  protty  shari)ly  in  a 
l)oint.  li,  sitiiiitcd  at  the  posterior  focus  of  the  ;'ve.  They  thus  form 
a  conical  or  pyramidal  bundle  whose  base  is  formed  by  the  jjupii 
r.  and  whose  ap(>x  l)V  the  ])oint  li.  The  cross-section  of  this  ))undie 
will  have  tlie  sain(>  siia|H'  as  the  pu])il,  iM'inn;,  therefore,  usually  cir- 
cular, hut,  in  cases  of  irregular  pupil,  heing  oval  or  any  other 
shape,  I). 

In  cnunetropia  the  retina  is  situated  at  the  posterior  focus  of  the 
eye,  iind  will  intersect  th(^  bundle  ('  li  at  K,  where  all  the  rays  of  the 
bundle  unite  in  a  single  point.  Conseciuently,  the  retinal  inuiRC  of 
the  point  .1,  which  image  is  formed  by  the  union  of  the  rays  com- 
ing from  .1  and  forming  the  bundle  ('  li,  is  a  single  sharply  defined 
I)oinf  of  light.  A  distant  object,  Ix-ing  made  up  of  a  s<'rie.s  of 
lM)ints,  such  as  ,1,  will  then  form  upon  the  retina  '.  series  of  sharply 
defined  points  like  li,  each  one  of  which  resembles  its  original  in 
arrangement  and  distinctness.  Henc  the  retinal  image  will  Ix"  a 
true  and  clear  representative  of  the  extenml  object. 


Flii    47. 


-a    ' 


Ditl'usion  imaK^-s.  The  ray«  enittlmtiiit;  from  n  tlisUnt  |K(itit.  A.  pnws  thnuiKh  tho  triangular  pupil 
C  C  C,  and  are  convermHl  to  form  h  pyramidal  bumlle  of  rays,  CH,  V  li.  C II,  unitiDt;  in  a  nharp  iKiint 
At  H  If  Ihi'  rctiim  is  at  .' it'iunu'ln>|>ia).  liii"  itnaKU  of  tlie  iH)int  A  Is  the  |>iilit  /)  If  the  retina  is  at 
1  ihyfieniplal.  the  itnuKe  ot  A  is  the  IriaiiKle  J),  which  Ik  larger  hihI  more  hazy  in  pro|x>rtion  a«  P  lii 
in  Irontuf  H.  If  the  retina  is  at ,)( myopia j,  the  Image  of  .4  i*  the  Inverted  triangle  A".  XJand  /,'arv 
ilill'nHion  linagi^. 


II 


It  will  be  odierwise  in  irnetropia.  Hen-  the  retina  is  either  in 
front  of  li  (in  liy|)e!ii|)ia)  or  behiml  it  (in  m  -•pia).  In  hyperojjia 
the  retina,  intercepting  the  rays  before  they  come  together,  will  have 
formed  upon  it,  as  the  re|)resentative  of  the  point  .1,  a  figure,  I),  of 
the  same  sha])e  as  the  pupil.  It  is  evident  that  the  further  off  1) 
is  from  li — /.  c,  the  greater  tlie  hyiH-ropia— the  larger  l>  will  be,  and 
therefore  th(>  fainter,  too,  since  all  the  light  that  in  emmetropia  is 
concentnited  in  the  one  point  li,  is  now  .scattered  over  a  compara- 
tively large  area. 

."similarly  in  myopia  the  retina,  being  behind  li,  will  have  formed 
upon  it  a  figure,  A',  of  the  .same  sluipe  as  the  pujiil  inverted,  ami  biggei 
and  fainter  in  proportion  to  the  degree  of  the  myopia. 

The  faint,  enlarged  images    I)  and    A',   formed  on   the  retina   ii: 


REFRACTIVE  ERRORS  /.V  GEyERAL. 


:,iiicli()i)ia,  and  rcprrsoiiting  ii  single  point  of  light,  arc  callod  (Inlii- 

siipii  images.'  .,111 

III  astigmatism  tlio  shajK*  of  the  tliffusion  nnagos  will  (l(>]Hni(l  upon 
the  amount  of  ametropia  in  the  different  meridians  and  the  shajM- 
i,i  the  diffusion  images  upon  the  direction  in  which  the  least  ame- 
tropic  meridian  lies.  The  six-eial  varieties  that  occur  will  he  discussed 
later  on. 

In  ametropia  the  retinal  image  of  the  distant  object  will  tje  made 
up  of  t.  series  of  overlapping  diffusion  images,  which  will  more  or  less 
<(infus('  one  another.  Hence  such  an  image  will  Ik-  blurred,  and  the 
more  so  the  greater  the  size  of  the  diffusion  iinagrs. 

The  size  of  the  diffusion  images  is  de[X'n(lent  not  only  on  the  degree 
.,f  the  ametroi)ia,  but  also  on  the  ,vue  of  the  pupil.  For  it  is  evident 
that  the  smaller  the  latter— i.  e.,  the  smaller  the  ba.se  of  the  cone 
(■  /i_tlie  smaller  will  l)e  the  sections  D  and  E.  This  sho\ys  us  why 
ill  aiiietropes.  and  likewise  in  presbyojH's,  who  for  objects  within  their 
near  point  also  see  in  diffusion  images,  vision  with  contracted  pupils 
is  much  A\iiT\yoT  than  when  the  pupils  are  dilated.  Indeed,  an  ame- 
trope  of  even  high  degree,  provided  his  visual  [)erception  is  intact, 
will  see  iiearlv  as  well  ivs  an  etnmetroj)e,  if  only  his  pupil  is  contracted 
ail  vKiximiini  or  is  made  artificially  small  by  the  use  of  a  pinhole 
isteiioixeic  aiM-rture).^  This  fact  is  utilized  when  in  t"sting  a  patient 
we  wish  to  asce.tain  whether  he  s<>es  jioorly  l)ecause  we  have  not  yet 
given  him  the  proper  glass,  or  because,  owing  to  some  imperfection 
of  the  media,  n-tina,  or  nerve,  the  seehig  power  itself  is  impaired. 
Ill  the  former  ca.s<<  the  pinhole  will  imt)rove  the  sight,  in  the  latter 
cnse  it  will  not.' 

It  is  for  this  rea.son,  also,  that  inyoi)es  try  to  improve  their  sight 
by  s(iueeziiig  their  lids  together.  This  in  effect  narrows  their  natu- 
rally wide  put;ils  and  gives  them  smaller  liffusion  images.  Hyj)eropes, 
wiio  JKive  n.iturally  small  pupils,  and  who  besides  can  get  around  their 
.li!liculty  oy  using  their  accommodation,  generally  do  not  need  to 
riiii)l(iv  this  device. 

I"()i  this  r<>ason,  also,  the  vision  in  ametropia  is  usually  worse  m  a 
iim  light,  whe:i  the  juiihIs  dilate.  And  many  ametroiu's  and  pres- 
livopes  secure  good  vision  by  •  nng  a  strong  light  which  falls  directly 
ii'lioii  the  eves,  and  s<i  contracts  the  pupils  to  pinpoint**. 

Hcsuining,  we  mav  say:  hi  (imctmpin  the  retinal  immje  of  a  distant 
IKinil  irill  he  a  (liffu.voi,  (maqe  whose  .v/iri/x-  viU  he  the  shafie  of  the  pujril. 
n„<l  irh,,.:'  si:e  will  he  (iireithj  jn-nimrtiomil  to  the  deifree  of  ametropia  on 
Ihc  one  hand  and  to  the  size  of  the  pupil  on  the  other. 

The  resultinn  hlurrimj  of  sight  will  be  directly  irrojiortimuil  to  the  sue 
iij  tin  diffusion  images. 

>  !  .uHlly  c«llu<l  .UffuMm  eirrlet:  but,  lui  pointod  nut.  v  hllc  Ke.iemlly  circul.r.  Ihey  m.y  hav«  «nv 
-h.i|v.  ilcjionililiit  upon  the  i.hH|io  i.f  the  pupil. 

^  s..ni..  of  the  ilrst  si«M  lacles  were  nolhli.K  hut  pinhole  »iHTtuiv«  In  raeul  plates.  W  "h  the-e  -i 
:  .\..|«.  cnilil  a-e  ilWltielly  at  a  (ligtanoe.  ami  a  pii'Hbyope  could  rea<l. 

'  TheuretieHlly  :  h»t.  an  a  raatler  of  fact,  the  pinhole  eiH.  off  so  much  Mght  that  the  tfit  If  not  a 
wry  ^.  rvitsjHlile  <>iie. 


80 


THE  EYE. 


'}  ; .  i 


K. 


Correction  of  Ametropia.  To  obviate  this  hlurriiig  and  onabl(>  the 
ainctn.pc  to  s«'(-  jx-rfcctlv  :it  a  distance,  \v(>  must  in  some  way  abolish 
his  aim'troi)ia.  This  is  effected  sometimes  by  the  aecommoibtion, 
som.'tinu's  1)V  tlic  use  of  glasses.  However  etiecte.l,  tlie  eorn-etioii 
pra(  liealiy  eoiiverts  the  ametrojK'  into  an  einmetroiM-,  and  he  sliould 
.see  Hke  one  i)oth  for  distance  and  near. 

Myopia.  Far  Point  in  Myopia.  Tlie  inyojx',  as  we  have  just  re- 
marived.  sees  a  distant  ol)ject  in  <liffusion  images.  Such  objects, 
therefore,  apiH'ar  blurred  to  him,  and  the  more  so  the  iiiglier  his 

mvopia. 

Hut  while  tiie  mvoix-  .sws  poorly  for  distance,  he  s<'es  well  tor  near. 
For  if  the  eve  is  such  that  parallel  rays  enti-rngit  focus  at  F  in  tront 
of  the  retiiia  (Fig.  44),  rays  that  <liverge  from  some  comparatively 
near  point,  R,  will  focus  back  of  F,  and,  if  F  is  sutficiently  near  the 
eve,  will  focus  right  upon  .V  .V.  Tl "  :  ye,  in  fact,  is  like  a  cainera 
w-hich  is  adjust«l  not  for  distance-,  "nit  tor  tlu>  luarer object  R.  It  is 
practically  in  the  same  condition  as  the  acconmiodatingeye  (hig.  46), 
and  like  the  latter,  mav  be  regarded  as  ecjuivalent  to  an  emmetropic 
eye  to  wiiich  a  convex  lens  has  been  added.  (Fig.  48.)  Such  a  con- 
no.  4H. 


The  myopic  eye  conridered  as  an  f!mmetr.>pic  eye.  with  n  convex  lena  K.l.le.!  The  myopic  e>e 
„my  be  regarded  w  an  emmetropic  eye,  E.  with  a  onve.  lens,  M.  representiuK  the  myop.a  added 
Suit.  H  lens  win  collect  ray.  coming  fn.m  its  f.Kus,  K.  and  render  them  p.irallel.  when  h.  the 
emmetropic  portion  ol  the  eye.  will  fiKos  them  ui.m  the  retina.  .V  .V,  The  eye  is  thus,  by  it.  exj^ew 
of  refraction  (r,>pn«.nte,i  bv  the  lens  ill.  nalnrally  adjnst.-.!  for  a  point.  R,  which  is.  therefore. 
Us  far  |,.lnt  The  focal  length  of  .If  -  -If  K-i  '  .  the  amount  of  extra  refraction  pro.lnccd  by  the 
myopia  -i.  e,|ulvalent  to  a  convex  lens  whose  liKial  length  equals  the  distance  of  the  Idr  point  from 
the  eye. 

ception  of  mvopia,  while  not  absolutely  accurate,  is  yet  essentially 
mi  and  is  so 'far  justified  in  that  we  can  imitate  ([mte  i)reci.-<ely  the 
conditions  of  .1  mvopic  ev  1)V  acHially  placing  an  apiiropnatc  convex 
glas>  before  an  emmetropic  eve.  Thus  if  an  emnielniiH'  wish  .->  to 
hav(>  an  idea  of  how  a  mvo|)e  of  S  D.  sees,  let  him  |)iace  an  S  1) 
conv.'X  glass  before  his  own  eve.  Distant  obj.-cts  will  at  once  apijeai 
altogetlicr  blurred  and  indistinguisliMble,  being  s(>(ii  ,<iin|)ly  in  outline 
or  only  as  a  unifonn  blotch  of  bhiek  and  while '  while  objects  jusi 
within'  ."/will  ai)i)ear  not  only  disthict,  Init  iilsu  magiiitied.  and 
fiirtheniinrc  will  be  «een  without  accoiiiincMlative  strain. 

Ill   fart,  so  far  as  vision  is  .  oiiceriied.   it   makes  little  difference 
wlirtlicroiieiseuntiiiuoiislvusing2n.ofhi-:Mromm.nl;tti.iii(Fig.  4()V 

(,r  i,.i<  .•!  +  ■-'  1).  glass  before  his  eye  and  u.ses  ii<i  accoiniiiodation,  oi 


HEFHAVriVE  ERRORS  IX  GESERAL. 


81 


is  myopic 


1)  ( Fig  4S  )  In  each  instaiico  he  will  ho  adjust^'d  for 
.,  ,lisfuicc  of  20";  at  this  distaiioe  ho  will  sco  clearly,  aiul  iM'yond  it 
will'seo  indistinctly,  In-cause  lu-  sc.-s  in  diffusion  ""»««';:• 

'rhi<  surplus  of  refractive  power,  or  extra  lens,  M  (Imr.  4S),  thai 

,  ,nvo„,-  possesses  ..ver  and  above  an  e.ninetro).e,  is  the  nu.us.ire  of 

ii  p  a.     It  also  gives  us  .lirectly  the  point  for  which  his  eye  is 

I  IjusUM    without  th..  exercise  of  any  .-ffort  ol  f '•<''";""' •f"'"7V,;;; 

;  V.  s  us  hisA,r  ,m„t.     For  if  R  is  the  far  point,  the.  -^^  and  A  together 

will  focus  upon  -V  .V  ravs  that  emanate^  fron.  It.      Hut   to  do  this, 

;   n make  these  ray^  parallel,  for  then  K,  the  emmetropic  qu<.ta 

;!  r.^-e  which  is  adjiilted  for  parallel  rays,  will  f-- ^^^  l-;j;;^- 

If   howVver   }i  is  a  lens  that  ren.lers  rays  coming  from  It  parallel, 

'n  ust  he  is  principal  (anterior)  focus.     That  is,  the  mm>trp,e  may 

,,^,L'ute.n,.  e,uirale^>t  to  an   .^wetropic  e„e  to  vinch  ha.  hen 

Ma  rourrs  ,,laJ harin,,  such  a  strength  that  U.  imncipal  focus  wM 

lie  prmsdij  at  the  far  jmni  of  the  eye. 

Flu.  49. 


.  >c     Ktt>8  II  (,,  A  (.  M.Mrm  K  .n'  •  ''  iiluminaled  b.hI  sei.^ls  oul  ni>».  A  t, 

,..  principle  of  .n„J,.i.-«le  fm-l  u„.l  w.M  •"'."  here  ..  n«l  '"^^'^f'-'.^  ";,,,,  ;,  ,..,  ^  „„|  g,ve 
pKrailel  my,,  /'  /..  /'  /..  k  ,liv,.,^-,.n«  as  if.h.y  .-nine  r.™  f;"  '  '  ,7^'',  „  '!  ."J^,  ,„,„  «  ,„  i,e 
, :,.,  p,H.*.    A-  U  hence  th.  pri„ci,«,  f.H-n,  of  f-^;-J-«';X ;--;■*••  «'"  •'"-  '"  '-  "'  * 

correction  of  Myopia  The  foregoing  r"'""^;';;;^.  ';;!;'';':;:;.i!:;\  t 
,„„,,.  ^„  ,„„luce  the  way  to  correct  myopia.  '  ';' "  "  . ,  .^le,  s 
,„  excess  „f  refractive  power,  such  as  is  represei  te.  h>  a  <onx(  x  u  lis, 
;     "  vill  h;.nnec,ed'hy  a  glass  that  will  I-'-f'^  ''- -J=^"  ^T 

;::r;rti-l;;- 

it   M,n<t   •idiust   the  eve  for  t.andlel  nivs.      .\s,  ho«e\tr,  '  '(    i  .y    • 
,     ;  ;'  iiUtl'l  for  rays  Ih.t  are  already  -ii-'-'^'-^'^Vmu  ?  1^ 
for  r,vs-  I{  r,  R  ('.  divrging  fn.n>  R,  the  e..r.rct.ng  gias^.  /•• '""^     J 
sueh  t  \o  nmke  parallel  rays  diverge  as  if  they  came  from  R.     Su.h 


83 


TIIK  EYE. 


a  glass  must  Ix'  a  concave  lens,  and  its  focus  must  be  at  R.  We  see, 
tliercfore,  that  the  i/lfi.-<s  which  rtirrerts  the  mijojiia  aj  an  ajc  miiM  be 
a  conanc  Icn.s  whose  focus  is  at  the  far  point  of  that  eije. 

.Myopia  is  usually  measured  hy  the  strength  of  the  j;lass  that  cor- 
rects it.  Thus  we  speak  of  a  myopia  of  4  1).,  meaning  an  eye  whose 
correcting  lens  is  a  —  4  D.,  ai.  I  hose  far  point  conswiuentiv  is  about 
!()"  in  front  of  the  eye.'  ^ 

The  efficiency  of  a  glass  in  correcting  mvopia  will  vary  somewhat 
acconhng  to  tho  distance  of  the  gla.^^s  from  the  eve.  For,  no  matter 
where  the  corivcting  (;la.ss  L  is  situated,  it  must  have  its  focus  at 
/(■,  the  far  point  of  the  eye,  in  order  to  give  parallel  ravs  the  proper 
direction  for  the  eye  to  focus  them.  If,  then,  /.  is  pushed  away  from 
the  eye,  say  to  L',  its  focal  length,  instead  of  being  R  L,  it  will'ln'  the 
shorter  distance  R  L'—i.  e.,  it  will  hav<>  to  be  a  lens  of  shorter  focus, 
that  i.s,  of  greater  power,  in  order  to  do  the  same  work.  For  instance, 
if  a  givii)  myopia  is  corrected  by  a  glass  of—  10  D.  ( -  4"  focal 
length)  place<l  J"  from  the  cornea,  it  will  need  a  glass  of  SJ"  focal 
length  (=  11..')  J).)  to  correct  the  myopia  when  the  glass  i.s" placed 
r  trom  the  coriien.  That  is,  what  would  be  a  projier  correcting  glass 
if^ placed  \"  from  the  r-ye,  luis  ijccome  l..')0  D.  too  weak  when  shoved 
V'  further  away.  \\'(!  sw,  then,  that  the  strength  of  a  concave 
y!ass~t.  e.,  its  ahili/;/  to  omrt  uinojnn—is lessened  if  the  i/lass  is  carried 
away  from  the  ei/c,  and  is  increased  if  the  (/lass  is  hrouqht  neanr  the 
e?yc.  This  is  true  whether  the  concave  glass  is  used  f(')r  distance  or 
for  near.  As  will  be  seen  from  the  above  example,  the  differe  ice 
produced  in  this  way  with  strong  glasses  is  considerable. 

It  IS  for  this  reason  ihat  we  see  personswho.se  gla.s.se'  do  not  fully 
correct  their  iiiynpja  pushing  the  gla.s.ses  close  in  against  their  eve- 
h.ls  111  order  to  .>('.'  .listiiietly  at  a  distance.  They  thus  in  cfTl'ct 
increase  the  effect  of  their  glas.ses. 

Accommodation  in  Myopia.  Near  Point.  The  nivope  can,  without 
using  .•my  ;i.ci.iniii.idali.iii  mI  all,  see  distiiictlv  an  object  situated 
comp;iiatively  near  him,  namely,  at  his  far  point.  He  can  still, 
tliirelore.  see  c|uite  iie;ir  obje.'t.v  sharjjly,  even  if  his  accommodation 
IS  paraly/e.l  witli  atrnpine.  |f,  |„.wever.  he  uses  his  accommodation, 
he  can  focus  down  upon  |M.iiits  still  nearer.  When  he  uses  all  lii.s 
.icc<iiiiiiiMdati(m  his  eye  is  adjiist.Ml  for  his  near  jmint.  Obviously 
this  will  i)e  nearer  to  his  eye  thai,  is  the  near  point  of  an  emmetrope 
having  an  ei|iijd  amount  of  accomiiioilatioii.  Thus  an  emmetrope 
having  t  I).  ,,f  accommodation  can,  i)v  using  the  utmost  accommo- 
dalive  eftoil.  see  an  object  situated  10"  from  his  evi'.  A  myope 
of  }  1).  uill  be  able  to  see  in  object  at  this  di.stance 'without  lisiiif 
any  ;i(e,.iii,no,iation  at  all:  and  if  he  does  use  4  D.  of  accc.mmo'^ 
'ImIioii  111  addition,  he  will  be  able  to  see  an  object  at  .V  from  the 
eye.     I'or.  as  cnnipared   with   the  einnielroi)e,  who  in   using  all  his 

'  TiK-  «tH(einciu  i»  iM,t  ,|iiili.  ur.unik'  i(,  «i.  Mi.iiil.l  proiiTl.v  l».  .i,,,,,..  thcdiMano-of  tl».  fur  |«,iiit 
i-n.ck.,,,...!,  „ni  .„„,.  ihf  i-Hiit  where  the  glau  1»  ,„„«|iy  placed,  but  In.in  ihe  n.Ki.l  ,«int  oC  the 
t'ye.  wliifh  iHHii  iTu'h  firnht-r  hark. 


HEFRAt'TlVE  EllRORS  /.V  llEyEHAL. 


«3 


iccoiiirnodatioii  lias  in  offoct  placed  a  +4  1).  glass  before  his  eye. 
he  is  like  a  person  who  has  a  +4  1).  jjlass  ( represent inji  (lie  surplus  of 
icfiactioii  ilue  to  his  myopia)  eoiuhiued  with  another  +4  1).  glass 
icprcsciitinp  his  aeconunodation)— (.  f.,  lie  is  in  eti'ect  an  eninie- 
troi«'  with  a  +S  I),  glass  before  his  eye,  or  an  eiiinietroi)e  who  is 
nAuii  S  I),  of  aeeoniinodation. 

A^'niyoiM's  rannc  nf  distinct  ri.siou  is  obviously  very  limited,  even 
when  the  nearsightedness  is  of  low  degree.  Thus  a  myope  of  2  I). 
wiio  has  ()  1).  of  aeeommodation,  and  has.  therefore,  a  far  jxiint  at 
'()"  and  a  near  point  at  5",  can  see  distinctly  tiirough  a  range 
of  only  15".  The  higher  the  myopia  the  more  this  range  diminishes, 
and  in  fairlv  high  degrees  it  tecomes  jjractically  ?til.  Thus  a  myope 
i,l  10  1).  with  an  accommodation  of  6  D.  would  have  a  range  of  only 
1..")"  (from  his  far  jioint  at  4"  down  to  his  near  point  at  2.5"). 

Some  conii)ensation  for  this  limited  range  is  found  in  the  fact  that 
a  myope  in  doing  near  work  is  partly  or  wholly  indi']>enfhnt  of  his 
iicconnmiliilion.    Thus  a  myoj)e  of  4  D.,  as  he  sees  distinctly  at  a 
disiance  of  10"  without  using  any  accommodation,  will  never  need 
to  have  a  gla.ss  for  reading,  no  matter  how  old  he  becomes.     A  myope 
of  even  2  I),  will  not  nee<l  to  use  glasses  for  reading  nearly  so  soon  as 
an  enimetroiM'  will.     For,  while  tlie  latter  usually  has  to  get  glasses 
when  his  accommodation  is  reduced  to  4  D.,  or  when  he  is  about 
torty-three  years  old.  the  myope  of  2  D.  will  not  have  to  get  a  glass 
until  his  accommodaticm  is  reduced  to  about  1.5  l).—/.c.,  at  the  age 
of  tifty-fivc   years.      For  the  same  rea.son  we  can  u.^e  atropine  or 
h<miatroi)ine  in  ihvojk-s  with  considerable  freedom,  as  we  can  assure 
Ihcin  that  the  instillation,  even  though    it    does  abolish  the  acconi- 
tiKHJation,  will  cans*'  them  little  or  no  interference  with  near  work. 
\s  nivoiH>s,  and  particularly  nivoin-s  of  fairly  high  degree,  need  to 
u-e  dieir  acconimo<lation  so  little,  they  have  not  the  same  facility 
ill  this  regard  as  enmietrojies  and  hyiK>rmet ropes.     When,  however 
uc  correct  a  nivoiM"  we  convert  him  suddenly  into  an  emnietrope,  and 
i„.  has  to  accommodate  like  one.     Naturally  this  sudden  .•issumi)tion 
ni  an  almost  disused  facultv  is  not  easy  for  many,  and.  indeed,  most 
invuiM's  fin.l  dillicultyat  first  in  using  their  glas.ses  for  near  work. 
Thr  older  the  j.atient,  the  more  pronounced  this  difhculty  is.     It  is 
a^iunisiiiiig.  however,  with   what   ease  most   myopes  reac(iuire   this 
aliility  to  use  their  accommodation,  many   doing  so  at   once,  and 
nrarlv  all  <loing  so  in  a  verv  short  time.     When,  however,  the  near- 
M-^lit' exceeds  12  D..  we  fre(iuentlv  hnd  that  the  myoiM-.  especially 
,1  he  is  of  .adult  age  and  has  not  used  suitable  correcting  glasses, 
:i!!!i.>t   even  ;!fter  persistent  etfort.  learn  to  use  as  strong  a  glass  for 
■I.  ar  as  for  distance.     In  these  cases  the  accommodative  faculty  is 
Hinally   lacking,   and   this   is  due.   as  anatomical   researches   have 
-hnwii."  to  Mtrophv  of  the  ciliarv  muscle. 

Ill  itivopia  of  low  degree  the  accommodation  is  usually  «iuite  .ictive. 
,11.!  ina'v  often,  indeed,  act  rj-ccssiirhi.  producing  an  apiiarent  exag- 
.  latinil  of  tiie  ne:irsight.    The  accommodative  etTort.  in  olher  wonls. 


84 


THE  EYE. 


will  cause  an  cxrossivo  liuijiiiig  of  the  crystalline  ions,  and  tlius  add 
just  s<)  much  to  the  rcl"iacliv('  power  of  the  eye.  already  too  Ki't'at. 
Tills  factitious  or  accoininodative  myopia,  pniduccd  i)y  spasm  of 
accommodation,  will  he  considered  later.  (See  under  "N'arietie.s  of 
Myopia.") 

One  effect  <  '  .■■  iii.s  •>  of  accommodation  in  myo|iia  is  to  produce 
an  nrcomnio...,  i.  runrvnjvnrf-insiijfirH'urii,  or  exoj)horia,  wliicli  may 
develop  into  a  n  ;ular  ■'  .-erRent  .scpiint,  which  at  first  is  periodic 
I  marked  onlv  for    -i  '  ' 


Its  mcipiency  ;i  (U\ 
l)y  the  u.se  of  cone, 
accommodation,  ani 

Varieties  and  Cat< 
eVP  as  an  emmet     . 


ifterward  constant.  An  e.\()|;lioria,  and  in 
.sipiint,  having  this  origin  may  he  corrected 
.lasses,  which  com|)el  the  patient  to  use  his 
nee  also  to  converf^e. 
>n  of  Myopia.  We  have  regarded  the  myopic 
;  <'ye  with  a  surplus  of  refractive  |M)wer  added 
to  it.  Tliis  is  true  of  many  ca.sf>s.  Tliat  is,  in  these  ca.ses  the  eye 
is  of  normal  lenjitli,  hut  the  cornea  or  lens  has  its  refractive  pow'er 
increased,  so  that  the  two  together  focus  too  strongly  or  hring  the 
rays  together  too  soon.  This  overplus  of  refracti%-e  power  may  he 
due  to  excessive  hulging  of  tlie  surfaces  of  tlie  ct)rnea  or  lens 
(curvature  myopia),  or  to  changes  in  the  density  of  the  lens,  cornea, 
or  a(|ueous,  altering  their  index  of  refraction  (index  myopia).  In 
mi)st  cases  of  myopia,  however,  the  cornea  and  lens  are  of  nearlv 
normal  curvature  and  density,  the  eye  heing  myopic  simply  1«>- 
cause  it  is  too  long,  .so  that  the  rays,  although  normally  focused, 
come  together  in  front  of  the  retina  (axial  myo|)iu). 

.\  transient  ciirraturc  mj/opia  is  produced  in  what  we  call  .'ipa.sm 
of  accommodation:  when  the  patient,  hy  excessive  use  of  his  accom- 
modation, temporarily  increases  the  curvature  of  his  crystalline  lens 
ahove  the  proper  amount.  This  (ircommitihiliiT  ini/ojiia  mav  happen 
( I)  as  the  result  of  excessive  near  work :  or  (2)  from  the  ert'ort  Of  trving 
to  see  hy  a  poor  light;  or  (;^  of  trying  to, see  when  the  sight  is  ohsciired 
hy  an  opacity  of  the  cornea  or  lens.  It  may  also  (4)  result  from  the 
effort  to  see  more  distinctly  in  astigmati.sm,  and  ('>)  it  freipiently  is 
pro(luced  hy  the  elTort  of  accommodation  exjiended  in  overcoming  a 
concave  glass.  .\n  emmetrope  or  a  hypermetrope  with  good  accom- 
modation can  see  as  well  with  a  — 1  I).  gla.ss  as  without  it,  hecause 
he  almost  immediately  contracts  his  cili;iry  mu.scle,  hulges  out  his 
crystalline  lens.  ;ind  thus  gives  his  eye  an  jidditional  refractive  [Miwer 
<if  1  I).,  which,  acting  like  a  convex  lens  of  that  strength,  neutralizes 
the  concave  glass.  My  a  similar  |)rocess  a  man  who  i.s  actually  mvopic 
1   1).  will  .see  MS  well  with  a       2  I),  as  with  .a  -1   I),  glass." 

The  <p.'isinodic  coiitr.iclion  of  the  ciliary  muscle  hy  which  ;i  man 
may  tlius  appju-enlly  increase  his  myopia  if  he  is  really  myopic,  or 
simulate  .a  myopia  wIh'M  he  is  .ictually  emmetropic  or  hyperopic,  is 
callecl  sj)ii!<tii  ()/  nirtDintidddtiiiii.  It  may  he  transient  or  last  for  a 
considerahle    period — years    even —according    as    the    cau.ses    which 

'  And  evou  If  nl  several  yt'tirs'  stumlliig. 


UEFHAVllVE  KHRORS  IN  (lESERAL. 


85 


In,...  ii  ire  transitorv  or  iM-niiiimMit.     Hoinatropinc,  or,  in  tht-  cius*. 
'r   p.'r'UH.t  sp!;>!m,atn,inn..,  n-p.-afMlly  inslill.-.l  will  abolish  th.- 
.  ,.;.,n,Hli<-  .■..ntractioi.  of  tlH>  muscle  a.i..l  with  it  the  TactiMous  myopia. 
'Y\{^<  m.nt.s  of  .lianiiosis  should  always  be  e.uployeil  when  there  is  a 
.,i<i,lci..n  of  <pasin  of  a.>eoniino.lation,  au.l,  as  ex|K-rience  shows  us 
,l,.,t  ii,  people  below  fortv-Hve  years  of  age  a  spanii  of  this  sort  very 
,;„,urntlv  exists,  it    is   itniK.rtant    to   use   hoinatropiue  or  atropin<> 
,    L-.T  we  ean  in  our  .•xaniinati..n  of  the  refraction.     ( )th.Twise  we 
Inll  ofl.'i.  .-stiniate  the  myopia  too  liiRh  or  the  hy|K'ropia  too  low. 
S.e  remarks  upon  "The  Tso  of  Cydoplegics."  later  on.) 
■  rcnnnmHl  nm-nlurc  m!io,m  is  usually  .lepen.lont  upon  structural 
,,,„„„..   in   the  cornea  or  lens,  due  to  .lis.-ase.     I'.xamples  are  the 
..n-oiTia  of  .■onical  cornea  and  that  associated  with  many  opac.tM"^ 
!  nllc  corn..a.  and  tlu.  nivopia  produced  by  a  crystahne  lens  which 
1.  dislocuted  an.l,  beiiiR  thus  freed  from  the  tension  of  its  suspensory 
li-nmeni  bulges  out  l.ecaus.M,f  its  own  elasticity.     Permanent  curva- 
,uv  myopia  is  a.ssociated  almost  always  with  astigmatism,  olten  of 

till'  irre"ular  variety.  .      ...      ■       , 

\M  ..Campl.^  of  in,lc.c  mnopin  is  that  often  occurring  m  the  .levelop- 
,„;.,;,  „,■  ,,uaract,  wh.-n  the  lens,  owing  to  alterations  in  .ts.len.sity,  and 
.  ridlv  to  sclerosis  of  its  nucleus,  l,ecomes  m..re  r.'tractive.  This 
„  vopia.'which  may  aniomit  to  several  dioptres,  is  olton  also  asso- 
I'i'u.'d  with  astiRinatism,  as  the  increas,-  in  .lens.ty  d.M^s  not  take 
,,|.„r  in  all  parts  of  the  lens  to  the  same  dejiree 
'  '  .  a, Jient  myopia  often  .leyelopin|,  in  iritis'  is  held  by  s.,nH^ 
„.  .  an  example  "f  in<l<'X  "'vopia  the  increas,-  in  refract, ve-.^r 
l„.i„.  attribut.'l  to  increased  density  of  the  a.|ue,.us.  Tt  is  doubtful, 
however,  whether  this  explanation  is  v.did. 

[rial  ,w,"pin  is  by  far  the  most  common  variety.     It  is  due    < 

ti,c -^radind  elon,ati;,n  of   the  eye  which  "I""-  "';';;  '7'' ,?^ 

„,  vmith   and  which  causes  a  jira.lual  recession  of  tu-  letu.a.        us 

. ,  '^s    c curri.m^  normally  in  all  eyes,  occurs  excess,v..ly  m  le.vo  .e.-j, 

as  it  y   's  on.  tends  I  make  them  more  and  more  nearsi.hte.L 

I'v'.;;'  millimetre  of  such  n-cession  corresponds  to  an  increase  of  about 

'  TluM-lIln-'a^olfi;  myopia  affects  almost  oxclusively  .he  ba.k  part 
,,,  Ve y  "v  cli  10S.-S-  its  gh.bular  form  and  bulges  out  m  the  fj.rm 
.  V2  '  Tl  e".  '  of  this  egg-shaiH".l  fiR^re  lies  about  at  the  yellow 
;  -u;:!  the  parts  in  the  vicinity  of  the  latter  consequen  ly  suffer 
,!;;;';.::;;' fnlm'the  stretching  produced  by  the  ••'"XluU  clnng  " 
■Il„.  ■,.>rt^  in  front  of  the  lens,  on  the  contrary,  suffer  little  ( hange, 
' !;:  ..!:;„:;  n',ai;:in;;ts  curvature,  and  the  anterior  chamber  its  normal 

''VL.,.,„  l,.r  tins  erresxive  elongation  of  the  back  I^'-J^f^'-lj^! 

,1...  reason,  that  is,  for  the  development  and  P'-^^^;''    '     '  ^use 

h,.s  no.  been  .satisfactorily  determined.    There  must  bo  some  cause. 


AmouDling  wmellme*  to  2  D.  or  more. 


86 


TllK  EYE. 


I'itluT  cxtcriiiil  force  or  internal  pressure,  actinj;  to  ilisten.l  the  haek 
of  tlie  eyehall.  This  eaiise  lias  been  variously  eonsidered  to  lie  the 
pressure  of  the  external  iniiseles,  es|M'eiaily  the  ol)li(|Ues,  uiuhie 
aeeoiniModative  action,  the  traction  of  the  optic  nerve,  etc 

Whatever  the  cause,  it  is  held  usually  to  he  one  that  is  particu- 
larly active  when  the  i //c.v  arc  iisvd  Jiir  t«iir  irnrk.  Statistics  are  forth- 
coininj;  in  aliiindatice  which  seem  to  show  that  myopia  increases /«;/•( 
/w/.v.si(  with  the  amount  and  c((niplexity  of  the  work  to  which  the  eyes 
are  suhjecteil.  Thus  it  has  Iwen  made  (|uite  certain  that  mvopia  is 
of  lowir  de>iri'e  ami  also  less  prevalent  in  the  lower  schools'than  it 
is  in  the  higher  s<'ho()ls  and  in  the  collejr,.s:  aiid  the  inf'Tence  lias 
heen  drawn  that  the  myopia  results  in  the  lirst  instance  from  the 
moderate  apjilication  of  the  eyes  in  the  lower  sciioois,  and  is  then 
eiihaiici'il  l.y  the  further  and  jireaier  strain  imposed  upon  the  eyes 
hy  the  more  complex  work  (,f  the  higher  schools.  This  inference, 
althoufrh  i)erhaps,  in  part,  corrcM.  i.s  not  really  warrante.l  hy  the 
statistics,  for  myopia,  heinn  a  profjressive  alTection.  ,ind  itu  reasing 
naliually  with  ajje,  would  of  necessity  he  more  frequeiil  and  of  hijrher 
gnide  in  the  older  pupils,  wiiether  they  use.l  their  eyes  for  near  work 
or  not.  .Moreover,  it  is  <|uite  fre(|uently  tlie  ca.se  that  mvopia,  e.s|M'- 
cially  myopia  of  hijih  degree  and  rapid  progress,  develops  in  tiiosewho 
do  not  use  their  eyes  for  near  work  at  all.  Thus  it  is  fairlv  coimnon 
in  peasants  who  lead  an  (,ut-of-door  life  and  who  camuif  read  nor 
write.  The  influence,  then,  of  near  work  in  pro(hiciiig  myopia,  although 
undoubtedly  markecl,  has  probably  been  considerably  "overrated. 

In  any  case,  the  use  of  the  eyes  for  near  work  is  not  the  sole  cau.sp 
of  myopia.  It  is  :it  most  tlie  vxcitiiuj  cause.  For  of  two  childn'n 
of  the  same  age,  and  both  subjected  to  the  .same  kind  of  work  in  the 
same  school,  one  will  become  nearsighted,  and  the  other  will  remain 
hyperopic  or  become  simply  emmetropic.  Their  .-mst  be  some  /w- 
ilisjm.'^iHii  aiHsr  acting  in  the  former  ca.se  to  pniduc  the  myo|)ia. 
.\ssuch  jiredisposinir  c.-iuse^^  l-.r,.  |,,.,.ii  alleged  t}u-  shape  (..'  the  orbit 
(a  low.  broad  o.bit  being  s'lpposed  to  favor  the  development  of 
myopia  i.  ;ibii..nnai  i  isertion  of  the  external  mu.scles,  especially  of  the 
obli(|Ues,  insullliieiHy  of  the  iiiterni,  etc.  .\  more  importaiit  cau.s(> 
piobably  than  any  of  these  is  a  n.alural  distensibility  of  iho  back  of 
the  eye.  allowing  it  to  recede  under  the  influence  of  even  a  normal 
pressure.  Whatever  the  predisjiosing  causes  .-ire,  tliev  .seem  lo  be 
nilirrilrd.  for  myopi.a.  .and  p.irticul.arly  the  raphlly  progressive  form 
of  It.  tends  to  run  in  families,  ("oiisanguinity  in  the  jKireiiis  also 
seems  to  have  -omi'  t  Itecl  in  producing  it. 

Complications  of  Myop;a.  Myojii;!  is  associated  (|uit.'  frefjueiitly 
with  ••oinplic.ations  of  the  fundus.  The  chief  of  these  are  the  so-callei| 
crescent  or  coiiiis;  rarefaction  and  other  degenenitive  changes  of  the 
'•lioioid,  gronpeil  under  tiie  name  of  sdero-choroiilitis  posteririr:  actual 
central  choroiditis:  lieinnrriia,!r(  s  ii  <!.•  choroid  or  retina:  the  formation 
of  a  black  .spot,  probably  due  to  piument  proliferation  in  the  macul.a 
liitea:  and  detachment  of  tlie  relit, ,i. 


REFllAtriVK  ERRORS  l.\  (iEXERAL. 


87 


f)f  till-  <•(»/(.'/.• 
I'iisl,  tliir   i; 


pap 

tlli'l.t    (IKHI-flnSllK 


ilirt'i'  v;iri('tirs  may  Im-  (listiiifiuislicd  : 
tln'  .■oiijicriilal  form,  skirling  the  lnwcr  bf)r(lt'r<)f  the 
tributcd  Ui  an  ain'^t  of  dovclop- 


Tlii-i  viirit'iv,  wliicli  is  at 
1 


OCIM 

iiiav 


tliru 


_ the  fipial  fissuri-),  is  usually  associated  with 

I'tc'dcuri"'  i«l'  iiivopia  and  aslinniatisiii,  altliouuli  it  "ft<'»  :»!'«' 
irs  ill  hyi  cropic  eves,     'llic  myopia  ioiiiid  with  a  conncnital  (•oml^ 


)(•  pvo^rcssi^c,  ailhoutjh  in  many  cas.'s  it   remains  stationary 


iifiii 


(I  the  (-onus  inferior  as  sui 


h  lias  no  .-iKTial  sinniti- 


caiiee  in  in(h(alm(;  an  ai 


Ivaiiee  of  tiie  myiii)ia 


The  second  i'onii  of  coiius  occurs  as  a  ino< 


hni 


,„•>.•,.„■ lerately  hirp',  sharply  de- 

1  white  crescent,  skirting  the  temporal,  or,  more  rarely,  the  nasal, 
■if  the  disk      It  mav  Ik-  coiiilmied  with  the  inferior  conus,  or  it 

the 


iii.iv  ehcroac 


■h  on  the  u'p|M'r  border  of  the  disk.     This  form  is 


■iTular  C'^ncomi 


taut  of  myopia  of  !U(Mlerate  dcKree,  that  Is  up  to 


10  I).     Vet  it  is  aliseiit  in  not  a 


few  cases  of  myopia,  even  in  tho.se 


(il   con 
or  wi 

adjacent    cho 
nivopia,  mu 


siderahle  amount,  and  frei|uen 


tiv  is  found  with  ( inmetropia 


th  hyperoi'ia.     In  itself,  if  imassi 


iated  with  rarefaction  of  th' 


roK 


1,  it   does   not  ar>jue  an   active  progres.sion  oi    tiie 


1  is  not  to  l>e  regarded  as  pathological 


The  third  form  of  conus  i 


wiiile  1 
coiiceii 
>iile  o 
laimu 
sometime! 


,,,, ..  the  \iiVff'  triangular  or  irn-Rular'y  oval 

i,.'itch  of"  atrophy  with   illnlefined  borders,  or  with  a  s<  fi  -i  of 
trie  bonh-rs  (terraced  conus).     This  may  occupy  the  t..;.'  „,i.. 


(f  the  papilla  or  spread  so  a- 
liar  C( 


'iivolop  the  latter  on  ail  f 


I'estations  o 


,..^,.     It  is  found  n'guhu'ly  witii  myopia  oi  10  D.  or  more, 

Iso  with  myopia  of  less  amount.     It  always  indicates 

to  be  reftarded  as  one  of  the  mani- 

osterior,  other  evi('"nces  of  which 


inus) 


|)nij:ression  of  the  myopia,  and  is  to  1 


if  a  sdero-ciioroiditis  j 


are  a 


iiomenon. 


Jmost  invariably  presen 


It.     It  is,  therefore,  a  pathological  phe- 


.<(lrni-rli<iroi(iitiK  po'itrrior,  un 


ler  wliich  term  may  Ih'  included  all 


f,  ,nn.  of  rarefaction  and  atrophv  of  the  choroi.l,  with  or  without  the  .U 
OM<ition  of  pifimeiit,  occurs  regularly  with  myopia  of  more  than  10  1)., 
1  sometimes  also  with  mvopia  of  only  f,  or  0  D.   Whenever  present,  it 

t,d  shows  that  we  are  dealing  with 


ites  ailvaiice  of  the  myopia,  a 


II  ai)n(irma 
,!■.    N'ei' 


Uv  distensible  or,  ;it  all  even 


ts,  an  abiioriuailv  distending 


irelv 


indeed  a  myopia  i 


mis  and  without  evidence; 
The  other   luiidii.-<    rhnttijet 


III 


tlaiiH 


na 


torv  alterations  in  the  ye 


.f  more  than  10  I>.  is  found  without 
f  rarefaction  of  tiie  choroid. 
-viz.,   hemorrhages,   degenerative   ami 
pot,  and  detachment  of  the 


iitiiia — occur  w 


111  -how  that 

inui-h   more  common   m 

luyopi:;  of  .')  or 


,ith  moderate  freiiuency  in  myopia,     statistics 
.nirarv  to  the  usual  opinion,  tln-se  accidents  are  not 
the  verv  high  degrees  of  myopia  than  in 


(i  !).      But  inferences  drawn 


from  statistics  aie  not 


ilirelv  tru.-tworiliv. 


The: 


ceidents  are  more  likely  to  oci 


iifier 


the  ordiiiarv  ( 


■hai 


IJIv'S    o 


liaxe  la>te<l  a  Ions;  time 


Progress    of    Myopia.     Myopia  is 
a>es  associated  with  an  inferior  conus,  no 


f   myoi)ia   (sdero-choroiditis  posterior,  eto 

rarely  congenital.     Some  nf  the 
loubt,  date  from  bir'i.. 


m 


THE  KYE. 


Mini  sdtiH'  (itlicr  coiijiciiital  rases  am  probably  liiu*  tn  iliscasc  of 
till-  eve  occiiriiin  in  utcro.  Hut  in  llic  ovciwIiclmiiiR  iiiajoritv 
of  «    ' 

the   airi'; 

tin^uislicil. 


as<'s  iiiy(i|iia  i-  an  aniuircd  atTcctinii  which  dcvolitps    iK'twccii 
if  five  an        went  v.     Three  <'lasses  of  cases  may  Ix'  <lis- 


jn  the  fiM  cl(i.'<f  of  ca.M .-  tlic  niyo|iia  never  exceeils  2  |).  Such 
a  iiivojiia  may  develop  in  laie  cliililliood  or  in  yontli,  in  whicli  c:use 
lis  ad\ance,  if  not  airested  s(M)ner,  ceuses  at  the  age  of  twenty-one 
i.r  twenty-two,  when  the  patient  attains  full  (rrowth.  A  myopia 
lif  tlii-  sort  may  als;>  start  in  adult  life,  anil  is  then  generally  the 
result  I'f  excessive  use  of  the  eyes  for  near  work.  This  low  myopia 
is  usually  associated  witli  astifrniatism.  It  is  probable  that  this 
association  is  not  fortuitous,  but  that  tlie  astigmatism  is  tiie  cuus<' 
of  the  myopia  :  that  is,  a  patient  starting  with  hyperopir  astigma- 
tism, converts  this  in  his  efTorts  to  .s«h'  distinctly  first  into  a  mixed 


then  into  a  myopic  astifimatism.     Myopia  of  this  amount 


ami 


not  u~uallv  assciciii 


led  will)  a  (-onus 


In  the  .•^criind  r'<i.-:s  itj  rnsix  the  maximum  pitch  to  which  the  myopia 
attains  is  about  to  '2  to  II)  I).  Such  myopia  develops  in  childhood, 
especially  durinp  the  school  a>;e,  ami  tends  to  increase  up  to  the 
lino  of  twenty-one  or  twenty-two,  when,  with  rare  exceptions,  it 
conies  to  a  st'>|).     It>  .idvance   «|)|M'ars   to  be  directly  |)roportional 


to  the  demands  ma<le  upon  the  eyes  in  sch 


)rk.     Hence  myo| 


iia 
)f  this  kind  is  often  called  "  .-chool  myopia."  Vet,  as  before  remarked, 
there  is  jiidbably  no  actual  intimate  relation  in  most  cases  between 
school-work  and  the  pro};ress  of  myoi>ia.  I-^xcessive  near  work  may 
initiate  a  myojiia,  but  is  not  probably  the  main  factor  in  causing 
its  a<lvaiice  after  it  has  started. 

Myopia  of  this  kind  is  often  accoin])anie(l  witii  astigmatism.  It  is 
fienerally  associated  witli  a  simi)le  temporal  or  na.sal  conus,  and  not 
with  the  |)iojjres>ive  (lai  j;e.  teriacod,  or  annular)  conas,  nor  with  true 
sclero-i'lmididitis  ))osterior. 

In  the  IliinI  rla.^s  of  rases  the  myopia  l)e<;ins  in  early  childhood, 
increases  rapidly  duiin'.;  the  growing  jM-riod  (often  reaching  10  or 
V2  1).  at  the  .age  of  t<'n).  and  so  far  from  coming  to  a  staiKl-still  at 
twenty-one,  ke(  p^  on  increasing  in  adult  life,  so  as  ultimately  to 
attain  b")  to  21),  or  even  L'o  to  .'{()  I).  This  kind  of  myopia  besiu-aks 
an  unusually  yieldinir  ami  distensible  eye.  It  is  almost  invariably 
associate(l  with  a  large  conus  and  marked  sclero-choroiditis  jMisterior, 
wlii(  h  may  develop  loiig  iM'fore  the  myo|)ia  has  reacluMl  a  high  grade. 

In  contradistinction  to  the  other  kind,  thi.s  form  of  iny()|)ia  is 
denoted  as  imiiirrssirc  or  jxrnirioiis. 

This  form  is  distinctly  pathological.  It  does  not  develop  particu- 
larly a.'^  the  result  of  excessive  near  work,  and,  indeed,  occurs  com- 
paralively  o'len  in  tho.se  who  u.se  their  eyes  but  little.  It  occurs  more 
oftcr  in  tli  foreign  born  than  in  native  .\mericaiis,  and  more  often 
in  di-|)en<;iry  patient.'^  tli.aii  in  the  well-to-do.  It  is.  in  fact,  a  vice 
of  development. 


Hlltn.UTlVK  EIIHOHS  l.\  (lESEHAL. 


H\) 


„„     •,     „.t..  ,.la.v  .liscnnlinnnnsh,,  so  that  tlu-  n.-HrsiKl.  ....u-ss  w.  1 

',;•;,  th-i-nn.-  ,H,int  for-,>.Tl.aps  s..v,Tal  y.ars    a...    tl..-n  su.l- 

i     ,  .k.-  n..  a.lvan.-...    Tl.is  is  show,,  in  .nany  .•as.-s  i,y  th.-  pn-s.....-,- 

;!l  ',  JnMc.i  .•rrs.M.nt  a.ljoii.ii.K  the  i.apilla.  oa.h  tt-rrac.'  n-pn-.s^-nlinK 

.,  nriio.!  of  rriH'\v<-'l  progress.  .  . 

U  .hoi.l.l  Im-  not4Ml  that  notall.-as.>sof  pro^n-smvc  iny..|.ia  an-,  ue 

,„  ',,„., „i.,„  .,f  the  h:u-k  of  the  eyeball.     The  a.lvance  .nay  Ik-  .Ine 

,. ,  ,1  increase  in  tlu-  corneal  curvature,  as  m  true  lenticonus  an.l 

J;       c    tain  other  cas..  not  strictly  classifia l.le  un.ler  tins  hea.L 

-huul.l  also  U-  ren.en.lH.rul  that  .nixe.l  cas<-s  ol  curvature  and  ax.al 

Mvupia   .lu.-  t..  changes  in  the  curvature  n.  the  cornea  an.l  lens  eon.- 

|„„,.  I  with  elonpiti..n  ..f  tlu-  eyel.all.  are  n..t  unconunon. 

Vi  ion    in   Myope..     Myoin-s  hav.-  very  hazy    sight   for  .hstance. 
iJ.  r..pe  of  i  1).  rarely  has  n.or,.  than  2  KK)  v.s,.jn.  one  jv.th  4  1) 
„;:;•. .!.un.  im^ers  acr..ss  the  ro...n:  an.l  ,n  tin-  '^  ^  ;  ;^--; 
,„..„.i.rht    tlu-  l.lurrinR  is  still  nu,r<-  pr.mounce.l.      lhi>  l.lun.ng  is 
;  ,  ,;     l,v  the  .r.latation  of  the  pupils  which  is  usually  present  in 
h  .-ases/an-l  whi.-h  acts  by  enlarging  the  .UtTus.on  '>'I='«;- 
1„.  ,„.„;  ,.,i„ts  n.yoiK-s  have  very  poo.  1  vision     ...  t;""'- -'^"I  " 
vii,  .  than  en.nu-t.-opes.  since  .u-ar  ..bje.ts  a,.iH-ar  to  th.-n,  lar^.  r 
,       1  . V  .1..  to  einmetr-MH-s.     Mon-over,  as  n.yo,K-s  .lo  .u.t  hav.-  t., 
1     ,•  acco,....u..la.ion.  eve.,  wl.e..  the  object  .s  .,u.te  ,u-ar,  th.^; 
. .      .•     an  ..bj.-ct  without  accon„,u..lative  stra..,.     As  an  ..ITs.-t    .. 
is    i     .    ',,  h.p,K-ns  that  they  hav.-  to  hoUl  an  obj.-ct  s..  dose  to 
i,    i      ,.  tlv    tat  tlu-v  cannot  keep  both  eyes  convc-ge.l  up..n  .t. 
11.'   «ei  i.,to  the  wav  of  looking  with  ..„  y  o.u-  eye  at  a  tinu- 
;;ll,  •,•„;  tlu-  ..ther  c-ye  to  .liv.-rge.    They  thus  have  only  n.onocular 

"'7uh  ,ln..cs.  the-  visio.,  in  .uyopia  of  low  an.l  nu-.Uum  aepn-es  is 
„.  .'illv  ..early  or  quite  norn.al..  I.,  n.yop-  ^^l;^^^^^,  ;^:^ 
i  ,.i,i„„,  better  than  20  40,  a.ul  m  n.yopia  of  20  I). «  r  '>^<  r  ^^'  '-'"  '> 
:,.  t  e.  Im  .  20  70  ..r  even  20  200.  Yet  if  marke.l  fu.u  us  changes 
-;.;.  !:lll;;t  ,1;;-  sight  ,nay  be  .nud.  better  than  th.s:  an.l  I  have  s.-e.. 

'  Z7:::::^^.::^^rt'::t ..  visi..  is  uk^y ..  b.. 

-j    ,:,.n:.l,  althouglf  if    the    refractt..n    be  «-rrecn-;l  c-.;^u^     - 
vHi.m  nriy,  n.  .:.any  c!us<-s,  be  brought  up  to  nearly  or  qu.t.   tiie 

'",'"''  '"","i"!"!vith  ...•irk.^.l  sdero-chomi.litis  posteri.)r  the  vision  is 
,.:;..:;;::  ^      .     1  -  'nl^re  are  he,T...rrl.agos,  degc.en.t.ve  or 

:;,,;;;,;!j,:";  dia;;;.;.  or  a  pig,.,ent  spot  m  th-  ...acma,  the  .ght 
-iJ;:„^"Slr^S  to^'ifiL-  is  — 3f  iS:^: 

;,„,  or  ...ore  pn.bably  of  the  conv.-rgence,  for  l^r^^^''" 
;.„;.,„  a..(l  co..vergence  are  rdaxed  the  pupil  regularly  diUtts. 


MICIIOCOPY   RESCHUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No   2) 


1.0 


I.I 


1.25 


1.4 


2.5 
2.2 


1.8 


1.6 


^     APPLIED  Its/MGE     Inc 

ar^         Rochester.   New    vorh         '4609        uSA 
'-aa        (716)   482  -  0500  -  Phone 


!M) 


THE  KYE. 


Jr 


MyofM's  also  s(iiiint  the  eyelids  in  order  to  diminish  the  size  ()f  the 
piiltil,  and  fliiis  to  lessen  the  size  of  the  (hfTusion  iinafjes.  For  the 
same  rea>on  myoix-s  incline  the  head  forward,  us  by  so  <loiiiK  they 
partiallv  eover  the  |>iii)il.  :ind  so  look  through  a  narrower  ehink. 

The  most  strikiiif!;  feature,  and  one  that  the  laity  take  as  a  sIrii  of 
nearsi^lhtedness.  is  the  manner  in  which  the  myo|>e  holds  objects 
close  uj)  to  his  eves  in  order  to  see  tlien>.  thus  hrinjiinj:  the  object 
within  his  far  i)oint.  lliis,  however,  is  not  an  absolute  evidence 
of  nearsiphteclness,  beinj;  sometimes  due  merely  to  habit,  some- 
times, also,  as  we  .shall  .see  later,  beinfi  found  in  hyixTopia  of  a  high 
dcfiree. 

Hyperopia.  Far  Point  in  Hyperopia.  \  \)A\m\X  with  uiicorrcHted 
hvpero])ia  sees  in  difTusion  imap-s.  Conseiiueiitly  his  sifjht  is  blurred, 
aiul  the  more  so  the  hifiher  the  hypero]>ia.  His  natural  distant  vision 
then  is  pool ;  l)ut,  contrary  to  what  takes  place  in  myopia,  his  \ision 


__:nr---fi 


K:ir  jxiint  ill  hv|«roi.lrt  and  P""r«!  nf  iniorgeiit  rays,  correction  of  liyperopia  by  accommoda- 
tion or  by  a  miivc.i  gla.ss.  U.  the  fur  i»iii.i  "f  the  hyiieropic  eye.  Kays  Midi  as  D  C  K.  D  C  R,  oon- 
vcrKing  tntturd  R.  will  hv  the  lens  C  C  (represciUinK  the  iMrnca  ami  crystalline  lens  colleclivel;)  be 
Kiven  the  a.liiilional  conversenee  C  S.  C  .V,  so  us  to  tie  focnseii  upon  the  retina  .V.  So,  also,  if  S  I9 
illnminiitert  and  sends  out  ravs  .V  C,  .V  r,  hacli  through  the  eye,  these  rays,  after  pas.slng  through 
(•(■andemerKinRfrnnitheeye.  will  take  the  direction  r  D.  CD.  as  if  they  divergeii  from  B  (prin- 
( i|.le  of  conjugiile  foci),  and'  will  form  an  erect  virtual  inmi;e  of  .V.  which  will  appear  to  be  at  R. 
II  supplementary  lens  correcting  tiie  hypi^ropia.  //  may  be  cither  an  actual  glass  lens  (artlllcial  cor- 
rei-tion)  or  mav  represent  tlic  extra  bulKing  of  the  crystalline  lena,  produced  by  the  acconiraodailon 
(natural  corrw'lion).  In  the  former  case,  i/must  be  of  such  a  strength  that  it  will  make  the  parallel 
rays  II II  II II.  lake  the  direction  />  r  A',  /)  C  I!,  and  converge  to  R.  for  if  they  are  Kiven  this  con- 
vc'rKcnce  tlic  lens  C  Ccan  then  focus  them.  R  must  then  be  the  princiiial  focus  of  the  lens  //,  and 
()  R  its  r.H'al  length  If  the  lens  //  is  moved  out  to  //',  ils  focus  must  still  lie  at  A"  for  it  to  give  par- 
allel rays  the  pn>i*r  convergence,  so  that  its  local  length  will  now  be  o'  K— i.e..  If  will  be  a  lens  of 
longer  I'.HUs— i  r.,  a  weaker  lens  than  //—and  yet  do  the  same  work. 


for  near  oi)jects  is  poorer  still,  for  if  his  eye  i^  naturally  so  weakly 
refractiiif;  that  it  cannot  focus  even  parallel  rays  upon  the  retina, 
still  less  will  it  focus  rays  which,  comiii;,'  from  a  near  object.  ;iie  already 
diver<jent,  and  lience  are  just  so  much  the  more  ditlicull  to  converjie. 

The  far  point  of  the  liyperopic  eye,  therefore,  that  is,  the  point 
for  which  it  is  natundly  adjusted  without  any  effort  of  accommo- 
dation, is  neither  at  far  distance,  as  in  emmet ropia,  nor  at  any 
neiirer  point,  .-is  in  nivopia. 

W  here.  then,  is  thefar  |>oint  in  hypero[)ia?  <  )r  to  put  the  ipiestion 
in  another  way,  If  the  eye  is  neither  adjusted  for  parallel  rays,  as  in 


RKFUACTIVK  ERRORS  I.\  OESERM.. 


91 


I'liuiK'tnii  m 


nor  for  divorgont  rays,  jis  in 


myopia,  for  wliat  kind  of 


is  it  adiiii 


;t(>d? 


rii.' answer  to  tliisciiu 


tion  is  sitnij'.c.     The  liypcropic  eye  'I'lR.  50) 


uili  not  1)1'  al)lc  to  focus  ttii'  ))aralU'l  rays  li  li  upon  the  rctnia  A, 
|„c  ,u<c  it  cannot  give  tiicni  .piitc  the  amount  of  coiiverf;ence  reiiuired 
,.'.ii,i,„t  ^'v  mav  sav,  bend  tiiem  (juite  stnmgly  enough.  Hut  it 
„  ill  U'ni<  ravs  lik,"'  I)  (\  D  (\  tliat  are  already  <'<.nverj;ent  to  a  certaii. 
,,n.mnt  an.l  which  will,  therefore,  re<iuire  a  les>  anumnt  of  additional 
',.,,„  v.iMvnce  or  l)."ndinp  to  brinp;  them  together  at  A  .  Hays  like  I)  ( 
I)  ( ■  if  not  intercei)ted  bv  the  eve,  would  meet  at  some  point,  as  li.  back 
,,f  tl„.  Idtci-  We  sav,"  then,  that  the  hyperopic  eye  is  adjusted  tor 
,„•  will  without  acconunodative  effort,  focu.s  rays  that  are  conversing 
iMuani  the  point  li,  lying  back  of  the  .'ye.  The  {mint  li  is  Ihvn  the 
jar  noiiit  of  the  hy])eropic  eye.  .  ■    ,     ,  ,  ,u-       i 

Ihe  less  th(  refractive  power  of  the  eye,  that  is,  the  less  a<lditional 
,.,iMven'ence  it  is  able  to  impart  to  the  rays  impinging  upon  it,  the 
.Mv.ternmst  be  the  initial  convergence  of  the  rays  C  t  which  can 
F,e  Incused  bv  it  upon  the  retina.  But  the  more  C  C  converge  the 
,.l„s,.r  will  li  be  to  the  eye.  Hence  we  see,  the  higher  the  liyperopia 
ilic  closer  the  far  pohit. 

Correction  of  Hyperopia.  The  hyperonic  eye  is  like  a  camera 
which  is  out  of  focus  because  the  sensitis.'  plate  is  too  close  to  the 
l,.ns  Such  a  camera  may  be  put  in  focus  .nther  by  carrying  the 
plate  ba.'k  to  its  proper  place,  or  by  leaving  the  plate  when'  it  is  and 
...Min..'  to  the  strength  of  the  camera  lens. 

In  the  eve  both  methods  of  comix-nsation  are  possible.  I  He  c;/e 
„„„/  hwilhni,  and  tiuis  shift  the  retina  back  to  a  pomt  wh.T.-  parallel 
,  , V.  will  l)e  focused  ujion  it.  Such  an  elongation  ot  the  eye  actually 
,.,kes  place  .luring  th."  growing  p.>ri..d,  and  thus  the  hyperopia  origin- 
:,||y  present  in  nu.st  eyes  is  gradually  lessened  or  even  entirely  neu- 

"  This  process,  however,  is  one  that  goes  on  very  gradually,  and, 
v.n  if  it  took  plac<>  very  much  fasfr  than  it  d.H-s,  it  could  not  Ik- 
i,ili/.ed  f..r  the  rapid  correction  of  hyiK-ropia.  This  mu.st  be  effect,  d 
Inn,  by  ad.ling  in  some  way  to  the  deficient  retractive  power  of 

"lilVhe  natural  eve  this  is  accomplished  by  nccommodalmi.  The 
:l,..nv  mus..le.  acting  in  .,uite  the  san.e  way  as  it  does  ^^^^'^n  ^'^^ 
,„„;.tro..ic  eve  focuses  .h.wn  from  a  distant  t..  a  near  object,  causes 


stalline  lens  to  bulge,  and  thereby  incn 


ases  its  refractive  jMiwer 


riv    th 


n'i|uisite  amo 


hown  in  rig 


imit    'The  con.lit'ions,  in  other  words,  are  \m 
Fig.  .')(),  where  the  lens  (',  representing  ' 


th 


!h  bv  tl 


le  acc( 


own   111    1  If;.   •"'.    -.  .'       ■    ,  .     ,  I,, 

stalline  lens  of  the  hvix-ropic  eye,  is  sui)plemee.te.l  b\ 
the  "additional  refractive  power  [lut 
The  conditions  that  will  be  observed 


a  and  cry 

ins  //,  which   repr(>sents   t 


jinmodation. 


alogous  to  those  shown  in  i'ig.  40 
d)ilitv  of  the  eye 


IV  neutralize  its  hyi)eropiM,  wi 


to  put  forth  this  accommodative  effort,  an< 
il  obviou^iv  diminish  as  the  elas 


92 


TUE  EYE. 


I 


■I 


i 


ticityof  the  crystalline  Ions  diininishos.  It  will,  tluMctdn".  docrcasc 
steadily  with  ajie.  It  will  also  he  reduced  hy  anytliinji  that  irnjjairs 
the  power  of  the  ciliary  muscle,  and  will  he  entirely  ahrojjatc<l  by  a 
cyclo|)le<ric  like  atroi)iii( 


\\( 


may  then  neutrali>-e  hyperopia  by  a  cert 


un  accommcM 


etTort.  produciii};  an  increase  of  refraction  represented  by  the  l( 


iativ( 


(Fig.  ")()) 


// 


^\ 


e  niav  also 


produci 


su< 


1  an  increase  in  refraction  by  a  (jlnxx 


Iriis  placed  directly  before  the  eye.     Theoretically,  at  least,  it  makes 


no  dilference  whether  //  is  actually  a  lens  of  jjlass  or  sitn|)ly 


th< 


represents 


extra   huljiinj;  of  the  cry-talline   lens  produced   by' the  cili 


iry 


muscle.  The  hypermetrope  focu.sed  for  distance  is,  in  fact,  in  the 
same  po.>;ition  as  the  emmetrope  focused  for  near.  In  either  case,  it 
makes  no  ditTerence,  so  far  .as  vi.-;ion  is  concerned,  whether  the  focusinj; 
is  done  by  accommodative"  power,  or  by  a  filass  lens,  or  {)artlv  by 
cine  me.ins  and  jiartly  by  the  other. 

Xaturally,  then,  hy; -.'ropia  is  corrected  by  acconmiodation  and 
arlilicially  by  a  convex  lens  which  either  neutralizes  all  the  hvDer- 
opia  or  .>io  nuicli  of  it  as  the  accommodation  fails  to  correct. 


Tl 


le  amount  of  liypero|)ia  is  usually  measurecl  iti  terms  of  the  gla.ss 
that  comjiletely  corrects  it.  Wlial^  then,  will  be  the  stremrth  of 
this  filass'.' 

If  we  revert  'o  Fi-;. .")(),  we  see  that  the  refractiiiR  media  of  the  eve 
rei)resen)ed  by  the  sinfjie  lens  C  will,  unaided.  ))ring  to  a  fi 
the  retina  rays  haviiifr  the  direction  I)  R,  1)  1{~^ 


"w^  upon 


('.  ('.,  rays  which  ar 


ilready  conver<;iii.u  toward  the  eye's  far  point,  /(".  The  fens  //,  ther(>- 
fore,  which  will  aijjust  the  eves  for  i)arallel  rays,  must  he  ju.s't  suffi- 
ciently stiotift  to  make  the  parallel  rays  take  this  same  direction, /> /^ 
and  converfre  toward  R.     If  it  does  this  much  of  the  work,  C  will  do  the 


rest  and  will  focus  the  rav; 


parallel  rays  converge  to  R  \~  ,i  h 


s  upoi,  the  retina.     Hut  a  lens  which 


mak(>s 


ns  will 


ise  principal  focus  is  .at  R: 


li<>nc(>  the  iilfiss  irhich  nnniili'tcli/  cnrmis  thr  hiip,ri>piit  is  a  convex 
lidrinti  ils  jiriiifipdl  l'(icii.''(il  Ihcfar  I 
the  st.itemeni  made  in  re<raril  to  tl 


lens 


7  lis  priiwipal  joni."  at  the  jar  point  itj  the  fii/peropie  ei/c.    fCompar 
■■•■■meni  made  in  re<raril  to  the  correction  of  myo|)ia,  pajje  S2.) 
IS  in  the  ca.-<e  of  myopia,  the  strength  of  the  correcting  lens 
n  hyi)eropia  will  rari/  oeeitrdiiKj  to  its  tlistonee  from  the  ei/e.     R  heinj; 
the  principal  focus  of  the  correctinft  jrla.^s  //,  //  R  is  its  focal  dis- 
tance.    If   //  is  moved  away  from  the  eye  to  //',  it  will  st 
parallel  rays  the  proper  converjience  :    that   is,  will  still  corr 


.lust 
1 


ni  give 


le 


rrect  tl 


hyi)er(>pia,  |)rovided  its  i)rincipal  focus   is  at  R.     Its  f 

now.  however,  is  //'  R.  which  is  greater  than  //  R.    Since  the  strengtl 


.f  1 


enses  diminishes  as  their  focal  distance 


//'  will  not  neecl  to  I 


increase 


tl 


ocal  distance 

ngth 

le  lens  placed  at 


)e  as  strong  to  do  the  same  work  as  if  placed  at 


//.     Or,  to  put  the  ca.se  in  another  way.  the  effect  of  n  convex  ;il, 


Ih 


n  eorreelin<i  hi/peropiii  is  I,  iijhtened  if  the  (jlii 


e  eije.  ;in 


1  is  ili 


shed 


IS  carried  aivai/  froi. 


I  IS  enrrii'l  tmriird  the  eije.     In  ca.se  of  a 


high  hyperopia  the  difference  jiroduced  in  th(>  correct ijig  <r];,ss  in  this 
w.ay  may  i>e  coiLsiderable.     Thus  a  patient  who  h.is  harFa  cataract 


IlFA-llMTlVh:  ERIKiR^  IX  (iKyiCIlAL-  'J^J 

}r  a  +11  I),  will  iiltcr  its  stn-iiRth  by  a  wliolt 


Airactcil  and  is  wcariii 

1"  lie  sliifts  its  positidi 


liol 


.trc  1 
sinn 


oiic-thinl  inch  fonvar 


1  or  l)acl\. 


ill]  l)c  can 


fullv  noted  tliat  in  gcncri 


d  this  increase  in  strenj;tli 


|l|o(|l 


iced  ni  a  convex 


"ftiass  by  shiftiiit;  it  away  from  the  eye  ap]) 


lien  the    glass    is    used    for   distant  vision 


Whei 


les 


1   a  convex 


!.■-<    is    '/.-■<'( 


/  jiir  midiiui.  ils  xtrmijth  ix  dim 


hid  1 


)V  carrvmn  i 


t  otT 


iViiiii  tlie  < 


ye,  |)rovided  the  l 


he  patient  is  eiiiinetroi)ic  or  hut  little  hypei- 


pic 


if,  however,  his  hyperopia  is  nion 


than  4  I).,  and  in  soin 


.  <.l:  w 
1)..  hi 


lien  he  holds'a  hook  far  off),  if  his  hyperoina  is  no  niori 


ould 


tiie  effect  of  his  glass  by  carrying 


it  off 


hall  .1  I'.,  ne  >miuhi  Uicrea 

""iTie  tnu- 'reason  whv  inanv  presbyopes,  even  though  emmetropic. 
,,ii<h  their  rea. ling-glass  away  fn.m  t!ie  eyes  when  it  is  too  weak, 
i.  that  thev  thereby  increase  the  size  of  tlwir  retinal  images,  although 
■It  the  same  time  they  make  them  less  distinct.  .,,•,, 

-n,,.  far  i.oint  of  the  hyperopic  eye  can  be  determined  directly 
frotn  the  strength  of  the  c.rrectimr  lens.     Thus  in  hypen.pia  of  4  I). 
„,  .„„.  ,.orrect<-d  l.v  a  10-inch  len-   the  far  point  is  10"  behm.t  the  eye. 
Accommodation  in  Hyperopia.     Near  Point.     The  uncorrect.-d  hyper- 
opic eve.  as  we  have  seen,  has  used  up  a  certain  amount  of  its  ac- 
,:,n„nodatioii  in  or.ler  to  neutraliz.'  its  hyperoi-ia  aii.l  to  s.-e  distinctly 
,t  H  .lisfince      It  has.  conse(|uontlv,  only  a  resi.lue  ot  acco.nmodation 
l,,i;  for  focusing  down  ui.on  a  near  point.     As  compared  with  an 
„„„„„,ropic  eve,  theirfore,  having  the  same  accominodativ.-  power, 
i,  ,,„J..,.,.  ,]hi,rts  „>  close.     Thus  a  hyperope  of  2  I),  who  iias  f.  I). 
„f  ac<M,mmo.lation  will,  after  nee.trali/.ing  his  hyperopia,  have  only 
1  1)  left  to  use  in  focusing  upon  near  objects.     His  near  p. .m,  there- 
lure'   will    be   at    about    10",   and   he    can    see   an   objec    that    far 
„n  onlv  bv  using  the  whole  of  his  acconimo.latioir  while  the  emme- 
,,„pe  with  the  .san...  accommodative  power  will  still  hav(>  2  DJ  It 
ulu'i,  vi.-wing  an  object  at   this  distance,  and  by  using  all  of  ins 
,,,„„,„„„ iat ion  can  f<.cus    down    to  7".       As    a    hyperoi.e  aiul  an 
,,,mietrope  of  the  same  age  have  about  the      me  amount  ol  accom- 
„,„datioi',    it    follows    that    the    hyperope   will    become    presbyopic, 
ihit   is    renuiiv  glass(.s   for  reading,  considerably  sooner  than   the 
...nmetrop.-  will.     For,  as  is  .-vident  from   Fig,  ofi.  his  -'ear  point 
1,:,.  ivceded    further   than  the   emmetropes-m    fact,  is  as  tar  ott 
,<  is  that  of  an  emmetrope  who  is  a  number  ot  years  older. 

\s  an  offset  to  this,  it  should  !>e  noted  that  the  hyperope  s  accom- 
n.ndation,  while  not  grc.ter  h.  amount  than  that  ot  the  (.nmu'trope 
,„•  inv.me  of  the  same  :■:.;  is  in  constant  exerci.se  and  is  more  iradilj 
,„aintained.  In  coiison.ince  with  this,  we  find  that  in  hypero] '■« 
111,,  ciliarv  muscle  is  particularly  well  developed. 

The  excels  of  accommo<latioii  which  the  hyjM'rope  has  to  put  foitli 
n-id-  fre(|uentlv  to  nrconimodatire  roinrruoin'-c-vrrss,  which  mM> 
,,  ni.-iin  as  an  esophoria.  or  may  lead  to  a  convergent  s.|uint  that  is 
,1   iii-(   marke-i  onlv   fur  near  points,  but  afterward  be<-omes  pro- 


4I.11I1CIM 


both  for  distance  and  near. 


94 


THE  EYE. 


In  .so„„>  oasos  ut  hyporoph.  the  acco.Min.Klatioi,  ,„av  bo  callo.i 
in  p  ay  s..  ,-x..,.ss,voly  as  t.,  ..vor-c.rr.rt  th,...rr.,r.  ,.v.-.,  f..r,lista..<-.. 
a  1  thus  r,.,H  ,;r  th,-  pat.ont  apparently  ,n,,o,nr.  This  is  ..sp,.,.iali; 
ho  oaso  if  astigmatism  is  pros..i.t  or  if  tiio  patioi.t  1ms  uso,|  i,,;. 
P  .por  Klassos.  I,,  as  soi.u-tiin,.s  happens,  a  concave  f,lass  is  p  e- 
s  .....  or  tins  apparent  n.y.pia.  the  patient  may,  l.v  contim  in,. 
i..>  constant  accom.no.laf.vo  otlort,  l,ecom,>  truiv  mv.pic 

I  he  hy,H.n.pe  may  corivct  his  hyperopia  entirely  with  his  accommo- 
1.1  tio     ,„•  ...ay  relax  his  accommo.lation  altogether  an.l  allow  us  to 

1  ouexe  ,  he  al  ows  „s  f.  correct  a  portion  of  his  hvporopia  with  a 

I    T'   .  ;    t"        •  ""'  ''"■7''"^^  ^''"  '■•"■•^'  "•'*•'  '"^  "'•'•"".mu.lation  (4 

(  IS, ...  fact  soaccustomo,!  to  usms  his  accommo.lation  continuously 
t  at  generally  he  <.annot  no  matter  how  we  nv^,  him.  jtivo  i  p  t h^ 
"t  ort  at  once  when  we  place  a  convex  jrlass  l„.fore  his  eve  1  ut  h e 
retains  at  least  .some  of  his  accommodation-/,  c.  .1-at  w.'.rk  If 
...  such  a  ca,se.  w.-  }iive  a   Rla.ss  .stron-.T  than  //  by  O.oO  I).',  the 


amount  that  U crriTied  ,.ll  the  time  I,  ■  tla- nccommoliM  T,' /„:, ^til  .  «'""»ni.Klttt.,m.    The 

be  c.rreclt.l  hy  the  mcomcKlati.,,,.  i,  eallcl    h.  nLuW^il'Lrli^^,^^^ 


pati.M,    will  a    once  begin  to  see  lo...s  .jistinctlv,  for  he  will  t    .„  i,, 

.■licet,  have  belore  his  eye  besi.les  the  len.ses  .1  an.l  //.  which    thor 

<'';.-n|ct  Ins  hyperopia  ...n.l  make  him  emm..tropic.  a  lens  of  ^  OSOD 
which  will  make  him  practically  a  myope  <.f  0  .50  I) 

A   patient   as  shown    in    Fig.    'A   w.niM   be  apparently  hvporonic 
;;.    r,::"TT'/;"  "y'''^?;^^  •-  actual  total  \i-pero,^a  w-luM^b 
.M-cropia.      The  ..nnj,.;  l,y,„ro,,i„,  in  other  worWs.  is  the  am     i 
'.«'''  t'"'  i'""<;-'t  will  .•.■veal   by   the  utmost  voluntary  relax 
his  accommo-lation.  an.l  is  represent,., I  by  th,.  hi,::e.;t  cnvex  Jhs 
with  .hu.h  he  ,.an  still  s,;,.  ,lis,inc.ly.     th,-  latr.,  /.j/J^^l^^Z 
cMiainmg  hyp,.ro,.ia.  which  he  will  not  ivveal  in  this  way  because  le 
k.rps  It  .■orivtcl  by  his  accommo.lation.      Th,.  tol„l  hn.a;,,uo  is  the 
sum  of  tne  latent  aii.l  manitVst  hyperopia  ' 

The  patient's  vision  will  be  p.aclically  the  same  whether  he  cor- 


the 


hyperopia   entiivly  by  accoinm.xlati. 


>.».  or  entire 


>.V  a 


•lEFliAV'nVh:  KHHOllS  IS  (lIlSKltM.. 


95 


,,,iiv.'x  plus?:,  or  i)!irtlv  by  tlic  glass  and  partly  l)y  accDminodatiDii. 
I  j.r  .-,1.1  In  cases,  tiu'ivforc.  whciv  the  patient's  vision  is  already 
,r,,n7|.  l)eeause  although  I'e  has  hyperopia  his  aceoniinodation  eorreets 
'ill  ol  it.  we  eannot  demand  of  a  eonvex  glass  that  it  shall  iinjji-ove 
\n<  A"hX,  hut  onlv  that  it  shall  still  keep  the  vision  as  good  as  it  was 
ImImiv  We  sav,"  then,  that  he  iuri'i>h  that  glass.  If  he  accepts  a 
vun\i'\  glass,  it  is  proof  tiiat  he  nas  liyperopia  of  at  least  that  amount. 
li  r,,r  instance,  he  s<'es  as  well  with  a  +  l.oO  I),  as  without  it,  lie 
,:iun..t  have  hvperopia  of  simply  1  D..  for  in  that  case  the  addition 
„{  1  .")()  !).,  by  over-corre:'ti.ig  the  hyperopia,  would  render  Inni 
Mi.iciicallv  invl)pic,  O.oO  !>.,  and  would  blur  his  vision. 

We  cannot  "sav  that  a  iiatient  accepts  a  concave  glass,  for,  as  we 
Ikivc  seen,  any  Verson  witii  good  accommodation  will  evercome  a 
1:,\\  concave  glass  and  sei-  at  least  as  well  with  as  without  it.  To 
MKive  ihat  the  patient  rcallv  re(iuires  a  concave  glass,  we  .should  show 
iliMt  he  sees  milhj  hvUvr  witli  it  than  without  it.  If  he  sees  simply 
,.  well  with  it,  or  ai)parently  sees  somewhat  more  sharply,  but  cannot 
•iituallv  disthiguish  any  nmre,  he  is  not  myopic  to  that  amount. 

Varieties  of  Hyperopia.  In  hvperopia  the  point  at  which  the  eye 
Incudes  i)arallel  ravs  lies  behind  the  retina.  This  may  be  either  because 
ihe  retina  is  too  far  forward,  or  because  the  retina,  being  in  its  proper 
niace  the  cornea  or  lens  has  too  little  refractive  power.  Hence  the 
Iivuen.i)ia  may  be  due  either  to  changes  in  curvature  (flattenmg)  of 
tlie  cornea,  or  lens  (curvature  hyperopia),  or  to  changes  in  theden.sity 
nl  ihese  iiK'dia  (index  hyperopia),  or  to  an  undue  shortness  oi  the 
ivcball  (axial  hvperopia). 

Cirvatiirc  hinnTKpUi  is  fouml  as  a  result  of  opacities  f)r  cicatrices 
,.t  ilic  cornea  associated  with  flattening.  This  form  is  generally  coin- 
liiiied  with  astigmatism.  The  peculiar  sort  of  curvature  hyperojiia  in 
A  Inch  one  of  the  refractive  surfaces  is  not  simply  flattened,  but  alto- 
u.  iher  abolished,  is  that  produced  by  absence  of  the  lens  (aphakia). 
This  in  eyes  ])i-eviously  emmetropic  produces  a  hyperopia  of  10 
M  I'D.' 

\u  example  of  index  hiiprropiit  is  that  which  develops  m  old  age 
i^  a  result  of  sclerosis  of  the  lens,  rendering  the  latter  more  homo- 
,'i  neous,  and  hence  less  refractive. 

AslaUnipvropia  is  by  far  the  most  common  kind.     It  is  also  appar- 

11, ly  the  Original  conilition  subsisting  in  the  vast  ma.ior:ty  of  eyes, 

1   examination  of    newborn  infants  has  shown  a  very  great   pre- 

.iiuleiance  of  hyperopia,  and  particularly  hyperopia  due  to  a  com- 

■ni alive  shortening  of  the  eye. 

Dining  the  growing  jM-riod  of  childhood  and  youth  the  eye  I^econies 
!(  a.lilvhngcr,  so  that  the  hijprropia  uroir.'^  /p.v.s-  nnd  less.  It  may  thus 
.  transfonned  intoemnietroi»ia,  or  jwissibly  go  over  hito  myopia. 
r!ii>  process  of  (>longation  regularly  ceases  at  tlu  age  of  twenty-two 
rars,  so  that  if  any  hyperojiia  is  left  then,  it  nnnains  stationary 
iii  nal'iT. 
I  tiie  iuillimetre  of  shortening  of  the  eyeball  corresponds  to  about 


THE  EYE. 


i).  of 


(xiiil  liypcrojiiii,  so 


tliat. 


lor  iiistaiicc.  an  cvi' 


wliici 


1   IS 


nun. 


slioitcr  than  noiinal  will  he  liypcroiiic  (i  I). 

In  axial  liypciopia  tlic  shoitcni'"-  allccis  cliicliy  tliat  |>ortion  of  the 
eye  hack  of  the  lens,  altlimmli .  -p  'i.illy  in  liijili  hyperopia  the  cornea 
may  he  flat  and  the  anterior  cliainher  shallow. 

A  patholojfical  form  of  axial  hyperojjia  is  produced  hy  exudates 
pressinj;  the  retina  forward,  hy  detachment  nf  the  retina,  and  hy  the 
presence  of  tumors  hehind  tin-  eyehall,  which  in<leiit   the  latter. 

Amount  of  Hyperopia  Two  classes  of  cases  may  he  reco);nized. 
In  one  the  hyperoi)ia  does  not  exceed  o  I).,  and  hoth  I'Xterior  and 
fundus  present  no  ahnormalities.  Such  hyperoi)ia  may  he  called  nor- 
mal. !I^-  ropia  of  over  ">  I),  may  also  he  iiorinal,  i)ut  very  frequently 
in  hype  of  this  amount  we  find  evidences  of  arrested  develop- 

ment, as  alhinism,  microphthalmus,  a  small  cornea,  an  imper- 

fectly    .-veloped  fundus,  etc.     Such  hyperopia  is  ahiiormal. 

Vision  in  Hyperopia.  The  si^lit  in  hyiwropia  de|H'nds  u])on  the 
patient's  ahility  to  correct  his  error  hy  means  of  his  accommodation. 
.\  youuR  person  who  has  an  ahundance  m  accoimnodative  power 
and  no  inordinate  amount  of  hyperopia  will  see  distinctly  and  without 
.•my  fireat  dilhcuity  hotii  for  distance  ;ind  near.  .\s  he  grows  older 
and  his  accommodation  diminishes,  he  will  he  ahle  to  see  distinctly 
only  hy  the  expenditure  of  more  and  more  etTort.  Finally,  a  point 
is  reached  where  near  vision  is  efTecteil  with  dilhcuity  an<l  strain, 
althoujth  distant  vision  is  still  easy.  Later,  distant  vision  hecomes 
dillicult  and  near  vision  impossihie,  and,  last  of  all,  liis  accommodation 
fails  him  even  for  distance,  and  he  sees  poorly  at  jdl  ranjjes. 

The  hyperopia  that  the  patient  can  fully  correct  hv  his  accommo- 
dation is  caih'd  jdciiltnliir:  one  which  he  can  correct  oi;ly  hy  calling 
into  exercise  an  amount  of  accoimnod.ative  jxiwer  which  induces  a 
converi;ent  s(|uint  is  called  rcliilirr:  and  one  whicl' 
rect  at  all  hy  his  accoimnodation  is  called  ohsdlulf. 

The  [leriod  at  which  this  failure  of  ;iccominodat"  • 
for  liyjieropia  occurs — i.e.,  at  which  the  latter  hec(, 
varies  a  good  deal,  according  to  the  general  huild  •iiio  c.)nstitution 
of  the  patient,  the  kind  of  work  to  which  his  eyes  are  suhjected.  etc. 
In  general,  persons  with  less  than  2  I),  hyperopia,  whose  eyes  are  not 
excessively  tax(>d  in  near  work,  will  not  suffer  serious  inconvenience 
mitil  past  twenty-hve  or  thirty  years,  when  they  will  generally 
require  a  glass  for  re;iding,  hut  will  not  .-ihsolutely  require  one  for 
distance  for  perhaj)s  ten  or  twelve  years  later. 

.\  liyperope  of  2  to  o  I),  will  prol)al)ly  experience  some  amioyance 
in  youth  if  he  uses  his  eyes  much  for  studying,  and  aft(>r  the  age  of 
twenty  will  usually  n^piire  a  glass  for  near  and  prohahly,  also,  for 
disl.-mce. 

Hyperopes  of  ;i  to  4  I),  u.-^ually  recpiire  glasses  in  childliooil.  jioih 
for  distance  and  near.  as.  while  they  still  can  see  distinctly,  they  do 
So  at  the  e\penM-  of  considerjihle  etVort.  and  hence  develop  eitiier 
an  ;isthenopia  or  a  convergent  s(|iiint. 


•:o  clot  cor- 

i/ensafe 
.ii'-nlute— 


UEFH.UTIVh:  ERkoRS  IS  i:ESKHAL. 


5)7 


llviMiciw-  i.r  more  than  ."i  I),  rarely  cmii  ovcrcoinc  tlicir  dcl.Tl  l)y 
„,,,n,i,i,Mlativc  (.tTort.aiiil  .in  not  (.ftcn  make  -iii  allcinpt  to  do  so. 
-.mil  uaticiils  siiiii.lv  iiavc  poor  vision  and  do  not  have  asllicnoi.ia. 
Ihrirsifilit,  fv.ii  with  the  l.rst  corn •(•  lion,  is  olt.-n  suhiiorniai  (2(140 
I,,  _'()'J(KtorU"ss). 

External  Evidences  of  Hyperopia.  HypcroiM's  often  iiave  small 
,„M„7.v  This  is  l)elieved  to  be  oceasioiied  l>y  tiie  exeessive  accomnio- 
l-ilive  etVort,  or  rather  the  excessive  conv.-rfjent  et!<.rt,  tiiat  such 
|,;,iii.ins  make,  as  the  acts  of  accommodatioii  and  convergence  are 
il-^o(iate«l  alwavs  witli  contraction  of  the  pupils. 

■[-he  front  <.f"tiie  eyehall  in  well-marked  hyperopia  olten  ai)l)ears 
l|.iii.  11,.,!  and  the  anterior  chamber  may  he  .shallow. 

M.,..t  hviMTopes  tend  to  hold  their  hooks  rather  far  away  on  account 
,,l  t|„.  recession  of  their  near  i)oint.  Now  and  then,  however,  a 
inti.'iit  will  be  found  with  hy])eroi.ia,  particularly  when  the  hyper- 
ImiM  i^  of  hi'di  degree,  who  holds  his  book  very  dose  to  him,  and  on 
tir.'t  accum?  is  thought  to  be  myopic.  This  mistake  is  the  more 
intmal  as  such  a  patient  often  has  poor  sight  for  distance,  because 
1,'i.  hviieroi.ia  is  t..o  great  to  be  n<-utralized  by  the  accommodation. 
.  »|  ,nur,se,  his  vision  for  near  is  s.iU  poorer,  and  the  more  .so  the  closer 
|„.  l.iings  ..bjects  to  his  eves.  Hence  he  is  not  rea  ly  like  a  n<-ar- 
H"liled  l-erson.  who  bv  bringing  objects  closer  makes  them  more 
,liMin<-t  The  hvper.iiM-  brings  the  object  i.rarer  to  make  it  appear 
larger,  and  hence  more  readily  distinguishable,  even  if  it   is  more 

Astigmatism.  Varieties  of  Astigmatism.  Disposition  of  the  Meridians 
in  Astigmatism.  In  astigmatism  the  .lifferent  meridians  of  the  .T'j 
have  diir.Mvnt  refractive  powers,  so  that  each  focus.'s  the  rays...  light 
dilferentlv  from  the  merl.lian  adjoining.  If  the  change  in  retractive 
power  takes  place  uniformlv  aii.l  by  regular  degrees  from  one  merid- 
ian to  .another,  so  that  each  m.-ridi.-.n  in  s-iccession  retracts  a  little 
more  St  ron.rlv  than  the  one  belVre  it ;  and  if,  furthermore,  the  refraction 
i„  „,■  meridian  shows  no  great  or  sudd(-n  changes  trom  its  cent.r 
to  its  periphery,  the  astigmatism  is  called  rcjnUir:  and  in  the  contrary 

Thit    kind  of  astigmatism   produced   by   .lifference  m   refraction 

iMtween  the  nmtral  aiui  peripheral  j.art  of  any  one  meridian  of   the 

I  vr  is  called  mrriditnial  (ihvrraiion.  ...  r      * 

In  most  cas.'s  of  regular  astigmatism  the  meridian  that  retracts 

hr  most  highlv,  that  is,  focuses  the  rays  of  light  most  .,i>iekly.  is 

vertical  or  within  ■.W°  of  the  vertical,  ami  such  astigmatism  is  sai. 

■,,  1„.  u-ith  Ihr  r„k  or  lUrvct.     Tlu-  next  most  frefpicnt  van.'ty,  called 

,^tigmatism  ,u„unsl  the  rule,  or  inverse  astigmatism,  i^.  that  m  w_hich 

'„.  most  highlv  refracting  meridian  is  horizontal,  or  withm  .50   <.t  t he 

..rizontal      i-ess  often  met  with  is  oW«/»c  astigmatism,  m  which  the 

Mrriiii-m  of  greatest  refraction  lies  at  from  litf  to  ()()°  from  the  vertical. 

in  regular  astigmatism  the  meri.lians  of  gnate-t  eurvature  (prime 

.Tidians)  are  usually  si/mmclricall!)  dw/w.sW  in  the  two  ey?s:  that 


J)« 


Tin:  i:yi:. 


.  iMith  Mil'  cither  jii 


it  vertical  nr  iusi  li(iriz(iiit:il,  ur  Ixitli  are  incliiieil 


Ipv  ail  c(iual  aiuuuiit  to  tlie  teiiipnial  nr  hotli  to  llie  nasal  side  ot  the 
vi-rtical.     Much  more  rarely  the  mcriiliaiis  are  /«im//i7  in  tlu'  two 


eves. 


It 


also  unconinioii   to  tiiul 


them 


/wn 


'tlM.     \'erv  rarely 


the  I 


irime  inerilians  in 


itlnr  siiiiniiftncdl  nor 
liie  two  eyes  are  at 


riijlit  «/(///«'•••■  to  eacli  other 

In  regular  astigmatism  the  meriiliau  which  refracts  the  most 
stronjily  almost  always  lies  at  rijiht  angles  to  the  meriilian  which 
refracts  the  least.  These  two  are  calle<l  the  iirlnc'iuil  mcridtons. 
The  amount  of  astijrmatisni  then  is  m-asurcil  by  the  ditTercncc  in 
refraction  cxistinj;  between  these  two. 

Etiology  and  Development  of  Asticmfttism  With  regard  to  the 
etiolofiy,  we  should  distinguish  i)etvvccn  idinjMilhic  or  jtri'iinrn  astig- 
matism, whic',  I-  not,  and  sirondnrij or  iHitluiltitiUiil  astigmatism,  which 
is  due  to  disea.se  of  the  eye. 

.\  certain  amount  (0.25" to  ().*)()  D.)  of  primary  astig.natisiu  may  be 
n-gardcd  as  jihusidlof/irdl  in  that  at  least  that  amount  is  found 


nea 


rlv 


every  eve 


i'hysiologicai   astigmatism   is  regularly  i)res( 


Ml 


botli  in  the  cornea  and  in  the  lens,  ami  in  both  situations  is  partly 
n  miliar  and  partly  irregular. 

The  hifihcr  ilfiiru  of  itrimanj  (ixliijmnlium  (over  1  D.t  arc  mainly 
of  th(>  regular  variety.  .Vstigmati.sm  of  1  to  2M  D.  is  very  fre(|uent, 
although  not  .so  nmch  so  as  to  he  regarded  as  iioruial.  .\stigmatism 
of  2  to  4  I),  is  fairly  common,  while  prhnary  astigmatism  of  more 
than  .")  I),  is  raie. 

This  non-i)liysiological  prim...y  astigmatism,  like  the  physiological, 
is  usually  pre.sen'  Ixith  in  the  cornea  and  lens,  although  the  cornea 
is  apt    to   play  a   much  larger  part   in  its  production.     I'"r<'i|ui'ntlv 


orneal    astigmatism    with    the    rule    is 


)mi)ine(l    with    lenticular 


-tigmatism    against    the    rul<',   so    ti>at    the    resulting   total    astig- 


a 

matism  is  less  Mian 


the 


conic 


111  astigmat'sm.     In  other  cases,  but 


less  often,  the  lenticular  astigmatism  adds  to  instead  of  correcting 
thit  of  tlie  cornea:  the  astigmatism  of  both  lens  and  cornea  being 
then  usually  inverse,  .\gain,  the  combined  corneal  and  lenticular 
astigmatism  v 
the  eve  as 


often  such  that  the  meiidian  of  greatest  refraction  of 
whole  d(M's  not  coinciile  with  the  meriilian  of  the  greatest 


curvature  of  the  cornea.  These  variations  are  imiiovtant  in  esti- 
mating the  value  to  be  ascribed  to  the  findings  obtained  by  tlic 
o]ihthalmonieter. 

In  the  cornea  primary  astigmatism  is  <lue  to  une(|ual  curvature. 
In  the  lens  prim.uy  astigmatism  may  also  be  due  to  unequal  curva- 
ture, but  more  usually  to  the  fact  that  tlr  lens  is  tilted  somewhat, 
and,  furtliermore.  that  it  is  built  up  of  sei)arate  tibrilia-  of  difl'erent 
densities.  These  tibrilla'  are  grouiXM"  .so  as  to  form  star-like  tigures 
on  the  front  and  back  surfaces  of  t.ic  lens.  Hays  of  light  pa.;.sing 
from  one  fibrilla  to  aiiotlu'r  are  refracted  somewh.'it  irregularly,  and 
thus  a  certain  amount  of  irregular  as  well  as  of  regular  astigmatism 
is  proiluced. 


HEfliACTIVi:  lAilions  IS  l.ESr.UM.. 


n 


,.n„nrv  •.-ticnuitisn.  is  .■itluT  .•..np'i.ital,  ..r  prnl.al.ly  n.u.-l.  n.nrr 

i^iz^  :S!;:=i  r;;;:;":5;:ii:i:'  ;="V: 

tlii^  is  the  ivfiular  inverse  astismatwii  ol  -  i<>  ■-*  "•'  M^"' 

;;::;;;irin;  "::"i.«^:-o.,  .,r  l,.  aU..n„i..ns  ,„  ■ 1™.,,-  ,„a,.l,.a, 

1..    .;.  ,.r  ..tliT  chanires  due  to  advanml  ape). 

'"  "■'■  '"■"»)■""  i1,v':r..'.r;;r, ::;;  s  :h»w  ,1;.;;;™..;  .lunn'. 

It  ,\'m.  .121  «;C  l>»v.'  ^7»       ,,;r"T'"    t  r.u..l,  tl„.  v,.rlir,l 

'"•;";'"■;  ^;;;  A"i™-3  S:  ■t:";l:,ai  ™™i,i,a,, » » «,« 


iictween 


III 


tl 


ic  "\ 


am) 
vei!  case  we  wi 


*^1 
ill  suii|i()s<'  this  to  measure 


mm. 


IW 


rut:  i:yi: 


If  now,  llic  rctin:i  ii  !it  I.  1  in  ffnl  of  .1,  all  llu'  incriilian^ 

of  llicfvi'  will  I"'  iiyiMinpic,  and  llic  liori/.oiiial  nicriili.in  most  so.  In 
I'ai't,  llii'  vertical  mnidiaii  will  'n-  liyiMro|iic  ;!  D..  Iifcaiisf,  so  far 
as  this  meridian  is  coiieeriied,  the  eye  is  1  mm.  loo  short,  while  the 
horizontal  meridian  will  Im-  hy|HToiiie  '.»  D.,  Iwcausc  so  far  as  it  i- 
(•oiicerMe.|  the  eye  is  I?  m.  ..  t<Mt  short.  Th.-  dilTereiice  in  niraction 
l>elwc<'ii  the  two  meridians— /.  c,  the  astifrmatism— is  therefore*)  D.. 
or  tlie  eye  has  a  hviMTopia  of ;{  D.  eomhine.l  with  an  astinmatism  of  (i  I). 

if  now,  the  retina  recedes  to  II.  rays  passing  through  the  %-erticai 
meridian  have  conif  to  a  focus,  and,  so  far  as  this  meridian  is  concoriifMl, 


The  abwilule  refraction  in  astigmatism.  Form  of  rtimiiilon  images.  A.  focus  of  rays  pBMtnK 
ihroiiKJi  •  rtical  meridian  II'.  B,  focus  of  nij!,  iirtsslng  throuuh  horizontal  meriilian  ////.  A  IS 
fcK-al  lnler\-al.  I,  compound  hyi»Topic  a-stlgnmlism  ;  II,  simrle  hyperopic  astigmatism  ;  III,  mixed 
astigmatism;  IV.  simple  myopic  ttstmmatism  V.  compound  myopic  astigmBtisra  E,  F.  G.  J.  K 
lormsot  diffiision  images  at  I,  II.  Ill,  IV,  V.  res[«ctivcly. 

the  eye  is  einmetroi)io.  In  fact,  if  by  usinjc  a  vertical  slit  wo  shut 
ofi'  all  rays  hut  these,  the  eye  would  he  adjusted  acciirately  for  dis- 
tance: hut  for  rays  pa,ssiiij:  throujih  all  other  meridians  the  eye  is 
Iiy|M"roi)ic,  uiul,  in  fact,  for  the  hori>,  mtal  meridian  is  hyix-ropic 
()  U,  We  have,  therefore,  still  a  ditf'erence  hotween  the  meridians, 
or  anustifimatism,  oftil).,  althou^rh  now  one  meridian  is  nninetropic. 
This  condition  is  called  simple  luijwropir  astijtmatism,  while  the 
condition  obtainiiifi  while  the  retin:i  is  at  I  is  called  niDijiduiui  hypcr- 
ofiic  astigmatism.     It  is  evident  l!   it  ihe  compound  dill'ers  from  thi' 


in:yn\fTivK  i.nitnhs  is  nEsr-iiM^ 


lol 


i ,..  aMipua.isn.  .u-.r.-iy  in  .u  l^n.  thr  .„...■   Mnount  of  hy,«.rn,u. 

i,/,l,i^  ,..,,.    :t  D.I  to  all  iiii-ri.li.-.hs  aliK 
ii.iw,  till'  n-tiiiu  ri-cfdcs  ti- 


'U|'|«l 


'1  two-thinls  .>!'      iiiilliiintrf 


ill      1„  ,|„-  vertical  i.irri.liai.  tlir  .•>(■  will  n-w  !«■  inynpic  1  D., 

;H.i:..,i."-'"    ;  -     '     ;  „';,„,  „:,k,.  »ii  ti..-  „„.,i.ib„s..i  .ho 

|"'"'";r   ' :  t>  i  ■  v  ■    -n,..  vif.™ run,,,  wi,i,-i, »,,, 

I      tliiir>  I)  have  now  Ix'cnmc  myopic.     I'  ni.n.ua.    , 

I' -~  ii'-i"  -  '  • "''  .  ,        .,      V  1-  1-   ■vi  .  .    V.    re  liVDcropic  1  it., 

II  M  .111.1  /'  /'  on  citlicr  side  ol    I     \  .  \\\  ri    ii>|«  >    i 

"''»';;;;.  t;;;".:;K'."?:'r;:;:™..M n,,i™ .  „.«  .,,,,„-. 

i.  ,iiyo|uci.  1).     11"  -I     -'l-'",.,,,      It  i>;  cvi.lciitlv  evolve,    from 

-T'T  ''''t\  'tile  ,vS;i-'Tv:' one  millimetn.  hehin  1  H,  all  the 
1  mally.  when  the  ■'^'•\  _;'.,.,,  ,„„.  .,   1)..  an.l  the  horizontal 

rr'^:^:^:.^^":^^.  '-1-. ii.i.-..i^^> ■• 

'-W::;;'';h.7^(;:;rS;;:s;:;in«with  a  ..crt^iin  amount  of  Hype. 
Jn        n    m V       ■  Kra.luallv  elonsatinp  his  eve,  or  by  eqimlly 

'  ;■  .-..t    tl/H  conversion  ..f  on.-  vari.'ty  ol  asti-n.at  s.n 
~  '         ;     .    .He^.l  <•.-   verv    fr..,u..ntlv   eitlu-r   th-oujrh    ^ra.lnal 

^^r^;       vr';;;;H,:^;lu.,r.linn..•ri".l....•.l^••-f.l-.t<•- 
.,     F  ,.,.    n-fvM.'tiv.-  ,..Aver  pn»h..'e.l  by  acconm.o. lation.      t 
.,v    :;JIJ  ;:r,m.h.  .l-ul  U-  an  artificial  incr...se  or  .lecvase  of 

V  1,1      !mv..  :      <ti,matisn>,  .•>|H.cially  wh...  pres,..t  m  the  cry^. 

,:l,'      ,...,. luce  c.;si.leraW.;  .l..fonnity  ..t  ••7;!;;;  j;  ^  -,, 
.    ,1„.  iva'on  whv  stars  l....k  lik.>  stars  inst.-a<    of  like  i""  "  *  ^"''^' 
:,;,      .riiilht    as  thev  should  -lo.  is  hcause  ot  ""^  l^^yl;  ,  f  ^- 
,;L,  1,?^  lens  .hu>  t..  the  star-lik..  'l'"P"f;":  .f'^:.,^  "  trin« 
;,.    ,,„M,lar   a>r.j;mati»ni   the   amount   of  aist.)rt,on    an.l   b.urnng 

)„  ..a'    ixnuls  upon  the  dOfu.um  image..     lu«,K.-ct.on  of  1  -g.  5- 


102 


77/y-;  i:yk. 


will  show  that  at  I  tho  difl'iisinn  imago  of  a  point  will  he  a  liorizoiital 
olli|)sc,  E;  at  II  a  horizontal  line,  /«';  at  III  a  horizontal  oval,  (! 
fwhirli  as  the  n-tina  recedes  will  be  converte.l  first  into  a  eirele,  then 
into  a  vertieal  oval):  at  I\'  a  vertical  line.  ./;  and  at  V  a  V('rtical 
oval,  K. 

At  II  the  iniape  of  a  point  is  a  fine  horizontal  line,  and  the  image 
of  a  horizontal  line,  which  is  nothing  Imt  a  series  of  jx.ints  stnuig 
along  horizontally,  will  he  a  series  of  faint  horizontal  "lines.     These 
by  successive  overlapping  will  reinforce  e.-icli  other  and  form  a  broad 
<listinct  horizontal  line  a  little  thickened  an(  I  hazv  at  its  ends.  (Fig.  5.1) 
«)n  the  other  hand,  a  vertical  line,  being  comi)osed  of  a  row  of  points 
oil.'  above  the  other,  w!"  („,•„,  .an  image  made  up  of  a  .set  of  faint 
horizontal  lines  one  alx,.,    the  other,  and  will  thus  form  a  dim    hazv 
more  <.r  les.s  broadened  band.     Hence  it   is  .seen  that,  although  the 


r\u.  :a. 


B 


I) 


B 


I,m.«i^  -r  a  I,,,,.  r..r„u.,i  i„  uMiLMn.ui.,,,.  .1.  a  v.Tli.-al  lino  co.isl.tinK  „r  a  viTlioU  r.n»  .,1  ,.„„l. 
/(  .t.s  ,„«,.■  »lK.n.  a.  in  ri„.  r.j.  n,  ,h,  voriln.l  ,„iri,lian  „f  th..  .ye  is  un„noir„,,i.  :  r  its  hnaee 

' '"■""'  "f ''/""■  '"  I-""-^  -''^'  •>>■  ^"1^-  '     it'  l>n''S.'.'  «h..i,  ,l,e  virtual  m.ri.lia,,  ,.f  ,1  '"'ve    « 

I'mniriri.,,,.-;  /,  i,.  n„aBi'  »Irmi  Ihc  l„.ri/nnial  meri.liaii  „i;he  t-.w  In  cTOinttroiiK-. 

vcrticid  nieiidi.ui  is  emmetropic,  the  image  of  the  \Miic;ii  line  is 
very  indistinct  and  th.'  im.age  of  a  horizontal  line  is  (|ui'  sluirp 
All  object- will  appe;ir  dr;iwii  out  into  horizontal  iJKs. 

At  i\  all  objects  will  appear  drawn  out  into  veitic;d  lines  and 
c(mse,|ueiitly,  althopgh  it  is  imw  th,-  horizontal  m.'ridian  that  is 
eniiiielropic,  the  horizontal  lines  aiv  seen  most  imlistinctlv  and  ver- 
tical lines  most  cle.irh-. 

Ill  other  w.ads.  in  >imple  ;isti^r,„Mtism.  nivopic  or  hvpen.pic  fhosr 
lu„s,,r,  >,,/,  m....'  ,/,.-/n,r/h,  nhirh  nn,  al  rn/lil  am/Irs  lo'lhr  rmmrtn.nir 
Inir/iliilii .  ' 

It  will  also  br  readily  >eeii  th.it  when  the  IVtilia  is  ;it  H  a  s.iu.'ire 
WuiiM  |,„,1,  IJI,,.  ;,,,  ,i|,|oim;  drawn  on.t  hiterally.  with  i!ie  (.•...-  ,|i-i:i-.,.{ 
^iii'l  llie  -ide<  blurred:  .a  circle  like  a  horizontal  ov;d  etc  '  |f"the 
leiin.a  were  al  W .  the  re  else  elTecl  Would  be  pro.luced.     In  fact,  as 


iii:riiACTrvi-:  khrors  ix  hesehm.. 


103 


. i„  ,.,i.r„u.lisn,  .■h:.n<ros  from hypon.pu'  to nnxo.l,  an.l  llu>n  to  n.>..l)    , 
,,;„.„.,•  of  th..  .listortion  will  .-han^..,  so  tl.at  sun.etim.-s  ...e 
.1  .    , 'tin,...  anotluT  s,.t  of  liiu'S  will  appoar  .l.stHU-t,  un.l  objects 
....,„  to  1...  -Irawn  out  now  in  one,  now  «.  anotn.-r  -I'rcH't.on. 

H..ia.-s  tlu-s..  distortions  of  shape,  asti^nuitisn.  pro.  uc-s  ^"'nu'CulaT 
,,,„  ,  nhj.rts  smuinK  to  have  close  to  them  a  la.nt  sha.low  of 
;i,!:,Xlves  The  position  <.f  this  .l<.ul.i.«  inuvRe  will  vary  aeconhng 
■,,  111,,  direction  of  the  i)rincipal  meridians. 

A    oii^odation  and  Astigmatism.     As  we  have  n.,ted    ^^^T^^ 
,•„;:  frmiientlv  alters  the  character  of  the  astijin.atism    changing 
!'"  ,    ;    vp,.n.pi<'  to  mixed,  and  then  to  myopic,  to  smt  th,.  need 
.  pSenf    vision,  but  it  rarely  changes  its  amount,  at  least 


i,.iiilhulnr  to  till'  iixt:'  Hri>  I'lniviMUi'i!  1"  •"■ 

,  ,,,„i.,llv  We  do  however,  fin.l  in  a  certain  mimber  of  cases  that 
:  '  :;ln;2;.  i  Vn.a,er  under  atropine  than  without  it  U-.  m. 
„     .,   .ui)pns..    that    the   acconnno.lati..n    had   coi  ceale.1    y- ; 

„„„„t  ,1  it  An.l  occasionally  the  astigmatism  becomes  le>s,  an, 
:;i..  „.■„■<  when  ••itropine  is  instilled.  fro>n  which  w.  should  inlei 
V  a-JSnatisn.  to  be  a  ipurious  one.  produced  by  une,,ual  accom- 

"clrlrctiofof' Astigmatism  Astigmatism  -nay  then  "'i;;^  '•';';;; 
,,v  ,o  a  vnv  slight  extent,  be  corrected  by  ''--'^''-f  ';'"^„,.;  , 
,;,,    ,,,,„„;„..datinM.    while    leavn>g    th..    ''"7"   ,;;^    r; '^f  f 

1,., 1.  ..,tT..,.ts  the  visi.m   fav..rablv   by  a.l.iustmg  the  .'><>    - 

;,„;.,..,■;  ..ts  .-f  lin..s.     a,.  ..y...  t.-r  instaiHv,  wh.-h  ^. 'I'    -  ■•"'^' j 
.„.,t<tl  by  Fig.  52,  U.  will  s....  h..nzoiital  lin(.s  .listincth.     but  m 


1(14 


77/ A'  i:yj-:. 


roadinp:  and  manv  othor  visual  acts  it  is  iiuportaiit  Id  sco  vertical 
lines  distinctly.  This  the  i)atient  may  do  by  exeitinfj  his  acconunn- 
dation  so  that  his  condition  is  changed  to  that  of  I\'.  He  will  then  see 
vertical  lines  distinctly,  and,  if  it  is  also  important  to  see  horizontal 
lines  distinctly,  he  may  do  this  by  narrowing  the  tissm-e  of  the  lids 
a  litth-  so  that  he  may  look  through  a  horizontal  chink. 

We  may  also  correct  astijimatism  by  means  of  ci/linders. 

(\vlin(h-ical  fila.sses  are  either  convex  (positive)  or  concave  (uoga- 
*ive).  The  nmirx  cylindrical  e;lass  siiown  in  Fip.  ")4  is  a  slice, 
A  li  ('  1),  taken  from  a  cylinder.  The  line  I'J  F,  parallel  to  the  axi.'. 
of  the  orifiinal  cvlinder,  is  called  the  axis  of  the  glass.  Rays  .such 
as  /  /  ent<M-ing  the  cylinder  along  its  axis  K  F,  pass  through  it  in 
tiie  i)lan(>  F  F  (I  11,  and  will  undergo  no  refraction,  because  tlii'  lines 
they  cncounterare  notcurved  but  .straight.  Rays,  on  the  other  hand, 
IS  A'  A',  entering  the  cyUnd"r  in  the  ])lane  ]M'rpendicular  to  its  axis, 
will  be  refracted  just  as  in  a  spherical  lens, 
for  they  will  strike  a  lino,  /.  L.  whose  curva- 
ture is  a  circle,  and  they  will  therefore  come 


U 


Jp 


r. 

"iimvi"  cvlinder. 


to  a  focus  at  a  j)oint,  M,  behind  the  glass. 
Rays  passing  tiirough  the  glass  ol)lii|uely  to 
the  axis  will  also  be  refracted,  but  not  so  nuich 
as  A'  A',  because  they  strike  a  line  which  is 
less  curved  than  L  L,  and  they  will  hence  be 
focused  at  a  point  behind  .1/.  The  more 
inclined  the  rays  are  to  the  axis  F  F,  the 
more  they  will  be  refracted. 

Hence  a  convex  cylinder  is  a  glass  which 
along  its  axis  produces  no  refraction,  that  is, 
acts  like  a  plane  glass.  .\t  right  angles  to 
its  axis  it  produces  its  maximum  effect,  and 
in  intermediate  meridians  pidchices  an  effect 
.vhich  increases  with  the  inclination  of  the  meridian  to  the  .axis. 

.1  cnanr  cylindrical  gla.ss,  .1  li  ('  I)  E  F  (i'ig.  .V)).  rejjresents 
the  cast  of  a  convex  cylinder.  Its  axis  would  be  /  //.  It  behaves 
precisely  like  a  convex  cylinder,  except  that  it  acts  like  .i  negative 
(<lispersingi  iH>tead  of  a  jiositive  (converging)  lens. 

In  tiaiiiirig  cylinders,  it  is  necessary  -nvo  thi'ir  sign,  strength, 
and  direction  of  their  axes.  Their  slrcn\,,'  is  that  of  their  meridian 
of  greatest  refraction  (  ■  nr— ),  that  is,  the  meridian  a'  right  angles 
1(1  their  axis.  The  ilinrllnti  of  the  axis  is  denoted  in  a  number  of 
ways,  of  which  thn^e  are  indicated  in  I'igs.  .">(),  ">7  .")N.  Whatever 
method  is  i..-ed,  it  is  always  best  to  have  on  prescrii)tion  blanks  a 
diagram  like  one  of  the  alxive,  and  to  indicate  by  a  stroke  on  the 
diagram  the  precise  direction  of  the  axis.  This  acts  as  ,i  useful 
check  and    guards    against    mistake   a.>   to   the   intent  of    the    pre- 

scribfl. 

.\  glass  which  is  comiiotindeil  of  a  spherical  glass  and  a  cylinder 
is  called  a  sjiIk  ni-riilindcr. 


REFRMTIVi:  KRRons  IS  <!KyER.\L. 


105 


In  to^tinR  refraction,  it  is  iniportant  to  bo  al.lo  to  a.l.  and  subtract 
..V  lor  with  facility.  How' this  is  .lono  is  shown  bc-st  ,ha,ra,n- 
.natically.     A  +2  cylinder  axis  (K)°,  for    ihstance.   is  denoted    b> 

0 


+2 


.-+2 


in  which   the  glass  is  .npposed  to  be  seen  face  on. 
n„.ndian  r.Mxis)  is  0  D.,  the    horizontal    niendian   has 


The  vertical 
the  effect  of 


n  {right «»«) 

Flo.  67. 


L<hn 


i;  {riijht '■lie) 

. .,  llK.  cyli.uier  is  dcn..tea  by  llu-  angle  il  makes  w.  h  the  y  rfca^l  «-;""'*•> ;    __ 

i„i-.il  or  on  the  tcn.i-.ral  side,  and  Is  written  as  follows : 

;li>iii/untali. 

Fm.  .T». 


.  .-."n.  .'t  -.'i"l.  etc. 


down  to  ;f   -■■«P 


one  eve,  and  fn,n,  left  to  right  in  the  other.  ''-'7!'*  '' f  •"•'^;' ^^'J^J,^^^^ 
,M,n.«rlnK.  for  the  ri«ht  eye  I.  the  »ame  in  the  symmetne.l  and  the  i^ralltl  mctho. 
1  .r  the  left  eye  the  nunil).'r"  niii  jnst  oinxisite. 


jiK.  .T*i).  while 


106 


a    t- 


////;  /'.lA-. 


I'.  si)li.,  ami  till'  iniiTV 


i'liiiii;  nil 


ridians  have  pffc.'ts  raiipiu};; 


In.ni  0  I),  to 


— •_'  1).  cvliiuUM-  1S()°  would  bo  dcuoteil  by 


-2 


— 0 


anil  a 


L'  SI) 


li.  hv 


—2 


-+2 


+2- 


+2 


I'siiii:  thosr  diagrams 


'.111 


+2 
1  iiotiii}:  the  r(>su 


Its  obtained  by  siipor- 


nnp' 


sin<'  one  sucli  diafiram  upon 


inotlirr,  it  IS  easy  to  prove 


grapli 


Iv  the  following  |iroi)osition: 
1     ■ 


1.  A  cvlinder  and  a  splicnca 


il  ill 


)f  tlic  same  strenjjth  and  of 


o])posito  sijrn 


\c  oiijinia 


ru 


tl 
:l.t 
1.  lso° 
■_'.  '\\y 


s  added  tn^et 
1  cvlindev.  but   of   oppoi 


her  make  a  eylinder  of  the  same  sireiifltb 


:ite  si<£n  am 


1  with  its  axis  at 


anjile: 


to    It. 


Thus 


1.00  sph.    _ 


<i  eviiniler 


;.(H)  sph.    _ 
s  of  tin 


•J.OO  evi.  ( 


0° 


1.00  evl.  !tO° 
-2.(M)  evl.  1(U)° 


+  1.00 


lame  siijii  am 


1  same  axis  added  tofjetlier 


niakra  evliiidci-e(|iial  to  ' 
.  ;i.(M)evl.<.tO°  =-  '  .VOO' 
-  -A.m  evi.  Hf. 


the  sum  of  the  tw( 


Th 


2.(M)  evl 


!K)° 


(■\ 


lind 


cvlinili'is  oi 


em  I 


iinl  to  the  ditTcivnee  between 


!M)0;  -l.(M)eyl.-_'0°  ~    -2.(K»  eyl.  20°  = 

the  same  axis  added   together  make  a 
the  two  and  having  tiie  sign 


if  I  III'  -iron,i:rr  eylimler. 


riuis    •  -.MM)  eyl.7.-)°   Z  ^  l.(H)eyi.  ,.)" 


1.0(1  evl.  V.r 
:!.()0  I'vl.  'Mf 


■J.OO  I'vl 


(i(P 


!M)  ;  vl.  (10° 


}.0(t  evl.  00° 
0. 


1.  CviiiidiT-  of  the  same  slgl 


1  ami  < 


if  I'lrual  streiii 


—2.00  evl.  (iO° 


'\h  erossed  at  riijht 


an>.'lrs  ma 
■10°   ' 


(■  a  ^|llu'ln•al  >riass  < 


if  the  same  streii 


nth.     Thus   •  2.00  evl- 


U(V 


2.00  eyi 
1.00  "sph. 


1S0° 


2,00  sph 


.(M)  evl.  :)0° 


l.(H)evl 


.").  Ci.nverselv.  any  s] 


alcnt    to  two  eylu 


iheiieal   filass  may  be  rei>re.seiited  as  equiv- 
<tren<;th  and  same  si<;ii  erossed 


dci's  of  the   same 


at   n 


rht  anirle; 


<l  at 


0  \nv  two  evlinders,  «  and  h.  of  the  same  sijiii,  when  erossea 
rjoht  angles  make  a  spherieal  filass  e.|i.al  in  strenfith  to  the  weaker 
(.^Ihioer  a  eombined  with  a  eylind.'r  equal  m  stren-th  to  tlie  dilTer- 
,,„,.,.  h,'twren  e  ami  />.  and  havh.fi  t!,.'  same  axis  as  the  stronger  e>j- 
i,;,l„,  /,     Thus  +1.'.<M.  .-yl.  00°  Z    -i  -tM)  <'yl.  1S0°  =-    +2.(M)  sph.  „ 

+  1.00  evl.  1N0°.  .    , 

7  \  Z  cvlinder  of  stienjith  n  crossed  at  niiht  ansiles  ui)on  a  - 
.-vlinder ',-f  -tr.',.;rth  h  makes  a  ghi-  whieh  may  be  repn-iMited  a  so 
iiva  -'-  si.h.'riealof,.trenKtlMM-onibhM'dwitha--eylindeio  strenjith 

,;,    .    M  and  havin-  the  axis  of  /-;  or  else  by  „    -  spheriea  ot  streuK  h 
/ nibined  with  a    ,    eviinder  of  strenfith  ia  +  h)  ami  havn.},'  the 


REFKAVTIVK  ERRORS  IS  (lESlUtM^- 


lt»7 


fvliiKlcr  at  rif^lit  iiiidlt 

cal  I'ffcct. 

Ill  sli()i"il<l  work  <<ut  tlicso  |)r<i[)i)sitioiis  by 


■Z  V.  V.'  ,..on..s.ti..ns  sluAV  that  wIu^m  t..  a    -    .•yl.n.l.T  w.  a.l.l 

Vv  i  H  -r  it.    iH-  sa,H..  axis  or  a  -  .■ylin.l.-r  at  r.ftht  ansles    wc 

:,/,/  n  mud.  to  tlH.  evlHulrical  .tT..rt;  a.ul  wh.-n  w.-  a.M  to  .t  a 

'''''.Ji.  in  tl...  san...  axis  or  .    .    c-ylitj^.-r  ..   n.l.t  and.s.  w. 

„/,/;,„■/  iust  so  nmch  from  tlic  cyimarical  .'ftfct. 

';';■  ::'"J;;;!  llLp'^s  aho^;;  l..ili.-at.-a.  an.l  l.y  ♦•..  sa,..,.  means 
"Cm  ..Iv  al  kh  t^  of  prol,l..ms  .•onnect^-l  witl.  c;yjinaru-al  c.un- 
,  ,r    mt     li.  .".n  .lo  sucl.  problems  at  onee  without  stoppn.g 

:;;  r."  '  al;  mtU  helan.loth^-  hewillbeeonsi.le,..  y 
i;.;„:ii",ppe.l  i..  an  phases  ..f  his  refraction  .,.rk,  an.!  will  seareelj  be 
,1,1,,  tu.lo  it  with  either  rapi.hty  or  preeision 

V  ...<i.,nallv  preseriptions  are  se...  in  whieh  two  ey  nul.'rs  an-  or- 

„,      ;.;  ;.l„.;'e.'to  eaeh  otlier.     -   'h  a  eon.lnnatum  c-an  alw.^ 

I  ,    V,  v..-nt  Ml  bv  me  eviie.ler  eombined  w,th  a  spluTiea  glass,     lo 

„   ,      ,:      ,    tren.nh  of  th..  axis  .,f  the  eylin.ier  an.l  the  s  reufith 

:  "nl  e;i<.nWr  ^s  in  these  cases  requires  a  trifion..n,etneal  e.,  eu- 

.   ,  .Iv  when  .•vlind.-rs  are  con,bine.l  with  then-  axes  e.th.. 

:  ';,:;„,!;,  ,t  ri.h.  anjrle;  that  the  .-.uivalent  jrlass  ,>,hero-eyhn,le,, 

■  viin.lrr    or  s|>here)  can  b.-  f.mn.l  by  the  above  snnpe  rules. 

A    'I'hVrieal  lens  .nay  be  n.a-le  to  have  the  e/M  .,1  .  ajluukr  b> 

iiiiio;  ii  iMiiicr  sideways  or  wy  an' 


'A^Ucation  of  CyUnders  to  Correct  Astigmatism      It  is  ex 

..^ff!.r,n,.  lo  IM,.  :.l.  that  uv  n.nv  '-''^H.^e  eo..,:it.o..  1       o     ■ 


down. 

It  is  evident, 

.iditio.i 
I  |,v  ..,.r-  .•tn.jlThe  Ii  D.  of  hyperopia  with  a  ^  ■[  D.  sphe.-.n.h^la---. 
,.  will  ,vn,le7  the  verti..al  n,e.-i.i;,M  e.n..',et.-op,e.  a.';!  ;;'ll  ''"I"  '  «• 
^,y:n.pinof,h.-ho,-izo.,tal..u.,i,H;u.fn..,Ul>..ob     .     N.^^^^^^ 

,„  „>•  V  -il  er  cMiJition  V  into  eon.ht.on  1\  by  n.r is  .1  a  -.}  H. 
„:     Vi      s.  Jhien  will  .li.nh.i^h  the  n^l.-a.-tion  ol  all  the  .ner.d.ans 

'v  .  nno.n.t  a...l  will  ...ake  th.'  ho.-i.outal  n.e.-.u.a..  enn..et.opu 
,  I  .  x" vt  "  d  n.e,-i.lia..  n.vopie  .1  1).  Lastly,  w..  ...ay  elunjje  eo,,- 
i,  11,  ,o  CO,  h.i..n  iri.v  ad.linff  a  -2  l)..an.l  .nt..  eo..ud,on 
'  V        I    1  a   -.  »  1).  spl...ri;.al  glass.     Thus  at.y  lor...  of  ast.gtna- 

'i;.  ■;'  be':.o,.ve,.ed  nito  si...pie  i.y.-op->: -t;.;:;^r  Sif^ 


bvn,ca..sot  a  sph.'.ieal  glass.     It  ivmains. 
inav  con-eet  si...ple  astiginatis... 


)\vn  i.i  Kig.  ")-  at 

,laci'  the  inactive 

al  meridian  of  the 


lallslM 

T..\'o.i.'et  the  si...ple  hyperopie  astig..iatisn 
il    we.houldusea    f  f.  D.  eyl.  ax.  00°.      Ihis' 
.i-,,!  Iheevlhideroi.positetheenm.etropicv( 
.,        ,  ,p,,„.i„.  ,lu.  h:..i:'.o.,tal  ..uM-idia...  which  is  iKvpenjp.c    , 
,,„„  „i  ,     „,,io..  ..f  ......  glass  which  a-ts  like  a  +<>  sph.     (  ppos  t 

■:,„';'  ..leriaians  of  the  eye  which  g.'adually  .e.-.-ease  .n  rel  ,c^ne 
,,„,  ,■,.„„  ..uunetropia  to  a  hyperop.a  ot  (.  D..  we  ,.!ace  a  glass 
iiirii   ir.ailuailv 


nil  iiie.-idia...  therefore,  ... 


•perop.a  oi    n  w.   »<    i""^>    ••  i~_    ^ 
fractivc   (lower  from  I)  to    f()   v 
turn  has  its  deticieiK  y  in  .cf .active  poNV.-r 


•etei 


I,  anil  thus  is  n.ade  e..unet.()i 


)1C, 


108 


N>, 


(i  cvl 


>;.   lS(t°. 


t   the 


Till-:  j:yi:. 


l-i)ll(lltlnll    slKIWIl    111 


IV 


slimilil   use  :i 


lis  w null  I  ciirrcc 


t   tlic  iiiyopia  nt  tlic  vcrticiil 


111(1  iif  t'iicli  siKTcctliii}:  .iicriiliaii,  aii< 


1  leave  the  lidiizii'.tal  lueiuli; 


111 


eiiiiiieli't)l>i('. 

A  little  eoiisuleratidii  w 
asti<j;iiialisiii  we  may  prnceei 
luav  place  hefore  the  eve  a  mnrc.r  v\ 


ill  slii.w  that  to  oiiieet  any  ease  nl  regular 

•'••l  ill  either  one  of  two  ways.     Hither  we 

v.i.r.M-  i-vlinder  of  a  strength  equal  to  the 


anioiiiil   ol   asliy;iiia 


tisni.  with  its  axis  ui 


the 


"liiliaii  of  {ireatesl 


fraetiiin,  and   then   coin 


ret  rat 


correet  the  refraction 
cyliniler  of  the  sanu 
refraction,  am 
of  this  iiK 


bine  tliis  with  a  spherical   f^lass   that  will 

-f   that   nieri(li;'n;  or  we  may  use  a  cnnntrr 

treiifith.  with  it.  axis  in  the  meridian  of  least 

1  add  a  s|)liencal  flla.ss  that  will  correct    the  refraction 


ridi; 
()  cv 


Thus 


ditioii 


I  iiiav  he  corrected  either  hy  +'.i 


>  ,  1.,  ax.  1)0°.  or  ^  !•  spli.  Z  — ^'  •'>■'•  ='^-  1^"°  -'•  <-'■'  ^^'•'  '"^'V 

,,.^., li'tinn  I  as  heiiiR  condition  II.  in  which  the  retina  has 

been  brought  forward  1  inni..  or  in  which  all  of  the  meridians  ol  tl 


refjaru   com 


eye  have  a 
as  condition 
that   all  I 


like  been  made  -i  D.  more  hyperojiic;  or  we  may  rejiar. 


1  it 


I\',  ill  which  the  retina  has  been  advaneeil  .i  mm.,  so 
diaiis  alike  have  been  iiiad(>  more  hyiieropic  by  !)   I). 


Ni  com 


litioii  11  may  be  corrected  either  by  ^(>  cyl.,  ax 


00° 


or  I IV 


()  sph.   r  — •>  '".V'-.  "X-  1'*^'^^  conditioi 


III.  either  by  —1'  sph.   _ 


()  cvl.  00°  or  by  +4  .sph.  _ 


cvl 


l.SO° 


by   — (>  s])h. 


0  cyl.  1S0°:  condition  IV.  by  — tl 
()  cvl.  '!K)°;   and  condition  \'.  by  — :'. 


1.  -^  +()cvl.  00° 


sph,  r  — (1  cyl.  1S0°  or  by  —0  cy 

In  jieiie'    1,  when  possible,  we  ])refer  to  combine  a 


sphei 


wit  I 


.-liiider  or  a  —  sphere  witl 


—  cvliiider.  rather  than 


combine  spheres  and  cylinders  of  opposite  sifjiis 


Nome  pr 


■(>fer  to  correct   a  ca 


<e  of  mixed  astimiiatisin   liv  rnissri. 


•:lliii(lcr>'.  prescribiiifi.  for  instance,  iii  c; 


1S0° 


Tl 


lere   is  no  s| 


leciji 


ISC 


advantasic  m 


e(|uivalent   prescription, 


i  sjih.  r 


HI. 

thi; 
A\  cvl 


4 


cvl 


+  1)  cvl 


otr 


aiKl 


th 


atter  iisiiallv  are  onlerei 


1S0° 
I. 


00° 
fripti( 
or  - 


_•) 


cvl 


i'r  the 


sph. 


Anisometropia,     .\ir  oiii(>trop 


liffers    m 


not    imcoiiiiiion. 
difference  mav  b 


i;i  is  a  condition  in   whi''li  one   evi 
its 'refract  ion    from   its   fellow.     Sli<;ht  decrees  of    it   are 


are    rare.      In    some    c;i~:(>s    the 
ascribed    to   pathological    influences   wliich   have 


silt 


\>'h    degree; 


ITecti 


liiferelitlv   the  two  eye: 


but    more  often   no  cause  can 


ascertained. 


Th^ 


more  ametropic  c 


ve often  has  very  jxior  sight,  and  fre<iiieiitly 


qll 


int^ 


ivergeiit    strabisliius    iKing 


particulriiiy   common. 


.\parl 


from  true  s(|Uiiit,  liyperplioria  :i 


ind  other  anomalies  are  more  IrequenI 


in  aiiisoinetropK 


thai 


I  in  other  eves. 


SYMPTOMS  OF  REFRACTIVE  ERRORS. 


Varieties  of  Symptoms  Common  to  all  Errors.     The  main  direct 
-symptoms  that  refractive  errors  produce  are  imiiairnient  of  sight  ami 


REfiiMTivi:  j:ju;<irs  is  gkshiul. 


10!» 


,l'll<l 


in  llic  (■yi'>.  1 


ipia.      \\\  ii>^llit  napiit 


is  meant  a  sense  of  f:iti,:iue  ami  (li-coiiilort 


rodiiced  1)V  u 


Tlien 


:iv  l)e  tatijiue  alone  Ui^licniipm 


lit  .r  I . 


I  li- 


the fatiKiic  may  l)e  aceonipanieil  l)y   pain   in   tlie  <'y 


,,,.ll.i  iii'ptd 


tigui 
iliilois),   pain    in 


>iiinii( 

,.-il.< 


■lival    irritatiDn    inai 


the  liead   [nMln'iittim  irjihaldliiiiv),  or 
lifested    bv   hicrymation  and  eonftestion 


"/' 


■((    irrllniis) 


Phis  hist   niav  h'ad   to  actual   conjunctivitis 


id  liiepliariti 
A  iieculiar 


t'onn  of  asthenopia  (/«(/«»r((W'»  astlimoiiiin  is  that  in  which 


-(■use  (I 


ii'  vertijio,  contusion,  am 


1  uncei-taintv  is  induced  l)y  lookinji 


at  ninvm 
.■ilTecle( 


<s.  and  esi)ecially  at  hiillian 


tlv  illuminated  ohjects.    Person? 


-Iio 


watclnii'; 


1   with   this  symptom  often  suffer   considerable  distress  from 
tore,  or  walking  in  a  crowded  street,  or  from 


ppini;  m  a  cmwdei 


Astl 


pnieessions,  hall  n/iV'hes,  or  play 


leiini'ia  may  o 


led  this  is  done  as  soon 


ill  niaiiv  case 


ten  be  r(>lieved  by  ceasing  to  use  the  eyes,  pro- 
the  syiiii)toms  manifest  themselves  :  but 


it  iM-rsists  for  iiours,  or  ev 


en  until  the  following  day. 


Ill 


SOIIK 


cases,  again,  tisthenopic  symptoms  ( 


1(1  not  appear  until  the 


inlldwing  dav.  ,  , 

Tl„.  .ause-  of  aslhenoi)ia  from  refractive  .rrors  are  partly  undue 
.„-,.,iuini."lative  effort  inrrommoddtivr  <,slli,',„>ina):  purtW  Xhoprv^i^un- 
,,„  the  eve  ami  the  congestion  of  the  lids  pioduced  when  the  latter  are 
„iu.M./e(i  together  in  order  to  narro  v  the  palpebral  fissure,  and  thus 
,.,' able  the  patient  to  see  more  distinctly  {tarsal  (islhe>u>i,ia):  partly 
.,  Itiain  imposed  ui.on  the  external  muscles  of  the  eye  {muscHlnr 
„,/,,,,„):  and  partly  over-sensitiveness  of  the  retina  {rc/<«« 
„sil,rJi,ia).  it  is  enhanced  by  anything  (bright  lighting,  etc.)  that 
,!iake>  unusual  demands  upon  the  eyes.  ,  ,       , 

li  .hould  .e  noted  that  asthenopia  is  by  no  mcflH.s  alirmjx  diiv  <> 
,,  rorhn'  .nor.v  It  is  often  due  to  muscular  anomalies,  particularly 
...Mivrrgence-insufficiencv  and  hyperphoria,  an.l.  in  not  a  few  instances, 
.,,  nasal  atTections,  such  as  jtressure  in  the  region  of  the  middle  tur- 
!„.,  ites  Someof  themo,st  severe  and  obstinat.' ca.ses  I  have  seen  have 
:,,.„„  ,iue  t.i  this  latter  cause.  Such  ca.ses  are  apt  to  be  as.socia  ed 
,,v,th  marked  eveache  and  occipital  pain.      Again,  a.sthenopia  is  oiten 

In,    I urasthenia  an<l  other  conditions  marke.l  by  enteeblement 

.1  I  lie  mavous  svstem.  ,    .     i 

i^esides  th."  headache,  .'veache,  etc.,  that,  .is  noted  abcjve,  may 

, ,  uiimanv  asthenoiiia.  or  inav  also  occur  imlei)en.lently  ot  it  m  con- 

,,,i„i'    with  refnictive  errors.  w.>  find  occasionally  oilur  .viniptomx. 

ail  a<  naus..a.  interterence  with  mitriti.m,  various  parasthesue,  etc 

!';.,!  Ti.aver  reflex  manifestations  (epilepsy,  chorea)  ever  are  caused 

.,    nira.tive  errors,  is  doubtful,  although   there   is  no  question  as 

,h,.  pnipri(>tv  of  correcting  such  errors  in  iM.rsons  afflicted  with 

..  n'ain,ses,'and  thus  ivlieving  them  of  at  least  one  sour.-,    of 

Symptoms  in  Myopia. 


'1^.    W( 


„,.  tind  that  in  myopia,  wiieii  m.t  of  inordinate  aiamint,  the 
nni.tom  >.-  .lie  inifwirment  oj  rish>,  for  distance,  which  is  -r.-ater 


It  '      I 
It 


110 


Tllh:  EYE. 


ti)  tlic  ilccico  of  lu'iusifilit.     Tlic  sijilit  t'lir  near,  i>n  thf 
tlicr  liaiiil,  is  very  disl'mct,  objects  appfaiiii^  not  only  clearer  cut 


in  |iro|)ortion 


:o  ina 


Init  al: 


isewinii,  einhroK 


)rk 


^nilietl,  so  tliat  tiie  iiatienls  are  ai)le  to  »lo  very  fine  W( 
lerv).     Al  the  same  time.  oi)jtH;ts  are  lield  very  close 


aixi  if  l)inociilar  vision  is  inaintameil,  tlie  excessive  convernenct 


[•ITort 


nay   produce   asthenopia 


The   l)lurrin.i;   in   distant    vision   nsyal.y 


causes  no  discomfort  in  ordinary  myopia,  but  in  low  myopia,  wheiv 
the  hlurringissliniit  and  the  patient  makes  constant  fruitless  etVorts  to 
see  distinctly,  a  ili.sa)ireeal)le  asthenopia  may  develop,  which  is  re- 
lieved by  a  concave  gla.ss. 

Ill  hiph  myopia,  particularly  when  there  is  advanced  sclero-choroi- 
ditis  posterior,  there  may  be  aching  {xiin  in  tlie  back  of  the  eyeball 
'■     '      '  has  tla.siies  of  r  ,. it,  asthenopia 


and  symiJtoins  of  retinal  irrildlioii.aw 
from  hviiera'sthesia  of  the  retina,  etc. 


lyjx 
In  myopia  tnu 


scfc  rolildiilcs  are  fre<iuent.     This  may  1m'  no  mop 


than  a  noriiiai  phenome 


non,  wliich  is  accentuateil  here  simply  because 


the  myope  sees  in  a  sort  of  haze  or  cloud  upon  which  lie  readily  pn 
jects  tile  floating  black  sjiecks.      In  high  myopia  the  floating  bodies  an 
larger,  and  are  (>vidences  of  ii(|uefaction  of  the  vitreous  itself  <hi( 
to  disease  of  tiie  fundus. 
Symptoms  in  Hyperopia.     In  liypero])ia  of  moderate  degree  tin 


sight  is 


1   for  distance  and  near;   and  if  the  accommodation 


effective,  is  performed  without  stt.iiii,  am 


hence  without  asthenopia. 


When  the  accommodative  power  is  low  as  comi>arcd  totlie amount  of 
liyperoi»ia,  nstliiiiopld  develops  for  near  work,  and  later  for  ilisiance 
111  high  degrees  of  hyperuiiia  \\\v  ."itiht  h(()ins  to  he  hliirml  for 
nd,  as  accoininodation  diminishes,  for  distance  too.  At  first 
the  blur  itself  is  momentary  only,  the  sight  clearing  u])  as  soon 
as  the  patient  rests  the  eyes;  but  later  on,  tlie  interference  with 
sight  becomes  m<ire  and  more  constant.     In  very  high  hyiiempia  the 


also, 
near,  a 


jiatient  never  set 


distinctiv  either  for  distance  or  near 


tism  tlie  sislit  is  blurre^ 


As  soon  as  the  vision  iK'comes  indistinct  the  astlieiiojiic  symptoms 
generally  cea.se,  because  the  patient  no  longer  tries  to  accommodate 

HciKlficlics,   fjicnrhcs.    etc.,   are    not    very   common    in    hyperopia 
uncomplicat'-d  by  astigmatism 

S3rmptoms  in  Astigmatism.  In  astigina 
by  the  characteristic  diffusion  images.  There  is  niorc  or  less  ills/(,rti(»i 
of  oiijects  looked  at,  and  there  may  be  wotiociildr  diplopin.  Moreover 
if  the  patient  be  using  his  accommodation  to  adjust  liis  vision  for 
different  lines  in  succession,  he  will  see  first  upright,  then  horizontal 
lines  distinctly.    This  produces  in  him  the  i>tTect  of  an  (ipinirenl  iim 


>l  of  I 


bject> 


that  wlieel-liki>  figures  ajipear  to  revolve  and  check 


patterns  to  dance.  The  re 


■suit  is  often  a  sensation  of  (rr//*/o  and /('»''■-<'«. 


For  the  sa 


me  reason  panorama  asihrnapia 


is  common  in  astigmatism. 


<  'r•■!in;^■^■  "^-ihrDiipiti  cki 


bineil  with  hcadachv  and  eiivurlu  '<  frei|uent. 


particularly  when  the  eyes  are  u.sed  for  near  work,  lik.  reading  or 
sewing,  which  re(|uires  accurate  definition  of  the  outlines  of  objects. 
In  low  astigmatism,  cunjunrtival  irritation  and  blvplutritit;  are  not  in- 


lih. 


Ill 


KFH.UTIVE  EintoRS  IS  CEM.KMj. 

mM|iiciit.  These  mio  doubtless  due  to  the  fro(|Ueiitly  re|.c:ite,l  sln.iin 
n.iitnictiiin  of  tlie  li'ls  iiia.le  in  order  t..  narrow  the  i.:il|.el)r:il  aperture 
;ind  thus  eiihanee  the  eleani<-ss  of  sijilit.  Tliis  euulraelioii  leads  to  a 
mere  nr  less  pertiuuietit  venous  congestion. 

QENESAL  £EMABKS  ON  METHODS  OF  EXAMININO 
FOR  REFRACTIVE  ERRORS. 

Varieties  of  Tests.  Routine  of  Examination.  We  have  various 
means  for  examining  tiie  eye  for  refraetive  errors.  In  some  ot  the 
lest-  used,  such  as  the  tests  of  visual  acuity,  trial  case  tests,  and  astiR- 
mitic  charts,  we  are  depen<lent  upon  the  patient's  stati'inents  of 
what  he  .sees.  Tiiey  are  Ik'Hcc  called  si,l>j,rtirf  h:sls.  In  others,  such 
•H  "those  made  with  the  oplithahnometer,  the  ophthalinoscopo,  and, 
>kiascopy,  we  are  inde|K'ndent  of  the  patients  statements.     These 

are  the  ohjcclire  lesh.  ,      ,  ,  ,  i  •      i 

Isually  both  subjective  and  objective  tests  should  be  combined 
ill  iii'dviiif;  an  examination.  Sometimes  the  sul)jective  tests  are  uiap- 
piicible,  as  in  children  and  illit.Tates;  but  whenever  they  can  be 
'luplie.l  thev  should,  in  Reneral,  constitute  our  court  of  last  resort,  aiul 
1  lie  evidence  derived  from  them  should  outweijih  that  of  the  obj<"ctive 
methods.  In  other  wonls,  the  correct  inn-glass  determined  on  is  that 
wiiich  gives  the  patient  the  best  vision,  an<l  not  that  winch  is  api)ar- 
,.-,itlv  shown  bv  the  ophthalnioscolK-  and  shadow  test. 

I'ractitioneis  differ  a  great  deal  in  their  estimates  of  the  relative 
vihie  of  the  tests  and  the  wav  in  which  they  .should  be  applied  in 
orictice      It  prol)abiv  makes  little  .lifference  what  routine  we  adopt, 
provi.led  it  be  svstematicaliv  jmrsued  and  contains  a  sufhcieiit  number 
„f  te<ts  to  act  ks  checks  upon  each  other,  and  tlms  ensure  certainty 
,,r  re-ult      I  shall  give  bri<'i1v  vnj  oin,  widinv.  premising  that  I  do  not 
,v.nr,l  it  as  essentially  superior  to  any  other  that  may  l)e  adoiited. 
^rt.Ttakhig  the  history  and  getthig  at  the  symptoms  I  make  an 
rxternal  and  an  internal  ,:xaminatio„  of  th."  eye,  using  in  su.'cession 
..MiMueilhuninali.m,  direct  illumination  by  transmitted  light  with  ..>e 
„,,l,thalm..scoiK>  at  ten  inches,  examination  with  the  ophtha  n.oscop.- 
1,  ■  the  in.lirect  method,  and  lastly  examination  with  the  ophthalmo- 
-;■„,.,>  bv  the  direct  method.     From  this  I  gather,  whetluT  the  eye  is 
i„,,ltliv'or  not,  the  probable  amount  of  vision,  the  pr.'seiice  o    opaci- 
ue.  or  other  .lefects  infrfering  with  sight,  and  ai-proximatebj  the 
-late  of  the  refraction.     F<.r  the  latter  puri)Ose  I  often  ad<l  an  oHIiand 
-timate  with  the  shadow  test.  ,      ,,,  ,  .  ;„  , 

rimse  who  use  the  ophthalmometer  should  here  make  an  (■xamin..- 
i,m  with  this  instrument,  and  thus  .letermine  the  amount  ot  corneal 
-ligmatism.     The  same  thing  may  be  roughly  d..no  with  the  I  laculo 

'tthen  take  the  patient  s  vision,  and  iH-gin  tlie  test  with  the  trial 
,M..  proceeding  in  the  way  hereafter  descril)ed  to  determine  rapidly 


m 


112 


Tin:  t:Yh:. 


tlir  Kla.--'  tliiit  (■itriccl-  llir  niaiii 
tlif  |);iliciil's  vision   Inr  in':ir.  iiiu 


rcadiiiy:. 


If, 


ill    llll'Sl    lll>t!llHM'S 


ill-til   IhiiiiMtnipiiif.  ami.   iiiiiiuM 


i'csl  crrnr.     I  at  tin'  >aiiir  lime  ti'-t 

I  tiiid  llic  tflass  that   suits  iiim  lor 

1  wisli  tn  use  a  cyclnpli'nic,  1  tlll'll 

liatclv.  licfniv   tlic  linin  lias  time  li> 


I't,  make  the  iiuiscic  tcsl>.      i-atcr.  w 


li>'ii  till'  (•vcliii.lc>:ic  a<li<>ii  I 


>(  th 


hitiiiatrnpiiic  is  (■oini 


ili>l( 


,  or  iiraiiv  so 


I  (li'tciiniiii'  tlic  iciractioii  w 


itii 


ski 


ISCdpV, 


'riu'ii  1  ciiiiliriii  nr 


iinHlit'v  this  result  with  the  trial  case 


and  tiiiallv  rUt 


rk  (ilT  these  last  results  afiaiii  l>y  skiaseojA 


111  certain  cases,  as  in  chiiilreii  am 


I  ill  verv  nervous  penple,  it  save 


time  am 


1  is  less  tiresome  to  the  patient  to  cut  the  subjective  exaniiiia- 


tioii  short,  and  to  proci' 
the  shallow  test,  iiiakinsi 


■d  at  once  to  the  oi)jective  examination 


with 


thi> 


elullv  as  possible.     Isinj;  the  cor- 


rection tliiis  found  as  a  basis,  I  ajcain  ma 
ami  now  }:<'ii<'i"i>lly  •'""'  ''"'^  ''"''"''  ''^  ^'' 


ke  the  test  with  the  trial  case 
little  left  to  do  in  order  to 


helinarresiilt,so  that  now  I  do  not  have  to  tax  the  pjitient 


arrive  at  t 

attentioii    unduly   nor   mtike    miu 


h   ilemaml    upon   his   patience   or 


judjimeiit. 

The  Use  of  Cycloplegics 

untarilv  exai;};erate 


.\s  we  have  seen,  the  myolH' inay  invol 


his  myopia,  ami  the  hyperope  wholly  or  partlx 


■onceal  liis  hyi)eroi)ia  by  usmj;  his  accoiniiioi 


lation.     Patients  whom 


ill 


we  examine  for 
out  the  precise 
to  alxilisii  the  accomnio( 


are  so 


ai)t 


to  do  this  Jiat.  if  we  wish  to  find 


refractive  state  of  the  eye,  it  often  becomes  necessary 

lative  etTort  altogether.     This  we  do  with  a 

rilv  used  is  homatropine,  a  2  per  cent. 


cvcloplejiie.     The  one  ordina 

solution  of  which  instilled  every  five  or 


ten  minutes  for  five  times 


pro( 


lu( 


■es  111  El 


neral  complete  paralysis  of  the  accoini 


iiodation  in  from 


I  a  half  froiii  the  time  of  the  first  instillation 

fr< 


X  hours.     In  instillii.>r  the  homatroinne  it  is 
to  have  the  patient  throw  the  head  back 


mil 


an  hour  to  an  hour  aiu  .    ,     .     ^ 

The  effect  soon  befriiis  to  wi-ar  off.  and  di>;ipiM'ars  entirely  m  Iroiii 

twenty-four  to  thirty-si 

best.as.Iackson  su-ifiest: .  . 

look  down,  so  that  we  iiiav  drop  the  solution  .lirectly  on  the  upjMT  part 

of  the  cornea.     The  eye  in  which  the  instillation  is  made  should  be 

held  open  until   the  I'latieiit  vohuitariiy  opens  the  other  eye.     This 

])reveiits  his  s(|uee7,ii  <i  the  dro])  out  of  his  eye 

Homatroi)iiie  is  an  ,rrit;int  producing  a  moderat:' coiifiestion  of  the 
eye,  which,  however,  i:'.  transitory,  and  has  no  ill  -ffects  whatever. 
■  Sometimes  .-cpolniinnc  in  0.1  l)er  cent,  solution  is  used,  but  m  my 
experience  it  has  no  advantafjt'  ovor  honiatidpine. 

In  cases  where  we  wish  to  produce  a  very  thorough  and  lastiiig 
(.fTect  — /.  c,  in  spasm  of  accommodiition— atropine  may  be  useil  in 
1  per  cent.',  or  in  i)articularly  obstinate  cases  1.")  jht  cent,  solution. 
This  is  instilli'd  ni^dit  ami  morniii}:  for  one  or  two  d.ays  before  the  ex- 
amination. The  patient  should  be  examined  three  hours  after  the  last 
instillation.    The  j.aralysis  of  the  accommodation  in  these  ca.ses  lasts 

fullv  :i  week. 

\\ilh  the  cvclojilefric  ncdr  rision  for  the  hypermetrope  and 
cmm.'irope  is  rend.'red  impossible.  ( Vcloplejlies,  besides  abohshnifr 
accommodation,    dilate    the    iHipil.     They    hence    render  tlu'  vision 


BEHlAVTlVi:  KlilHtliii  ••>'  iiKXKIlAL. 


iia 


,„  ,n..-tr..,.i!i  wurs.',  n..t  ..nly  l.y  pn-v.-i.tiiiK  acr..mn.o.lativc  effort. 
;,;„  Mso  l.v  inm.asin«  th-  si.,.-  ..f  tl,.  .lilTusmn  mu.p..;  an. 
it  ,-  mnrrallv  fcviixl  tlial  .'V.Mi  with  .nnvctiui.  tl.r  viM.m  uiuI.t  .i 
■v  l„,.l.-iji.-  i;  lu.t  s..  k.rn  a.  with  th.-  pui.ii  .•.mtrart.-a.  M..r..„v.-r. 
,j„. ,  ilataticn  of  the  pupil,  hv  l.-ttin-  i..  an  exress  ot  iijjht  i.r.Mh.c.s  a 
„;;..„„..  ,Wz//.<,  To  obviate  this.  .!>  ,«..ent  "'"y  >";  ;f'; '  ' 
,„  wear  snmke.l  glasses  as  lonp  as  th.-  i  .p.ls  remam  -hlate-l.  tin. 
U.\nii  espeeiallv  ..eeessary  if  he  is  expose.l  to  l-r.^ht  sunh^ht. 

■nu.  i.'.tie.,t"in  xvhon.  atropine  or  hon.atroi.nu-  ha.,  been  nis  .1  e.| 

,houl.l    .e  warned  not  to  Ir,,  lo  use  his  <•//,>■  l<.r  near  work  until  the 

,1  ,,    of  the  .Iruii  has  eon.pl'-t.'lv  worn  off.     Otherwise,  l.y  usu.k  Ins 

:;,:;.:l;;tion  when  stiu'in  a-w.:>kene.i  sta,e.he  may  strain  the 

,.ve     in.l  may  even  eause  a   eoiulition   ol   ciliary  spas  n.        .>..((•  a 

,;„;      si   .  M  not   use  his   eys   for  steady  reading   f-  tlurty-s.x 

,  tter  still   fortv-eifilit  h.mrs  affr  the  last  instillation,  it  homatro- 

l,;;,;.  haril'en  used;  and  not  for  eight  or.  still  Ix-tter,  ten  .lays  if 

•iirooine  has  been  use.l.  . 

1  pen.iK.s,  who  are  so  greatly  .leF.ident  upon  aee..m.no.latio 

,,'    Ivioislv  v.>rvnuH.h  affecte.l  by  eyel..i.legu-s.  th.-.r  sight  b.-ing 

ndeivl  ba.l  f..r  distance  an.l  near.     Myo,H-s,  .>n  the  oth.T  hand,   o 

whom  a<-e...nm...lati..n  plays  but  little  part   in   seeing,  suffer  but 

''f)b.,"v!<rs'dX"r'"a'go(.(l  deal  as  to  the  nece.'^.iity  of  ming cyclople.iic. 
i,.  1,  te  mining  refraction.     In  ..ew  York  they  are  not  so  often  em- 
o"s  elsewhere,  and  many  practitioners  iH-lieve  that  they  can  .  .;- 
i  .:  n'f  action  accurately  without  tlu.ir  ai.l.    1 .1..  ""'I.^'^'^";'",   I" 
,  i  >      I  have  s,>en  a  numb.-r  of  ca,ses  in  which  the  refraction  could  not 
,ve  bee.     leterinined  otherwise,  ami  in  which  a  s..ru.us  error  in  the 
..     J  :.n  W..U1.1  have  resultc.l  if  no  eycloplegic  ha.l  ^;-:  ;'>:'f;  ;^;^ 
Mv  exiM-rience,  in  fact,  lea.ls  me  to  use  a  cycloi)cgic  in  all  casts 
ul     ,.  1  c"  when  the  patient  is  under  forty-five  years,  an.l  in  s..me 
.  wlie    he  "bet .voen  forty-five  an.l  fifty.    It  has  been  my  ex,_H"ri- 
.,   .  th  aduri  g  the  perio.l  fr  .m  forty  to  forty-five  a  cycl..plegic  is 
;;:.cSw  lln^^'ant,  L  at  th^^  tin.e  patients  are  partu-iadyap^U, 
.v  ..t  their  .iccominn.Uitioii  ex.  .>s.sively  and  hol.l  ..n  to  it  tenac  ousIn. 
iV  '  1  ii,U  le-age.l  Pationts  I,  of  curse,  take  care  to  ex.-  u.le  any 
:  .  ii.  ,.  !,f  glaucoma!  in  which  th<.  instillati.>n  of  a  "'y;^';;  'J .  J  "  ^^ 
u'  disastrous.     In  mv  experience,  honiatr..pme  properly  app lie     is 
'        , .    v,st    majority  of   cases,  fully  as   efficient    an.l   reliabh^  as 
:,;,.,!,,;,«>      I  fimt'too!  that  chil.lren  yiel.l  rea.lilv  t..  lu.matropun- 

'"i^v.^;  mif  lu;.;tin'w:M!t;/  complete  re,ara,ion  from  the  use 
,,CCvcl..pl.'gio     This  is  sh..wn  by  the  fact  that  the  patient  will 

■  k.  <.  ine  in.    .me  glas.s.  .soinetim..s  another,  an.l  that  with  the  .<ame 
:  t'^vS    .1  vad.^,  s.,  that,  as  he  says,  "  the  lett.vrs  erne  .uul  go, 

■  he  o  ";"he  tes/  car.l.  FurThe^m■..^  the  result  "f '  j<' "^J-^^; 
.nuination  with  skiasc.py  or  the  ophthalmoscope  will  not  agree 
nil  the  glass  found  by  the  trial  case. 

8 


114 


rm:  a.)>;. 


W'licli  llii-  li;i|i|p<'lis,  \M'  ti'ivr  the  cyrluiilcjric  liiiilc  lime  tn  act,  lillil  ill 
till'  iiiciiiiliiuf  iiislil  it  -I'MT.il  liiMcs  a;;;iiii  al  -\\ny\  interval.-.  It'  this 
fails,  we  sliiillld  ll-r  al|ii|iiii('  ill  I   In  1  ..">  per  I'f'llt.  snliitiiill  -cvi'nil  tillK's 

ilaily  t'nr  a  snir-  of  ila.ss.  Miit  it  is  vriv  i;ii'ciy,  iiidi-cij.  that  ri'>uit 
iim-t  lir  liail  III  ilii-  cxitciliciit 

Keratometry.  Placido  Disk  Determination  <f  Corneal  Curvature  in 
AstigmatiHm  by  Keratometry.  'I'lic  cnnica  acts  kr  ;i  cdiivcx  niiinir, 
,1111 1  w  ill  iicncc  irivc  a  siii,ill.  erect  rellectinii  of  an  .  'iject.  ~iicli  as  ,i  disk, 
|)lacei|  in  t'lciiit  III'  it.  The  inure  cimvex  the  c<irne,i,  the  siiiiiller  this 
rellectiun  i<.  \\  hat  is  true  nf  liie  ciiriiea  as  a  whnle,  is  true  i>f  each 
>e|i,'irate  ineriiliaii  nl  it.  If,  then,  all  the  cnriieal  ineriiliaiis  are  ei|iially 
ciiiivex,  the  rellectinii  nf  a  circiiLir  disk  will  al.sii  In-  circular:  hut  if 
some  inrridiaiis  are  inure  cmivex  than  nthers  -that  is,  there  is  corneal 
astii;inatisin  the  relleclioii  will  he  oN'al.  aiiil  the  siiiall  diaineter  of 
tif  o\al  will  lie  in  the  nieridi.in  of  jireatest  ''urvatiire  or  >;reatest 
refraction. 

This  |irinci|>le  is  utilized  in  the  a|i|ilication  of  the  I'luviilo  ilixk. 
This  is  a  white  disk  heariii}:  a  series  of  concentric  hiack  riiijis  painted 
on  it.  (I'i;;.  2.)  The  ohservi'r,  huldinji  this  iM'fore  the  patient's  eye, 
anil  looking:  thr(iw>;h  the  hole  in  the  centre,  .sees  the  reflection  of  the  disk 
in  tlie  cornea.  If  the  retlc'ii'-,.  is  circular,  there  is  no  corneal  astij;- 
niatisni:  if  it  is  oval,  there  is  lemilar  corneal  astipnatisni,  the  meridian 
of  j;r''!it''^t  curvature  lieiii'j  in  the  short  axis  of  the  ov.-il.  If  there 
is  irrciiular  corneal  astifiinatisin,  the  reflection  will  he  irrejiularly  dis- 
torted, or  will  change  its  shajie  abruptly  when  shifted  from  one  part 
of  the  cornea  to  the  other. 

Since  the  corneal  reflection  of  the  I'lai  ido  disk  ^rows  smaller  as 
the  curvature  of  the  cornea  hecomes  greater,  and  also  liecomes  more 
oval  as  the  corneal  astifjinat'  ■  increases,  we  may,  hy  iiM-asuiiii}; 
this  reflection  accurately  in  its  itilTereiit  diameters,  calculate  hoth  the 
;iclual  curvature  of  the  cornea  in  all  its  meridians  and  the  jirecise 
amount  of  its  ;istii:inatism.  Both  determinations  are  much  more 
rapidly  inaile  with  the  ophihalmometer.  which  in  principle  i-  a  spe- 
cially luodihed  I'la.'ido  disk. 

Ophthalmometer,  The  ordinary  type  of  oplithalinouieter  is  that 
devised  hy  .laval  and  Schii'itz.      '  l'"ij;.   .')).'! 

The  o]ihthalinometer  i  I'i;:.  .IIM  coiisis  -.  .'  .i  telescope,  .1  containing 
a  doulile-refrai'tinir  prism,  a  jrraduatr  I  di-ik.  //,  havinji  a  hole  in  its 
'•(•litre  thro'iyih  which  the  felesco|)e  o.-isse  ;  and  an  arc,  ('.  hearing 
two  slides  or  mires,  I)  and  E.  The  are  ('  is  ;ittaclied  to  the  tele- 
scoiie,  which  is  so  mounted  as  to  tu'ii  freely  in  the  central  hole  of  the 
disk  li.  and  as  it  turns  carries  ('  aroviiid  witii  it.  The  hole  is  hijjhly 
illuminated,  usually  hy  artitici:il  liiihl.  Tlie  p.itient  sli^adies  his  head 
on  the  chin-rest  /•',  and  looks  into  the  larfre  end  of  the  telescope: 
the  iili<i'i\-er.  oliservinir  at  the  patient's  eye  tlimu;:!!  the  other  end  of 
till'  telescope,  will  see  the  cornea,  and  upon  it  the  reflect i(i;i  of  the 
disk  ,in(l  slides,  hut  because  of  the  douhle-refnictinj;  jirisin  in  the 
tele-cope  will  see  two  imafics  of  eacli  slide.     The  two  central  imajies 


itEi  n.\rrivi:  uniiovs  is  ui:si:i:m. 


116 


-I  /»  Mlhl  /•-',  whicll  ;itr  ••li'^i  lop'tlliT.  ululif  mIv  nlivivi'd,  llir  two 
„,i,.f  c.iHs  iM'iiiK  iirulci-tiMl.  Kai-li  (f  lli.-f  im.mr^  is  liiMM-tr,l  l.v  a 
I  ,,k  lin.Mtii.l  ilictflrscu|«'i^rcv..l\c.l  until  llir.laik  Iiimm.I  uiif  iiiia^c 
-   ,|,l,n,\iii..ilclv  < linii.iiis  with  tin-  .lark  lin.'  "f  tln'  ..llirr.     Tin- 

I,,,,',    roimcrtill-i'llir   •^\'V••'   \-   IIh'H    ill    ..lir   nf    tlw    piiliripal    IIKTlillalls 

,,l  ,hr  cuiii.a.  that  i-.  ••itlicr  lli-'  iii.Ti.liaii  nl'  ^ivatot  <ir  llu'  iin'ihliaii 
,1  |,:,-I  niivatiiri'.     Tli"'  min-  aiv  imw  Ah\  In  ami       '  aidr,'  lli''  arc 


Javal-Sclii"tz's  o'lhllmlmonieter. 

,  „„til  til.,  images  of  I)  a.1,1  E  just  tnu.-li.  Tl.r  l.-l.-scnpr  is  tl,.;,, 
.  v,,1v.m1  thnni-h  '.»(»°,  wlu'M  the  line  .•onucctuiji  tiic  slides  will  l»'  m 
;„.  other  i.iiu.ipal  inrriiliaii  of  the  coni.-a.     ll  the  niiajK-  /'     :   1  /'. 

,w  n.     lap  or  arc  separated,  tli«'re  is  a  e«nieal  asliiiniat    .,    <-.   :" 


nun  propoi 


■lioiial  ti  their  distaun-  apart. 


uodel  of  op'  Ihaliiioi 
..ilappiiiiiof  the  ii....^'e-^  is  lueasurei 


ueter  shown  in  V\X   •")■•.  tlie  . 
I  (lirectlv.    l>  is  a  par: 


.'rata, 


m 


&'i' 


IIG 


77//;  j:yk 


and  A'  is  a  tifiuri'  witli  a  scries  of  notches  or  stops.  Tlic  instrument 
is  so  urailiiaU'tl  tliat  tiic  iiiiiiilx'r  of  steps  l)y  wiiich  A'  overlaps  1) 
re])resents  tiie  nuinher  of  (lioi)tres  of  conieai  astijtniatisiii. 

In  anotiier  niodi'l,  when  overiappinji  is  present  after  tiie  telescope 
has  been  rotateil  into  tli<'  secoml  i)osition,  the  slides  are  separated 
until  thev  just  toucii  aj;ain.  The  amount  hy  wiiich  the  slides  have 
liei'ii  moved  to    aeconi])lish  this  is   read  olf  on  a  scale  behind  the 

disk. 

In  both  varieties  of  the  ophthalmometer  the  radius  o/  nirvdliirc  ot 
the  cornea  in  any  meridian  can  be  detern.ined.  In  the  first  model 
it  is  read  off  from  the  arc  <\  beius  shown  by  the  distance  l)et\veen 
the  slides  when  they  are  separated  so  far  that  their  imafj;es  on  the 
cornea  are  just  in  contact.  In  the  second  form  of  ophthalmometer 
the  radius  of  curvature  of  the  meridian  examined  may  be  read  off  on 
a  .scale  behind  the  disk.  In  both  forms  of  ophthalmometer  the  index 
shows  the  .situation  of  tlie  meridian  wiiose  curvature  i.s  beiufj;  meas- 
ured, and  in  th>  case  of  the  ])rincipal  meridians  it  indicates  the 
axis  of  the  correcting  cylinder,  which  nmst  lie  in  (>ither  one  meridian 
or  tlie  other. 

The  oi)hthalmom"ter  does  not  show  what  khid  of  astigmatism— 
hyperopic,  myo|)ic,  or  mixed— is  present.  That  is,  it  <loes  not  .show 
what  is  the  absohile  rvjriwtiim  of  the  principal  meridians,  t)ut  only 
which  of  the  two  is  the  more  refractive,  and  the  difference  in  refraction 
between  them. 

Moreover,  the  ophthalmotneter  indicates  simply  the  corneal  astig- 
matism anil  its  axis.  It  does  not  reveal  either  the  amount  or  the 
direction  of  tlie  total  astigmatisin,  except  in  aphakia,  where,  the 
influence  of  tlu>  lens  being  removed,  all  the  astigmatism  is  corneal.  In 
any  other  cas(>  tlie  result  is  only  an  ap])roximation,  although  often  a 
close  approximation  to  the  true  findings. 


OPHTHALMOSCOPY  AS  APPLIED  TO  THE  DETERMINATION 
OF  REFRACTION. 


Direction  of  the  Emergent  Rays  when  the  Fundus  is  Illuminated. 

When  we  throw  light  into  the  eye  with  an  ophthalmoscopic  mirror, 
and  thus  illuminate  the  various"  points  of  the  fundus,  these  points 
themselves  si-nd  out  rays  that  <liverge  in  every  direction.  On  their 
wav  out  these  rays  encounter  the  lens  and  cornea,  which  alter 
their  course  to  a  greater  or  less  degree,  according  to  the  refractive 
l)ower  of  the  eye. 

The  eye  being  l)ut  a  combination  of  lenses,  the  actual  course  taken 
by  these  emergent  rays  will  be  determineil  by  the  law  that  governs 
the  direction  of  rays  passing  through  lenses.  Tiiis  law,  called  the 
Utir  iij  ciujiifidlc  jiiri.  may  be  thus  stated:  If  a  lens  has  such  a  strength 
that  rays  emanating  from  a  p>int  /i".  are  brought  logellier  al  a  point 
.V,  tlieii  rays  that  emanate  from  the  iMiint  .V  and  travel  back  through 


REFRACTIVE  ERRORS  J\  (lESERAL. 


117 


ih,.  l.Mis  will  he  hrnuuht  totjether  at  R,  and  will  form  tlicrc  i»  rciil  iiivoited 

iniMficof  .V.     (Fifi.  1!>.)  _  „  ,  .,    .,. 

U  tli<-  lens  is  of  such  a  strength  as  to  focus  i)anillcl  rays  at  A  (1  ifj. 
l,!).  then  rays  oinanatinp;  from  .V  will,  after  i)assinfi  back  tlir.)u<;h  the 

Icii-i,  enierRe  jximlM.  i.  /.   ,i    , 

If  tlu-  lens  is  of  su-.-h  a  strength  as  to  focus  at  A  rays  I)  [  ,  that 
■,re  coiiverftinjj  to  the  point  R  (Fig.  50),  the  rays  emanatnij;  from  A 
will,  after  passing  back  through  the  lens,  direrijv  as  if  they  came  jrom 
/,'   and  will  form  at  R  an  erect,  virtual  image  of  A  . 

To  apply  'hese  i)rinciples  to  the  eye,  we  may  say  that  m  emme- 
tropi'i  theVays  that  emanate  froii'  the  illuminated  fundus  will  emerge 
from  th(>  eve  parallel  to  each  other;  in  hyperopia  they  will  diverge 
from  the  far  point  lying  back  of  the  eye:  and  m  myojna  they  will 
converge  toward  the  far  point  lying  in  front  of  the  eye:  and  m  either 
,-:ise  will  form  at  the  far  point  an  image  of  the  portion  ot  th^  fundus 
ihat  is  illuminated.  ,     ,       .i 

The  behavior  of  emergent  ravs  is  the  same,  whether  the  eye  is 
naturallv  emmetropic,  hyperopic,  or  myopic,  or  whether  it  is  made 
Ml  by  the  addition  of  a  convex  or  concave  gla.ss  placed  betore  ttie 

Determination  of  Refraction  by  Direct  Illumination.  I  f .  when  we 
<tuid  otV  fifteen  inches  from  the  eye  aiul  th.'n  throw  light  into  it,  we 
.,v  a  clearlv  dehned  image  of  the  optic  .lisk  and  vessels,  we  know 
ih.t  this  is  the  image  formed  by  the  eye  itself  at  its  far  point,  as 
.hown  in  the  prece.ling  paragraphs,  and  that  this  ima-e  must  be 
,.i,lu-r  between  us  and  the  eye  (myopia  of  (i  to  7  D.  at  least )  or  behind 
il„.  eve  and  close  to  it  (hyperoi)ia  of  1  D.  or  more) 

ir  'as  we  look  into  the  eve,  we  move  our  head,  this  image  ot  the 
lund'us  will  move  in  the  opiu.site  direction  m  myopia  and  m  the 
sMue  ,liivction  in  hvi.eropia.  This  is  because  we  refer  the  movement 
,;,  ihe  plane  of  the' pupil  which  lies  behind  the  image  m  myopia  and 
,„  front  of  it  in  hvperopia.  It  is  the  same  experience  that  we  get 
-u  ■!  railroad  train  When,  lookuig  out  of  the  window,  we  see  objects  m 
i|„.  foreground  apparently  running  backward  and  objects  m  the  tar 
li>laiice  running  forward.  «  .,.  j      , 

Determination  of  Refraction  by  the  Indirect  Method.  In  using 
■he  indirect  method,  we  should  hold  the  object  lens  with  it.s  prmciiml 
„ru<  at  the  anterior  focus  of  the  eye.  that  is,  ab.uit  halt  an  inch 
„  front  of  the  cornea.  Hence  a  two-and-one-half-mch  lens  shouli 
i„.  i„,i,l  three  inches  from  the  .>ye.  When  we  <lo  this,  the  size  .. 
!„.  object  seen  in  the  fundus  is  not  altere.1  by  the  presence  ot  axial 
ivperopia  or  mvo|.ia,  and  the  distortion  j.roduced  by  astigmatism 
-   relatively   slight,   .so   that    tlu'  optic  disk,   for   mst.anee,   ajipears 

iiiniallv  round.  ,         ,  , 

If  h-.'wev.'r,  we  carrv  the  lens  closer  to  the  eye,  then  the  api)arent 
r  uf  the  disk  diminishes  in  myopia  and  increases  m  liyperoi)ia, 
;,ii,.  i„  ...nnu'lropia  il  r.•main^  the  sanir.  If  we  carry  the  g  n<s  aw.'.y 
mi  the  ev.-,  the  reverse  change  takes  place,  the  optic  di.sk  Iwcoming 


'--^.i-:  :"Z:.^: 


i'  .-^ 


118 


TlIK  KYK. 


.mmrontlv  smaller  in  hvporopia  and  largor  in  invopia  while  in  oniinc- 
trTr  as  Ihw'  it  ron>^ns\.n..l.an„-.l.     In  n.ark...!  hyiK-rop.a  an.l 

If  V    ,  vunin'  a  pati.-«t  witii  l,vp.-n.pic  or  n.y..pK'  ast.g.nat.sni  sMtli 
L    n  .-        '  ...  ii-  .lisk  will  loclk  iiko  a  horizontal  ova    wh.-n  our 
XX  W.^  tJ  th.  oyo,  ronna  whon  vvo  carry  tu- , lass  hack    o  U 

S  n.lara  positi..n,  and  a  vertical  oval  .    wo  ^^•' 1>'>'-='^V  "' -f  v^rtic a 

J-    t    -r       n  astigmatism  apainst  the  rnle,  th<>  disk  will  h.   a  x.-rt  ca 

; V     when  th(>  jrlass  is  clos.-,  and  heco.n.-s  a  horizontal  oval  when  th 

lluit  ^Sthdrawn.     In  marked  astigmatism  these  changes  are  very 

'"DTe'Siation  of  Refraction  by  the  Direct  Method  As  ^v.;ha^•e 
se.Mi  if  we  illuminate  the  fundus  of  an  emmetropic  eye,  ra>s  will 
^  .  iire  f  om  iaralh-l  t.>  ..no  another.  If  w<.  ourse.ves  arc  enmie- 
„  <  or  ■•  k,'  o  rselv,.s  so  with  the  proper  gl.  -s  and  relax  our 
rrnn  o  I    it  completely,  wo  may,  without  additional  ai.l.  focus 


!'"- 'T?r'^'•'s^fSs"''";Fi:;';. 

;;s:;';iu 'liph^;^;::.'":  ^.t  u'di^^mct  image  of  ti.  fundus  if  wo 

"t  Tt^  •  t;::;;',^;';t  have  ...w  sin.p,v  touring  hefo. 
,h  IStJ^'le  of  .he  ophthahnosoope  that  lens  -l.-h  w.  corn-c.  h  s 
.Muetn.i.ia  an.l  thus  render  hnn  onnnotropic  We  shall  thus  a> 
'.,!':       .fundus  distinetly.     XW  thus  arrive  at  this  rule:  Ihv 

of  the  line  vess.-ls.  nrefcral.lv  near  the  niarula.  or  a  l-a^t  n,n  nuL 
t  tl  e  emporal  sille  of  the  disk,  and  aseeHain  the  g  ass  with  win,;, 
won'.,  see  it  ...ost  .listh.ctly.     A  ...ore  satisfactory  test  object  still 


REFRACTIVE  ERRORS  IX  GEyEIUL. 


119 


i.  ,\,,  tine  granular  .narkin.s  „f  the  fun.lus  in  tho  vicinity  -f  th.- 
vfllt)\v  spot.  .        roii.lcr  the  nationt  cniniotnipic 

l,v  puttnif?  up  any  •>   tlio  HJ»f"t''  K  ncrfcM-tlv  distinct  view  of 

„;„s,.opo.  cnsciuently  wo  c-ann,.t  o»  tan  '^  _^^*^^^^  ^.  •„,;  , 
„„.  ru'naus.  Tin.  nu.st  Nve  can  ^J^'V^'^^^^J,^  4  D. 
„  i.U.„s  omnjetrojn.  ^^I^PPJ^^  f  tdllii^V  i^cropic  1  D.  .As 
with  th<>  rule,  an.l  t» '»*  h»^^ ^"^J^^  ^  „phthaln,..sco{K>  his  vertical 
s,...!!  as  we  put  up  a  -'-1  U.  ^^Jj'  J"*  .1  ,  ,„.  ,^,,^,,,1  „,.  hcri-  . 
„„„.i,lian  will  .e/-.nmetropic  ^J  f  J^^  .f  ^.^  ,,  ,,,.  ,„.  into  it. 
.ontal  lines  distinctly.     As  he  sus  out  o,  >  ^^^  ^^^^^.^^^^ 

j^ettinfT  the  same  kind  of  view  "^ '»   f^^f    f  t  e  horizontal  vessels 

iK.rizontal  ones  very  hazil\.  ,     j^^  j    .^j.tig„,a- 

This  example  shows  ^^T^^^'^Z^J.  runnin,  in  the 

,is,n  the  ijUix.  that  gives  us  ^^^"'''JJ^  ;,„,„,,,  „,,  rvirmiim  of 

:;r,i;ri,5';;x'i;iL,  ^.  -2  n  «..„  .j  .h..  .^  ,uon.i™  .>  -1  n- 

direct  method  ar         follows:  p„,rected  bv  the  proper 

1.  Our  own  retractive  errors  ^'^^    ;;.,: ^^^^^ 
,!.ss  and  our  accommodation  '-"P'  "     ,; .    ;'^     ,,  H,,  i  haVe  seen 
„,is  vari.s  in  .lifferent  ^ople.  ^  j  ,  J^  .^         ,u,l,,,,l„.ists,  that 

"f  the  -''--P-^;;-':::  irrl  '  .     5.^^'ly  -;l-  -ntrol  as  they 
ihcir  accommodation  is  stiii    u  i 

lu'lieve  it  to  be.  chmild  be  conii)letelv  relaxed.    It 

•_..  The  patient's  accommodation  ^^^^^}^^IU^.  -^  .xM.nine.l  in  a 

i- 


,.  Tlu>  patient  saccomm..m.^™.;^.^  .^  ^^^^^„.,„.,,  j,  , 
fTHierally  supposed  that  h«  ^ '  •■  '■'•^^ '  r^^^  ,,  i,v  „„  means 
rk  room  without  anything  to  hx  upon.      lius 

Iwavs  the  cas<'.  .   .        ,      „,,_r„ptiii!r  class  shou 

:i   Tlu-  ophthalmoscoiH.  c^ntf  "'"f^^^'^'^r"','!"*'  f:f  ;  .j  i^Uf 
,..1.1  at  the  anterior  focus  of  the  patients  eve.  this  is  a 


:hould  be 
inch 


„  L'n;  '^1  ot"  "i1,;m>'  «i"-i.  <-'i "- ' "-  ■' "■'■ 


m^ 


iww^mrm- 


lliO 


rut:  EYE. 


pationt's  accomnuKlation,  tlie  findings  siiould  i)0  ciiaractorizcil  as 
approxiinatr  only. 

The  direct  inctliod  is  inuch  used  in  estimating  the  relative  refrae- 
tion,  and  iiencc  the  rcUdire  dcplh  aitd  pmminenvp  of  tiie  diiTerent 
portions  of  tile  fundus.  Thus  if  we  see  tiie  Ixittoni  of  an  exeavation 
in  the  disk  witii  a  —4  I),  and  tlie  edge  witii  a  +2  I).,  we  k\w\\  tiiat 
tlie  deptii  is  ap[)r()xiniately  2  mm.,  eorresponding  to  this  difference 
of  (1  1).  So  also  an  exudate  or  a  detaciiment  which  we  see  distinctly 
with  a  ^4  I).,  while  the  surrounding  fundus  reijuires  only  a  +1  1). 
to  make  it  visible,  is  1  nun.  liigh,  corresponding  to  the  difference  of 
.]  D. 

SKIASCOPT,  OR  THE  SHADOW  TEST. 

Principle  of  the  Test  with  the  Concave  Mirror.  If  we  stand  off 
at  1  m.  from  the  patient  and  throw  light  into  his  eye  with  a  con- 
cave mirror — for  instance,  the  mirror  of  the  o])hthalmoscope — we  shall 
see  a  light-red  reHex  filling  the  pupi'  Then,  if  we  turn  tiie  mirror 
siightly  the  light  will  gradually  lea.e  the  pupil,  and  darkness  will 
succeed  it,  until  the  ])upil  becomes  efUirely  black.  The  direction  in 
which  the  light  moves  in  passing  from  tiie  pupil  depends  upon  where 
the  far  point  of  the  eye  is.  If  the  far  point  is  between  the  observer 
and  the  patient,  (he  light  will  move  off  the  pui)il  to  the  right  when 
the  mirror  is  turned  to  the  right,  and  rice  versa  :  that  is,  the  light 
will  move  \rilh  the  mirror.  If  the  far  point  is  not  between  the 
patient  and  the  ob.^ierver,  that  is,  is  either  I)ack  of  the  head  of  the 
observer  or  of  the  head  of  the  ])atient,  the  light  will  move  miainsl 
the  mirror,  or  to  the  left  when  we  turn  the  mirror  to  the  right. 

Instead  of  watching  the  movement  of  the  liiht,  it  is  usual  to  watch 
the  movement  of  the  dark  area  or  shadow  which  follows  it  and  moves 
with  it,  hence  the  term  skiascopy,  or  shadow  test,  applied  to  this 
method  of  observation. 

If  then,  stan<ling  at  1  m.  we  see  the  shadow  move  with  the 
mirror,  we  know  that  the  ])atient's  far  ])oint  is  between  us  and  him, 
and  lies  within  I  m.  of  the  eye.  He  must  then  be  myopic  more 
than  I  I).  If  we  slowly  approach  him  until  we  reach  a  point  when 
the  shadow  begins  to  move  against  the  mirror,  we  know  that  at  this 
distance  we  have  just  passed  his  far  point,  so  that  it  is  now  just 
back  of  our  head.  The  point  at  which  this  change  of  movement 
from  with  to  against  occurs  is  called  the  point  oj  rerer.'^nl.  It  ob- 
viously coincides  with  the  patient's  far  jioint. 

Instead  of  thus  moving  up  to  the  patient  to  ascertain  his  point  of 
reversal  or  far  ])oint  directly,  we  usually  stand  at  one  distance,  gener- 
ally 1  m.,  and,  by  putting  glasses  on  the  eye  we  are  examining,  change 
its  refraction  until  the  .sune  reversal  takes  place.  A\'hen  this  ha.s 
1m  en  effected,  we  have  put  his  far  point  just  Ivsck  of  us,  that  is,  jtjst 
beyond  1  m.  W  ith  the  next  weakest  glass  we  should  have  ■  ut  his 
lar  point  just  at   1  m.  and  made  him  myopic  ID.  iiake  him 


Jk 


RKI'RACTIVE  ERRORS  IS  <;ESER.\L. 


121 


("iiiiiictrnpip,  \v<'  should  now  give  him  — 1  I),  in  addition,  since  any 
inyo|)('  of  1  I),  will  l«'  made  an  cnnnctropc  l)y  a  concavf  glass  of 
iliis  strcnfith. 

If  staiiiUnR  at  1  ni.  wo  pet  a  inovonient  of  the  shadow  against  the 
mirror,  we  know  that  tiic  patient's  far  point  is  between  us  and  iiini, 
I  hat  is,  lie  is  not  myopic  1  I),  or  more.  He  may  l)e  hyperopic,  enmie- 
iropic,  or  myopic  less  than  1  I).  To  determine  his  refraction  and  its 
precise  character,  we  now  add  cojivcx  glasses,  thereby  increasing  his 
refractive  power,  until  we  finally  get  a  movement  with  the  mirror. 
We  have  then  ju.st  brought  his  far  point  down  to  within  1  in.  and 
have  made  him  myopic  1  I).  As  before,  we  make  him  emmetropic 
by  giving  him  — l"  D.  in  addition,  or  by  subtracting  1  I),  from  the 
convex  glass  previou-sly  put  on. 

The  actual  practice  of  conilucting  the  .shadow  test  may  be  stated 
as  follows: 

We  stand  slightly  more  than  1  m.  from  the  patient.  If.  usmg 
a  concave  mirror,  we  get  a  movement  of  the  shadow  xcith  the  mirror, 
we  add  concave  gla.sses  until  the  movement  just  goes  against.  The 
last  gla,ss  (highest  concave)  with  which  the  shadow  still  moves  with 
the  mirror  is  the  ri'versinq  f/la^x. 

If  the  shadow  movement  is  nfininst  the  mirror  to  start  with,  we 
add  convex  gla.sses  until  it  just  begins  to  go  with  the  mirror.  The 
lirst  gla.ss  (lowest  convex)  with  which  the  .shadow  moves  with  the 
mirror  is  the  rcrer'^iiifi  (/lass. 

\,l,l  ji  _i  n.  to  the  reversing  glas.s,  and  the  sum  will  be  the 
oiircctinij  (ilo.-<s  recjuired. 

Thus,' if  we  get  a  movement  with  the  mirror,  and  if  by  addmg  a 
—2  1).  we  get  a  movement  against,  while  a  —1.75  D.  still  gives  a 
movement  with,  .ve  know  that  the  patient  is  myopic  -1.75  + 
.  _i)  „r  —2.75  D.  If,  in  anothe-  case,  we  get  a  movement  against, 
which  tinally  is  converted  into  a  movement  with  tlie  mirror,  by 
:i  4-;{  I),,  the  patient's  true  correction  is  +3  +  { — D  or  +2  D. 
So  also  a  movement  against  that  would  be  just  reversed  with  a 
1  I),  would  indicate  emmetropia  (  +  1  D.  +  (—1  D-)  =  0);  and 
one  reversed  with  a  +0.25  D.  would  indicate  a  myopia  of  0.75  1). 


0: 


-1  =  —0.75). 


Application  of  the  Plane  Mirror.  Many  use  a  plan(>  mirror  instead 
iif  a  concave.  This  gives  a  brighter  illumination  and  a  better  marked 
movem(>nt  of  the  shadow,  but,  as  I  have  r-^peatedly  found,  from  the 
wry  largeness  of  the  movement,  tlie  plane  mirror  is  likely  to  give 
I  confusing  result  in  determining  the  reversal  in  astigmatism,  and  I 
iiri  sure  that  I  have  gotten  more  accurate  results  with  the  concave 
mirror  in  the.s(>  cases. 

With  a  plane  mirror  the  motion  of  the  shadow  is  just  ojiposile 
■iml  ohhtnicd  with  a  amrnve  wtrror.  That  is,  when  t,i.  far  i)oint  is 
iirtweeii  us  and  the  patient  we  get  a  movement  against  the  mirror 

nd    the   rules   above  given   should   simply   be   reversed,  the    word 

with  "  behig  substituted  for  "against,"'  and  vice  versa. 


!b^.ttii>SIMai. 


'S?""ia!Hi 


122 


THE  KYK. 


Distance  at  Which  Test  is  Made.  Wo  may  stand  at  any  .listanco 
in  niakii.n  tlx-  sliadow  t(>st.  W.'  should  then  make  a  pn)i)()rti(.nat(> 
addition  to  tli(>  rcvcrsiiif,'  glass  in  order  ♦■>  obtain  th.-  proper  cor- 
n-ction  If,  for  instance,  we  stand  at  I  m.,  the  glass  with  which  we 
obtain  reversal  at  that  distaiiee  puts  the  |)atieiit's  far  point  at  5  nj  , 
that  is  inak.'s  hii.i  nivopie  1.50  I).  Hence  we  shall  have  to  add 
—  1  .■)()!)  to  the  reversing  glass  to  obtain  the  true  correction.  N), 
also,  if  we  stood  2  in.  we  should  have  to  make  an  addition  of  only 
— OoO  D.  to  our  reversiiifr  'lass,  which  in  this  case  will  make  the 
patient  niyopic  f)..')()  I).  In  liie  majority  of  cases  a  distance  of  1  m. 
is  most  practicable. 

Testing  the  Result.  To  prove  the  result,  we  put  the  reversing 
glass  before  the  eve,  and,  standing  at  1  m.  or  a  few  inches  beyond, 
note  that  the  shadow  goes  with  the  mirror.  We  now  approach  a 
few  inches.  If  our  reversal  is  accurate,  the  shadow  should  now 
move  against  the  mirror.  ,  .  ,     ,        a 

Character  of  the  Reflex.  If  the  ametropia  is  very  high,  the  reHex 
is  very  dull— in  fact,  we  scarcely  see  any  light  in  tlie  pupil.  In 
proportion  as  we  add  correcting  glasses  and  get  nearer  the  reversal, 
the  reflex  lieeomes  brighter,  becoming  very  brilliant  and  white  when 
the  reversal  is  reached.  Hence  when  we  see  a  dull  reflex  not  attrib- 
utable to  opacities  of  the  media  we  add  strong  glas.ses  at  once  (several 
I)  at  least):  and  if  the  reflex  is  still  dull,  change  the  ji'.ass  for  one 
wiiieh  is  I  or  1  I),  stronger.  As  soon  as  the  reflex  becomes  bright  we 
make  slight  changes  (()..")()  to  0.25  D.)  in  the  glasses  added. 

The  Test  in  Astigmatism.  To  determine  astigmatism,  the  shadow 
test  is  made  as  follows:  We  l)ut  on  glasses,  +  or  — ,  until  the  move- 
ment in  one  meridian  is  reversed.  When  this  occurs  and  the  astig- 
matism is  of  anv  amount,  the  luminous  reflex  is  converted  into  a 
well-defined  band  of  Uqht  running  precisely  in  the  direction  of 
the  meridian  that  we  have  corrected.  We  then  proceed  to  correct 
the  meridian  at  rijit  angles  to  this.  We  may  do  this  by  adding  more 
spherical  glas.<e  until  reversal  is  obtained  in  the  second  meridian 
also.  When  this  is  done,  the  band  of  light  will  be  seen  again:  but 
it  will  now  run  in  the  direction  of  the  second  meridian,  or  at  right 
angles  to  its  formi-r  direction.  The  difl'erence  l)etween  the  reversing 
glas.ses  of  the  two  meridians  will  give  the  astigmatism,  and  the  direc- 
tion of  the  band  of  light  will  give  us  its  axis. 

Thus,  suppose  that  at  1  m.  we  get  a  movement  against  m  all 
directions.  With  a  +2  I),  we  see  a  band  of  light  running  at  7.5°. 
By  careful  a<lditioii  of  glasses  we  find  that  +2.25  I),  just  makes  the 
shadow  go  with  the  mirror  in  this  meridian.  In  every  otlier  direction 
the  movement  is  still  against.  Making  our  mirror  now  move  pre- 
cisely in  the  axis  of  1().5°,  we  find  that  when  we  put  on  a  +4..50  I), 
the  "band  of  iigln  Hes  in  this  axis,  and  when  we  put  on  a  +5  D. 
the  shadow  just  begins  to  go  wi(h  (he  mirror.  The  reversing  glass  is 
then  -^2.25  1).  in  one  meridian,  and  +5  D.  in  the  other,  an<l  the 
astigmatism  is  the  ditference  between  the  two,  or  +2.75  1).     Adding 


REFRACTIVE  ERRORS  IX  OESERAL. 


123 


_1  I)  for  the  (listaticc  of  the  point  of  reversal,  we  have  as  the  tru(> 
curreetinp  glasses.  +1.25  D.  un.l  +4  I).,  respeetiyely,  an.l  thejotal 
-rlass  .■(.rreetitiji  the  error  woul.l  he  +1.25  _  ^2.;.)  cyl.  ax.  <o  . 
"  \  i.u.re  aeeurate  way  to  eorreet  astigmatism  is,  after  \ye  hav(> 
„h'taine.l  reversal  in  <.ne  meri.lian.  lo  leave  on  the  rertrsinu  ,,lassand 
,ul,l  ciiUnders  with  their  axes  in  the  line  of  the  n.rreeted  men.han 
Thusin  the  ease  stated  we  should,  after  Hn.ling  that  +  2.2o  reversed 
i„  the  .n..ri.lian  of  75°,  leav-  this  glass  on,  and  ad.l  +  9;'."»'^':%^).'il' 
t'l.-ir  axes  at  75°  until  reversal  was  obtamed  m  the  meridian  ot  lb.j  . 
I'n  this  e:,so,  if  our  eorreetion  is  accurate,  we  shoul.l  get  an  even  rever- 
sal not  oiilv  in  the  m..ri.lian  of  165°.  but  in  all  meridians  alike  for 
our  Kla.^s,  if  correct,  abolishes  the  astigmatism  ami  makes  the  patient 

siiiiplv  mvouic  ID.  ,       ,     ,        X    i.      MI  u„  f...Uir 

( )ur  estimate  of  astigmatism  by  the  shadow  test  will  be  f  uilty 
unless  we  move  the  mirror  xtrictb,  in  one  of  the  pru,n,ml  meruhnn^i. 
If  w..  swerve  from  this  meridian,  the  shadow  will  make  an  obli<iue 
.novment,  apparently  sli.ling  off  the  line  in  which  we  swing  the 
narro-  Hence  if  we  do  get  an  obli<iue  movement,  we  shoul.l  change 
th.-  direction  in  which  we  nu.ve  the  mirror  until  we  get  it  g'-mg  right 
in  the  plane  in  which  the  shadov  -nds  to  move.  n  <'t  "T  ^^ords 
we  should  so  manage  the  mirror  t.  ..  when  it  moves  the  shado^  %v. 
,„„ve  precisely  with  or  precisely  against  it,  and  not  slide  off  dH 

'"tIus  same  tendencv  of  the  shadow  to  make  an  oblique  or  sk<-w 
movement  is  notice.f  when  we  apply  cylinders  in  making  the  est, 
and  happen  to  have  placed  the  cylinders  .somewhat  out  of  axis. 
When  this  occurs,  we  shoul.l  shift  the  axis  .,f  the  cylinder  until  the 

(ibli.iue  movement  ceases.  .       i     i  „. . 

h  irrequlnrastir,n,ntism  we  get  all  sorts  of  irregular  m..vingsha.lovNs, 

forming  kakn-loscpic  patterns  on  the-  P"P'',,.^"^'\Vwe  In'.v  V 
„..t  necessarilv  in.licate  an  incorrigible  .•..luliti.m  f..r  ^u'  n u  >  !)> 
pati."nce  .letermine  a  more  or  less  r.'gularly  m..vmg  sha.low  m  a.l.lit ion 
|,;use.l  by  a  regular  astigmatism  which  is  susceptible  of  correct...., 

''•'ceiiS'andPeripheralShadows.    ^." '"'''•''''''"'''V'nTf.trllilerT 
the  ornea  has  a  .liftVrent  ref.action  ...  .ts  c..ntn>  and  at  .ts  H...ph.r> 
,  g,.  a  .loubl.-  sha.bw.     Thus,  with  the  ,H.r.ph<.ry  .•...metrop..^  and 

l,..'ent.-e  hvperopi.'  0.75  D.,  we  will  with  .  -  1  D.  -f';;;^  ",;;>;; 
s.>e  a  sha.low  start  fr.m.  the  t..p  of  the  pupil  ami  ^^^^^'"^y.^^, 
move  ..ur  ...irn.r  .l..wn.    .\t  the  san.e  t.nu-  we  w.ll  n..t..;e  a  h...-  ^lul.l..^^ 

"vllrZn  son.e  ,...i..t  i.i  the  lower  half  of  the  pup.l  an.l  ...ove  upwar.l, 

'"'^ITi;;;^!?;' i;:^:>  put  ..n  a  +1.75  D.  .m  this  contrary  n,oven.ent 
of 'the  .■e.itral  sha.l.nv  be  abolishe.l.  so  that  we  get  a  umf..nu  .n..N.- 
in.Mit  with  the  n.irror  clear  across  the  y.up.l.  u,..a,,w,u„ 

,  1     „.^,.  ,,f  thk  «iirt  we  find  two  sha.l.)WS  .level.)ping 

n..ar  the  centre  of  th.'  pupil  a.i.l  going  t..  ...eet  each  ..ther.  like  the 
blades  of  a  pair  of  scissors  (sciss.ir  movement). 


'ttJFils 


124 


77/K  f  !'/■:. 


Tsuallv  in  such  casos  the  truo  r..fn,r.ti.)n  is  tiuit  sli.m-n  l>y  tl«' 
,n„n.  ii,t".'ri..r  sluulnw.  and  not  l.y  the  i,...iph..ral  ..lu'.  Hms  m  lu- 
(.•is(.  just  c'it<>(l,  tiic  (•..rrcctiiij:  jjiass  would  i>r<.l)al)ly  Ix-  +().<;)  i^.. 
....rrospon.liuK  to  the  hyixsn.pia  of  th.-  inon'  (••■ntrai  an-a  ol  th.-  pupi  . 

Skiascopy  as  a  Conflrmatory  Test.  O.u-  of  th.-  most  us.-  ul  ai.].  i- 
c.itions  of  the  shadow  t-st  is  in  cufinnin!,'  th..  K-ass  louu.  l.y  sul.- 
i,M-tive  .-xaniination.     Suppose,  for  instance,  with  tho  tnai  case  we 

Lvo  found  (-1.50 1). sph.  2  +''-v>-'-;'-^: '•"*■•  "•' ;;;;' % ':: 

class  f  I  D.,  .ual^inR  +2.50  D.  sph.  Z  +\-J:\  O;!;  i'^-  '•"  •  ,  »*>  ^" 
doinjr.  we  nial^c  the  l.atient  n.yopie  I  1).  WiWi  this  cias.,  when  w.j 
„.e  a  concave  n.irn.r  an.l  stan-l  at  a  little  bey.m.l  1  m.  we  should 
iret  a  movement  with  th<-  mirror  in  all  meri.liaus.  Then,  by  r.-uik 
X  few  inclies  near.-r  the  patient.  W(.  should  get  a  movement  aRamst 
the  mirror  in  all  nu-ridians.  If  this  r.-versal  .Iocs  not  taUe  place  for 
•dl  meridians  at  the  same  instant,  hut  occurs  a  few  mch.-s  nearer  the 
patient  for  one  than  for  anoth<-r.  the  astiRmatism  is  not  properly  cor- 
rected, an.l  we  shoul.l  change  the  strength  of  th<-  cylm.l.T  accor.hngly 
„„til  tiie  r(>v.-rsal  is  ,ierf.Ttly  oven  f..r  all  m.-ri.hans  alike.  It,  apun. 
th.>  axis  of  the  cvlinder  is  not  corn'ct,  we  will  observe  that  the.sha.l..w 
makes  a  s..mewhat  obli.iue  m..v.-nu-nt,  which  is  eorr.-ct.-.l  wli.-n  we 
set  the  cvlhuler  at  th.>  pr..p.-r  axis.  iMnally,  it  the  spL.-rical  glass 
is  n..t  cirrcct.  e.  ,,.,  if  in  the  .ms.-  .-it.-.l  it  were  +1.1'..  mst.-a.l ..  -  l.oO, 
wc  sh.uild  fin.l  that  with  our  trial  glass  the  ivversal  woul.l  tak.'  i)lace 
rather  nearer  than  1  m.  .    .  ,, 

The  Use  of  Cycloplegics.  In  using  the  sha.l.)W  test  it  is  generally 
es^(-ntial  that  the  acc.)mm.Mlati.)n  be  relaxe.l  with  a  cycl.)pl.>gic, 
alth.nigh  in  manv  cas.-s  w..  may  get  .[uit.-  an  accurat.-  .ieterminati.m 
without  this.  Ma.le  with  a  .-y.-L.pl.'gi.'.  skiascj-y  is  an  extr.-mely 
accurat.'  test.  Tf  .Ion.-  with  suffici.-nt  care,  the  refraction  may  l^o 
estimated  up  t.)  within  one-eigiith  of  a  dioptre. 

SXJBJECTIVE  TESTS  £&  GENERAL. 

Varieties  of  Subjective  Tests.  In  all  subject iy.-  tests  of  refraction 
w.'  an-  .l..p.Mi.lent  up..n  the  inf.)rmation  furnished  by  th.'  patu-nt 
hiniM.lf  as  to  what  he  sees.  .V  mimb.-r  ..f  such  tests  have  b.-.-n  .l.-vised. 
the  use  of  elaborate  apparatus,  calle.l  optoni- 
of  th.'in  has  superseded  tiit 

of  the  trial  cas(>. 

has  to  1)0  rosorte.l  t.i  in  any  event 

■iubiective  tests  are  of 


use 


some  of  which  r.'.|uir.'  tne  use 

oters.    refra.'toin.'t.M-s.   etc.     None  . 

which  is  ii.it  .mlv  the  best  sub.ie.'tive  test,  but  wliicU 
wh.'tlier  .)ther  m.'thods  are  used 


or  not. 

In  general  it  may  bo  sai.l  that  tiiese  .ither 
little  service  or  else  are  sui)erf1uous.  _  _        t      i-i 

Direct  Detenninatio.!  of  the  Far  Point  in  Myopia.  In  high 
nivoi.ia  we  mav  form  a  rough  id.-a  .if  the  .■.m.mnt  of  the  error  by  de- 
t.'rmining  the  "fartlu'st  .listancc  at  which  the  patient  s.rs  Ime  print. 
If  f.,r  instance,  he  b.>gins  t.)  ni.l  it  at  3"  from  the  eye.  we  know 


jtEfRACTivi:  Kiiiiiu:s  rs  (ikskral. 


125 


that  his  fur  ixuiit  i^  .i",  or  that  liis  inyoi-ia  is  \:\  D.  This  nioth.MJ, 
c.r  course,  is  of  very  liinilc.l  a|iplicatioM.  and  jjivi's  only  a  roujtii 
,i|iini.xiniation.  .       .     ,   ,        ■     r  ^i 

Astigmatic  Clock-face.  The  astijimatic  clock-fiu-.'  is  friMiumtly 
ummI  as  a  sul)i«'ctiv('  test.  Tlic  clock-face,  or  fan,  consists  of  lines  or 
l.iin.il.'s  of  lines  radiating  from  tli<"  c:'iitre  of  the  dial,  as  shown  in 
j-jir  (il.  If  a  man  having  hyix-ioinc  astigmatism  with  the  rule 
looks  at  such  a  dial  he  will  see  the  horizontal  lines  (those  running 
from  III  to  I\)  most  di>tinctlv,  as  his  vertical  meridian  is  most  nearly 
..mmetropic.  If  he  has  mvopic  astigmatism  with  the  rule,  he  will  »'<' 
the  vertical  lines  nmniiig  from  XII  to  VI  most  distinctly:  and  it  he 
has  ()l)li(iue  iistigmatism,  die  correspoiKlin"  ohlKiue  meridian  or  the 
meridian  at  right  angles  to  it  will  be  dearest 

Tjic^c  differences  come  out  most  sharply  when  one  of  tlie  i)rincipal 
,„eridi:ins  is  emmetropic  or  has  been  made  so  by  a  glass.  Ileiice 
inaiiv    II  order  to  determine  astigmatism,  proceed  as  follows:  Ihey 


Fia.  61. 


Klu.  »■'-. 


Astigmatic  clock-&ce. 


ray's  a.stlgmatic  letters. 


,.ut  Oil  spherical  (preferably  convex)  glasses  until  one  hue  m  the 
'.l,,ck-face  is  perfectly  sharp.  Suppose  this  to  be  the  vertical  ine, 
nid  that  the  spherical  gla.ss  ust-d  is  +2  I).  Then,  with  this  glas.s, 
ilic  horizontal  meridian  must  b(>  emmetropic.  Successive  cylinders 
lie  now  added  with  their  axes  horizontal  until  the  clock-face  appears 
uniforinlv  sharp,  so  that  the  lines  are  iM>rfectly  defined.  Suppose  it 
,.jk,.^  .1  JLi  05  t.yl  is()°  to  do  this.  The  combined  sphere  and  cylinder 
'^■2  ,ph.  -  _r.25  cyl.  ax.  180°  or  +0.75  sph.  3  +1-25  cyl.  ax.  90 
-liould  then  be  the  correcting  glass.  ,     ,      ,  ,     ,  , 

If   this  'lethod   is  adopted,    the  gla,ss   found  should  always  be 
■..nlirmed  bv  a  trial  made  with  the  test  types  .    •     u    • 

Personallv,  I  have  found  that  patients  differ  so  much  in  their 
Mimates  of  the  lines  seen  most  distinctly  and  of  the  effect  upon 

li<tin.-tnes.s  produced  bv  adding  glasses,  that  I  do  not  use  the 

■Inck-face  as  a  i)riiiiarv  t(>st,  but  rather  use  it  at  the  end  of  the  exami- 
ati<.ii,  to  confirm  the  result  obtained  with  the  test  types,  ami  see  it 


m 


1'2(( 


77/ K  KVi:. 


till-  jilass  I  liavc  fouiul  witli  the  latter  tnakes  tli  •  clurk-larc  appi-ar 
|,.  rfcctlv  unifoiMii. 

V  Mi.MlilicatK.ii  of  tlu'  clnck-facc  is  /'m//'.s  ustiuwuhr  /■'//<rs  w...  i. 
arc  block  IcttiMs  made  iii.  ..f  horizontal,  vertical,  aii.l  various  ohli.iu. 


lines 


•  III 


To  the  patient  with  astininatism.  some  ( 


if   thesi-  letters  look 


.itc  black  aiul  some  urav.acconliiiK  to  tlu-  axis  of  the  astigmatism. 

Testing  with  the  Trial  Case  and  Test  Cards,  liy  lar  the  In'st 
examination,  ami  one  which  should  never  lie 
1m'  use<l  at  all,  is  exiK'rimental  testing  with  the 


method  of  subjective  examination,  a 


nejilected  when  it  can 


trial 


case  am 


1  t  -St  typ 


The  trial  case  contains  convex  an 


1  coll 


cave  spherical  glasses  from  0 


L'.")  1).  orO.l-'  I).  to.'O  I).,  and  cylindrical 


cl: 


from  ().■_'"»  I',  to  (■>,  or  in  some  case 


N  1).      It  is  alwavs  best 


to  have  these  glasses  in  pairs. 
The  trial  case  contaill^■  also  prism 


when  the  other  is  Wmfi  examin 

(li.sks  containiiiK  stcnopa'ic  slits  or  ix'rforatioiis,  etc 


blinder  for  covering  one  eye 
1,   red  anil  other  colored  fjlasses. 


The  trial  frame  for  holdiiiR  the  srla.sses  us«'d  in  testing  should  be 

I  steaily.     It  has  two,  or,  in  some  frame>,  three  cells  on 

are  slijiped.     In  a  good  frame  these 


stronji  an 

each  side,  into  which  the  glas.sc 


•lis  mav  be  readilv  moved  in  and  'Uit  from  the  nose,  forward  or  back 


tov.aril  the  oyo.  and  up  or  down 


We  are  thus  enabled  to  centn; 


accurately  th'e  glasses  placed  before  the  oyos;  and  we  should  take 
care  to  do  this  in  everv  .'ase  we  are  testing. 

General  Rules.  In  tin-  examination  witli  tlie  trial  case  the  following 
general  rules  should  be  borne  in  mind: 

Rli.K  I.  One  ejie  should  he  tried  ut  a  time,  the  other  being  covered, 
not  clos«'d.     The  vision  of  tlio  ove  losted  should  then  be  taken. 

Ih  i.K  II.  The  streHijth  of  the  ulasn  ice  tnf  before  the  eye  .should  be 
selected  according  to  the  patii'Ut's  vision  at  the  time.  This  i.s  true 
both  ni  the  glass  wo  begin  with  in  order  to  get  the  first  approximate 
cM-rection.  and  of  the  successive  glasses  we  add  to  this  ap[)n)ximate 
correction,  in  order  to  gi't  nearer  and  nearer  to  the  true  result. 

Thus,  if  we  have  a  patient  with  vision  of  20  2()()  or  less  and  we  feel 
liretty  sure  from  the  objective  (-xamination  that  the  poor  sight  i.s 
due  to  his  refractive  state  alone,  we  would  begin  at  once  with  a  spheri- 
cal gla*  of  from  -i  to  •'>  D.  (  +  or  —  as  the  case  rcMiuired).  It  would 
be  of  no  u.se  to  try  a  niudi  weaker  si)herical  or  any  cylinder,  as  a 
patient  with  this  vision  would  not  appreciate  the  diR'erence  made  by 
such  a  glass.  If  the  vision  were  thereby  increased  to  20  70  or  20  20. 
we  wouM  add  a  si)herical  glass  of  I  to*2  D.  When  the  vision  had 
become  20  10  or  20  .iO  \\i-  would  add  0.75  spli.  (or  if  applying  cylinders 
a  l.(M)  I).)  to  the  con.cting  gla.ss  alr(>ady  in.  With  vision  of  20  .W  + 
,„.  o()  ;i()_  w(.  would  adil  0..')0  i>.  (sjihere  or  cylinder).  Finally,  when 
the  vision  had  become  20  20  we  may  add  a  glass  of  0.2.')  I).,  as  then 
the  patient  may  be  able  to  notice  "the  very  slight  difTereiice  that  a 
glass  of  this  strengtti  jiroduces. 

This  rule  no  longer  holds  good  when  the  patient  has  poor  vision 
due   to  opacities  in   the   media,  or  in   the   retina  or  nerve.     Then 


REFRACTIVE  ERRORS  IX  (iEXEJi.lL. 


127 


,1  weaker  uku^n  tlmii  that  imlicatetl  l)y  this  rule  will  often  produce  an 
iilH.reeiaWle  alteration  in  r*in\\\.  Hut  in  such  cases  ii  is  itest  to  |)roceeil 
;i('(or(lin);  to 

iiri.i;  III.  InnervousandtidjjetyjMTsons.  or  in  chill Ireii  when  they 
;.'(t  tired  and  inattentive,  or  in  any  case  when,  from  defect  in  xUv 
rye  its"lf  or  from  lack  of  mental  training,  the  patient  cannot  tell  what 
he  sees,  we  should  (/r()/>  llic  Ivstiitti  irillt  the  trull  r<i!<v  altogether,  instil 
liomatropiiie  and  deternune  the  refraction  carefully  l>y  skiascopy. 
Wiien  we  have  made  as  careful  a  determination  as  possil)!e  hy  this 
method,  we  may  then,  with  the  ulnan  thus  found,  resort  to  the  trial 
(•;,se  to  confirm  our  result. 

llri.K  1\'.  hi  vxtiiiiiiKitiiin  witltoiii  a  ciidofihjiv  we  select  as  a  meas- 
ure of  the  n-fraction  the  hij;hest  +  and  the  lowest  —  glass  that  pives 
die  patient  the  b'st  vi.sion.  It  is  evident  that  a  man  having  full  use 
(if  his  acconunodation  and  seeing  eiiually  well  with  a  +2  I),  and  a 
•  2.25  1).  glass,  should  have  at  least  +2.25  I),  hyperojiia,  for  if  a 
f-2  D.  reallv  maile  him  emmetropic,  the  addition  of  even  +0.25  D. 
would  hlurhis  sight.  So  also,  if  a  patient  can  .see  as  well  with  a 
+  0.75  U.  as  without  it,  he  must  have  at  least  0.75  I).  hyperoi)ia,  the 
iMtter  being  measured  hy  the  highe.^it  +  gla.ss  that  lie  iicnpti'.  -Vgain, 
if  the  patient  were  myopic  1.50  I),  he  would  see  well  iiot  only_with 
a  — 1.50  I).,  but  l)y  using  his  acconunodation,  also  with  a  —1.75  I). 
or  a  —2  1).,  which' would  over-correct  his  myoi)ia:  hence  the  lowest 
of  the  three  glas.ses  would  1h'  the  real  measure  of  his  refraction. 

IUlk  \.  When,  on  the  contrary,  we  examine  wilh  a  qichplenir, 
we  select  as  a  measure  of  the  refraction  the  lowest  +  and  the  highest 
-  glass  that  gives  the  patient  tlie  best  vision. 
l{i  I.K  \I.  As  we  have  seen,  the  strength  of  a  concave  glass  is 
dii;iini.><hed  and  that  of  a  convex  glass  is  increased  when  the  gla.sa 
i<  carried  awav  from  the  eye.  For  this  rea.son  when  testing  refrac- 
tion witli  lenses  in  the  trial  frame,  we  should  be  sure  that  they  are  nt 
Ihr  sniiir  distnitcv  from  the  eyes  that  the  patient's  glasses  will  be  when 
lir  wears  them;  oth  nvise  we  will  make  an  error  in  our  estimate,  an 
error  which  iiiav  I  of  .sensible  amount.  If,  for  instance,  the  trial 
fr.ime  stanils  out  too  far  from  the  face,  our  estimate  of  a  —  glass 
will  be  too  strong  and  of  a  +  glass  too  weak.  In  the  case  of  "strong 
'.'lasses  the  error  will  amount  to  a  whole  dioptre. 

Hn.K  \II.     If,  in  the  course  of  the  investigation,   it    becomes 
■I). parent  that  the  rision  cannot  he  rendUij  hrouijhl  to  nnrnidl  hfi  (uvj 
■:!nss  tried,  it  is  best  to  re-examine  the  eye  with  obii(|Ue  illumination 
,iid  with  the  ophthalmoscope,  to  see  if  any  opacity  in  the  media, 
liM'ase  of  the  fundus,  or  marked  irregular  astigmatism  may  not  be 
irsent,  causing  an  incorrigible  defect.     X'ery  often  the  u.^e  of  a 
:vdiiatic  is  necessarv  to  reveal  such  conditions,  es])ecially  in  the  ease 
:  lesions  in  the  vell'ow  «pot.     Examination  of  the  field  of  vision  is 
-.,  often  very  helj^ful,  ns  it  mav  reveal  less  of  central  vision  'due 
rliaps  to  tobacco  amblvopia,  etc.)  or  a  marked  and  increasing  con- 
ation of  the  field,  ind'icative  of  a   neurasthenic  state  that  cau-ses 


S" 


128 

tho  aiiil)lytii)ia. 

<if  ail  I'Vf  tlial  is  s(|uiiiiiiin 


Tin:  EYi: 


Wv  A\on\<\  also  I..'  on  tin-  lookout  for  tin-  aml.lyoj.ia 
•III  cvo  nun  IS  snuinliiiK  or  oner  was  Mil.j-ct  to  ^.niiiil. 
Routine  of  Procedure.    My  owm  ,.ro..,..lun-  ...  ;'-'''«;';•'";;:';" 


flllloWr 


I    til-l    "/'/''.'/   ''"■  "/'/"■"•'■"""'''    "■"'■'"' 


■tiitii.  ili't<'niii..t'il  l)y 


tlic  c.irsorv  I'xaiii.i.al.oii  ..lai 


inoscopi 


This  corrci  t.o..  «o. 


Ic  will.  skiasc(.py  or  will,  tl.f  opiiii.ai- 
.il.l,  ill  j;i'i.fral,"l><'  a  spl.rrical  j;iass,  .1. 


ami  a  cvliixli'r.  H. 

Scco.i.l,  I  ailil  to  tiiis  rorivct.oii  a  s«-r 


H'S  o 


f  \th 


SCl('( 


t.'.l 


llccnrdl.lH 


to  what  I  <'all  ■'""■ 
aiiotlirr  c|iiickl\ 


roll  III 


I  11/  tlif  '  -ial  cast-. 


That  is,  1  a.id  oi.f  after 


1.  A  cuiivcx  sphi'i-t 


•_>.  A  coiivfx  (•> 


iiiiclcr  with  its  axis  in  th(>  axis  of  li 


;{.    Thi 


<ai.ii'  fvh.i 


Icr  with  its  axis  at  rinhl  aiijlli's  to  li 


1.  A  concave  cyiiiiiler  witii  its  axis  11. 


the 


ax.s  ol 


li. 


iiiider  with  its  axis  at  rini.t  aLgles  to  H. 


.').  The  same  cv 

(i.   A  coi.cave  sphere, 

These  adilitioiis   form  a  series  o 


pi-acticaily  all  chai.ces  that  can 


.,  ,i  co.iihiiiatioiis  which  represent 
lie  made  ...  the  sphero-cyhnder  .1  H. 


Tims,  i 


if  A  and  li  ai-e  l)<>tli  convex 


the  additions  made  will: 


1.  Add  to  A  and  leave  li  alon 

•_».  Add  to  li  and  leave  .1  alone. 

;{.  Diminish  li  and  ad.l  to  .1. 

4.  Diminish  li  and  leave  .1  alone 


li  a.id 


sh  .1. 


,').   Incri'ase  li  a.id  dnnmi- 

().   Diminish  .1  and  leave  li  alo..e.  _ 

iM.r  exanipl.-,  if  +-'■>»>  Z   +  ^■^■^  '■>•'■  '»«    '''''''  '":  P'^  ^'"P'"-''  ">: 
in  the  frain>.  und  a  J  .ss  of  0  .",0  D.  were  added  i.i  makmft  the;'  .-ound, 
the  successive  ad.litions  made  and  the  comlmiaiioiis  resi.iun!;  tliere- 
from  would  be  as  follows: 


Additiimi. 
+  0  Tn)  liph. 
-.-  O.Sll  I'vl      9C 

+  o.'iii  cyl.  it-u 

—  0  .'lO  cyl.    '.*) 

—  o.Mi  cyl.  ISO 

—  o.:«i  "I'll. 


RaalUug  ^wnbinfitiim. 

+  3.U0  ■  1  ■-••'>  cyl.  «i° 

+  2..T0  ^  l.T.'i  cyl.  90 

f-  a.OO  •  0.7.1  cyl.  90 

+  2..'*)  +  0.t:>  cyl.  !>() 

+  2.00  f  1.7.1  cyl.  90 

,-  2.00  f  1  2.1  cyl.  <M) 


The  streii<;tli  of  the 


successive  glasres  added  in  making  this  round 

will  lie  {Toverned  l)v  Rule  II.  ,  •       •        1 

Third,  as  soon  as  l.v  makiiifi  the  round  I  reach  a  combination  that 
iiiMirove's  the  sifibt,  l  suhsllhile  tins  nnr  nnnhinatiiDi  for  the  old  one. 
With  this  new  "combination  as  the  approximate  correction  I  .start 
•iL'ain  on  the  round  of  the  trial  case,  not  usually,  how.-ver,  from  the 
be.rinni,!".  but  ad.linji  a  glass  similar  to  the  on.-  that  gave  in.prov.-- 
me.it  before.  Thus  if  I  before  got  iniprovemeiit  by  crossing  with  a 
—  cylinder.  I  keep  on  crossing  -  cyli.iders  u.itil  I  fail  to  improve; 
then  I  try  liie  nex(  niaiinMi\  .'<•  of  the  round. 

Hv  making  successive  ~  ,bstitutio.is  I  soon  get  a  glass  which  i.s  not 
improved  by  any  add.ti  ;is  (+  01  —  sphere  or  +  or  —  cylinder). 


nt.fiucTiVK  Kiinous  is  uesehal. 


129 


Tlii'U  I  iiiiikc  minutv  va 


iriatious  iti  llw  «/(n  «/  the  cylinihr  aiul  ><•«•  if 


litis  is  ju 


4  rijjlit- 


( H'lcri  tilt"  putioiit  ciiiiiK 


>t  iiidiratc  tli«'  axis  witli  prrMision,  saying 


-taiirf,  that  lie  sci-s  (•(luaily  \vi 


liii'  III 

7(1^.     Ill  siicli  :i  ••:isf 


11  with  tlic  cvliii'Ur  at  citluT  mf  i>r 


I  turn  llif  cvliiKlcr  up  (toward  'Mf)  ill 


itii  till 


vi,i„„  i-  .-vidrntly  l.l.irrr,l.  tl.-n  l.;in^'  it  Lark  until  tlir  sijjht  U'^jins 
1  thfii  til'-"  till-  ifailiiiK.     Suppose  this  to  he  .M 


to  (Itar  apiin,  aii 


tatc  tin-  cylintlir  down  (towan 


1   now  ro 

hluis.  tlu'ii  oiK't-  inon 


npanam. 
,-)(t°  aiK 


I  (1°)  until  aiiaiii  the  si^lit 


S()° 


,„ hriiiR  the  cvriiidiT  Lack  until  thr  sijiht  Hears 

Supp..se  this  to  1k'  at  :.(i°.     Then  the  axis  inu.-t  lie  l.ctween 


Working    iM'twcen 


these  limits,  I  try  apiii 


to  find  at  just  what 


point 


l„.l„w   MPandat  just  what  point  aLove  ^(1°  the  si«ht  rearhes 


t-^  j;:catest  clearness.    Sup] 


I  can  thus  narrow  the  limits  down 


lo     l.t 


an< 


I  11 


Then  the  axis  o 


f    the  cvliiuler  in  all  prol)aLilily 


ies  niidwav  Letweeii  these  limits,  or  at  70' 


When  this  point   is  s( 


■ttli'il  satisfactorily  1  may  assume  that  my 


sure  o 


(•orrection  is  jx-rfeet,  Lut,  to  Ix 

-hiiihiir  ti-"!  in  the  way  already  deseriLed 


f  it,  I  usually  /'nuc  i 


7  hy  tin 


The  ehanp's  and  successi 


ive  siiLstitutions  in  this  roun< 
vhile 


1  (vf  the  trial 


ileed.  atte 


i<(.  are  made  with  preai  rapuiiiy,  umk.m,  ......  ..  • alnio>t  me- 

,l,;,„i.-allv,  and  thus  in  a  very  short  time  the  ,. roper  filass  can  he 

,,„;„,,,„;„;.;,,„„,.  i„  parti.'iilar,  we  can  Le  sure  that  no  other  ^lass  than 

,1„.  ,,iie  we  have  fixed  upon  will  answer  as  well.  ,,■,,,,,. 

I„  order  to  determine  wh.'ther  the  vi.hu  >r>lh  the  pupil  ddoUd  L> 

,  .v.loi.lefiic  rc.presents  what  the  vision  will  U'  when  the  pui-il  c.n- 

,,;ts    o  its  normal  size,  1  slip  a  disk  with  a  4  mm.  a,K.rture  in  it 

;:    .    ,„e  cnrectin,  ,lass  in  the  trial  frame.     I  thus,  m  ''T.^t,  roduee 

,i ,,         ;,  ,.,  ,h,.  normal  size  and  eliminate  the  disturLin^r  efk-ct  of  the 

,avs'p!issin,r  throiijrh  the  iH.riphery  of  th-.  pupil.  M  often  are  n.-t 

1  lik.'  thos.'  passinjr  th-oiii:!.  the  centre.     In  most  ca.-es  this 


rcfrai'tet 

disk  will  iniprovi 


i'lten 


look  sharper  and  blacke 


the  sifiht,  and,  in  jiarticular.  will  ii 


that  the  correction  is  the  jiroper 
ivduction  in  the  spherical  compone 


lake  the  test 
If  tills  is  the  case,  I  feel  confident 
line,  and  will,  after  any  necessary 


It,  Le  accepted  when  the   efl'ect 


>t  lh( 


cycloiile)iic  has  suLsidi 


It  should  Le  iiote( 

'.(.-1    re 
'hat  we 


■1  tiiat  the  test  at  20  feet  does  not  ahv.iys  fiivt 


the 


.ults  for  jar  distance.     It  is  well,  therefore,  to  .ry 


the  fila 


have  found  Lv  havinft  the  patient  look  out  "f     '<' ;^"';'; 

hether  a  —  0.2o  D.  added 


nd  then  to  oLserve  w 


ilo  the  far  distance  a 

uis  not  sharpen  the    sifjht    matt 

uies  of  Lricks  and  mortar,  etc.,  in 


riallv,  defining,  f  r    instance 


the 


listaiit  luiuses  Lr-tter.     If  it  does, 

iiied 


lie  CO 


.!■  distance 


rre.spoii.linf:  reducti'on  should  Le  made  in  ih.'  glass  detern 


Alter  I  have  determined  the  correc 
WvA  it  :H!  ndvantaire.  especia 


■i-ii 


ctiiifi  glass  for  each  eye  separately, 
llv  ill  testinc  hy]>eroiM's  without 


cycloi 


lesricto  put  the  eorreetim,  for  each  eije  w  the  jra 


!\nd  h 


tient  look  at  the  tt 


■A  cards  with  both  eyes  at  once.     It  may 


if 


130 


tlu'r*  turn  f)iit  tliat 


THE  KYE. 


lill  take  sdiiic  julditidii  to  tlic  cmT.-ctioii  in 


(ilir  eye  or  liiitli  wliicli  he  iliil  not  take  hci'div. 

Tin'  IckI  I'lir  iKiir  is  made  .-iiii]ily  by  piittiiij;  on  cacli  eye  its  |iio|)('r 
correction  atnl  llicn  niakinf;  the  iiaticiit  use  hotli  eves,  and  find  what 


d  ;rlass  li 


adiiiiionai  f;iass  lie  ncciis  lor  Ins  rcadiiifr  <ir  working;  distance — i.e.. 
we  make  liic  patieiil  csseniiaily  an  eininetrope  l)y  glasses,  tlicn  con- 
duel  tlie  exainin.iiion  in  tlie  same  way  as  I'or  eininetropes.  (See 
Cliapter  II.)  Tliis  examination,  of  course,  should  he  made  eitlier 
hel'ore  inslilliiifr  the  cycio])e};ic  or  else  some  days  after  the  effect  of 
tlie  latter  has  suhsided. 

An  exaiii])!!'  will  indicate  iiKtre  clearly  the  method  of  procedure. 
A  patieiii  not  under  a  mydriatic  has  vision  of  L'O  L'O.  I  put  mi  him 
+  ()..")(),  then  i  0.7."),  then  *  l.(K)  I).,  which  he  accepts:  hut  he  rejects 
a  1  1.1'.")  1).,  that  hlurriiif:  his  sijrht  a  little.  !,ea\in<;  the  r  I.(M)  s|)h. 
in,  I  :iM  rO..")()  cyl.  ax.  first  at  !»0°,  then  at  1S(P.  Both  are  rejected, 
hut  tlie  former  ^ives  less  hlurrinjr.  I  then  -mM  — ()..")()  cvl.  1N0°,  which 
coiiverlsihe  l.tKlinto  •  tl..')()  ~  *()..")()  cyl.  ax.  <l(l°.  This  sharpens 
thesifrjil  coiisiiierahly.and  1  immediately  substitute  -r()..j()^  -t  {)..")() 
cyl.  ax.  illP  for  the  +1.00.  As  the  iiatieiit  shows  astifriiiiitlsm  with 
the  rule.  I  follow  the  lead  that  he  indiciites  hv  now  addim;  successively 
+  0..")0  cyl.  ax.  <)0°,  and  -0..".()  cyl.  ax.  lSO°.  With  neither  is  the 
.-ijlht  hetler,  nor,  in  lact,  is  it  as  <rood  as  without  the  jrl:i.-s.  Now 
makin<;  the  -round"  with  .-i  •  O.L'.")  I),  sph.  and  cylinder,  I  liiid  that 
the  sphere  improves  more  than  the  cylinder,  indicatiiif;  a  correction 
of  +0.7.")  sph.  ;  ;()..")()  cyl.  ax.  <I0°.  The  jiatieiit  accepts  no  further 
chanjre.  I  now  rotate  the  cylinder  .and  find  that  the  sh;iriM'st  vision 
and  also  the  complelest  ei|uali/,ation  of  lines  of  the  a.-tiL'matic  clock- 
face  .are  ohtained  with  the  cylinder  at  ,S0°.  The  linal  correction, 
therefore,  is   ^0.7.")  si)li.  ~     •  0..")()  cyl.  ax.  S0°. 

The  oilier  eye  tested  in  the  same  way  shows  -().,")()  sph.  ~  '  O.7.") 
cyl.  ;ix.  KHP.  With  lioth  eyes  together  he  accepts  an  addition  of 
+  0,.")0  s]ih.,  and  for  reading:,  takes  ;i  further  adilition  of  +  ((.7;")  sph. 
His  (Mstaiice  jilass,  therefore,  would  he  R.  +  l.L'.")  sjili.  ~  ^  0..")0  cyl. 
ax.  ,S0°:  I,.  .  l.Ottsph.  Z  0.7.")  cyl.  ax.  100°.  His  rea.liiifr  jr|;,.sses 
would  he  H.  -  L'.(K)  s|)h.  "  *().,")()  cvl.  ax.  S(l°:  I,,  i  1.7.")  sph.  3 
+  0.7.")  cyl.  ;ix.   100° 

Take  another  instiince:  .\  jiatient  under  homatrojiine  has  indi- 
c;iieil  hy  the  iiph thai moscope  and  the  shadow  test  a  fjlass  of  ahout 
'1.7.')  s|ih.  ~  f  l.(M»  i-yl.  7;")°.  With  this  he  }r<'ts  1>0  10  vision.  I 
add  in  succession  fO..")Osph.,  M),.")0  cvl.  7.")°,  4  O.ilO  <  100°,  -0..")0 
cyl.  7:)°,  — 0..")0  cyl.  1(m°.  and  0..")0  sph.  I  find  ,  ,,  of  all  these 
comhinations,  -  0..")0  cyl.  10.")°  improves  tli<'  most.  I  suhstitute  the 
rorrespondinj;  comhination,  ^  1.2.")  spii.  ^  i  l..")0  cyl.  ax.  7.5°,  and 
now  jret  I'O.'iO  ^  vision.  I  asain  add  — 0.')0  cyl.  ax.  l(i")°,  hut  fail 
to  improve;  then  ^  ().,J0  cyl.  7.")°,  with  the  same"  result.  -()..")() sph,, 
however,  .seems  a  little  lietler.  and  when  I  try  the  "round"  with 
0._'.')  n.  jri.'isses  f  fret  im|)rovement  with  -O.'J.')  sph.  .Makiii<:  the 
"round"  airain,  no  ulass  a<lded  helps.    I  change  tlie  axis  of  the  cylinder 


nin-UAvTivt:  khroiis  is  aEyKHM. 


V.'A 


I    fail    to    p't    any   certain    result,    tiie   patii^nt's    answers  Ix'iii^ 


am 
ratlier 

-l.jO  cyl.  7.")" 

-l.oO  cyl.  ax.  7")°  and  apply  the  shadow 


va>;ue.     The  jiatient,  therefore,  seems 


to  1 


lave 


l.tMl  sph.  _ 


tlie 


liadow  moves  w 


I'o  prove  it,  I  jnit  in  tiie  trial  frame  a  +2.00  sph.  _ 

test  at   1  m.     I  find  that 

lirections.  hut  tiiere  is  a 


it  olihque  mov( 


itli  the  mirror  in  all  i 
iiient  which  is  corrected  by  rotatinji  the  cylind( 


,  ,  ,1  it  stands  at  ()0°.  I  then  hnd  that  1  fret  comi)lete  reversal  in  t! 
i,  ■.•ridian  <>f  00°  when  I  stand  just  within  1  m.,  hut  do  not  get  rever.-al 
ill  the  meridian  of  l.")0°  until  I  >:o  hack  some  distance  heyond  1  m. 
The  cviinder  then  needs  streiifitheninfj.  Suhstiiutins  +  1.7o  cyl.  ax. 
(iO°  for  the  +1..")0  cvl.  already  in,  1  now  find  that  I  get  complete 
even  reversal  in  all  meridians  alike  at  I  m.  The  correction  is,  there- 
fore, +  1.(K)  sph.  C  +1"'  <■>■'•  *'<>°-  ^^'*''  ''"'^  "''  ^'"''  *'"'  1'"'"'"^ 
now' gets  20  2()-r,"and  the  astigmatic  clock-face  is  perfectly  even. 
He  gets  even  sharper  sight  when  I  juit  up  a  diaphragm  with  a  4 
mm.  aperture,  which,  in  effect,  restores  his  jiupil  to  the  natural  size. 
Hut  when  he  looks  out  of  a  window  he  sees  far  distant  objects  better 
with  — O.2.")  added.  Hence  his  full  correction  for  distance  is  finally 
determined  as   -f  0.7")  sjih.  C  +l-"'"»  ''}'•■  t'**"- 

Rules  for  the  Prescription  of  Glasses.  It  being  supposed  that 
we  have  found  a  patient's  total  refractive  error,  we  now  have  to 
determine  what  glass  to  prescribe  for  him.  This  de])en(ls  ui)on  so 
many  factors  that  no  rule  can  be  laid  down  which  will  cover  all 
casei.     The  following  are  the  general  princii)les  that  I  follow: 

1.  I  correct  all  the  dsligwalisw  that  the  patient  has,  unless  it 
is  over  (i  1).,  in  which  case  he  is  sometimes  more  condortabl  '  and 
-rets  (|uite  as  good  vi.sion  with  the  astigmatism  slightly  under- 
'(•orrecte<l.  I  do  not.  however,  hesitate  to  prescribe  cylinders  of  more 
than  (>  !)..  when  these  give  ai)preciiii)ly  better  sight  than  glas.M's  ot 
less  stliMlgtll 

.\stigniatism  of  only  0.2o  or  O.oO  1).  I  do  not  i>rescribe  lor.  unless 
the  symiitoms  (astheiiojiia,  blurring  of  sight,  etc.)  seem  jiarticulaiiy 
to  call  for  the  correction,  or  unless  the  jiatient  has  to  use  his  eyes 
for  very  close  and  continuous  ne;ir  work,  or  finally,  unless  the  patient 
is  going  to  use  a  glass  anyhow,  in  which  case  I  regularly  add  the  cylin- 
drical correction  that  he  reipiires,  however  small. 

2.  I  correct  the  full  amount  of  luijopia,  and,  wherevi-r  I  can,  have 
ihe  patient  use  the  same  convction  for  liistaiice  and  near.  If  he  is 
much  bevon.l  the  age  of  forty  years,  this  is,  of  course,  imiHissible; 
an<l  even"  below  that  age  we  may  have  to  give  the  myope  different 
glasses  for  reading  and  distance,  jiarticulaiiy  if  he  has  not  used  con- 
cave gla.s.ses  before  for  near  work.  But  in  myopes  under  forty  years 
of  age  1  make  th<>  attempt  at  any  rate  to  gel  iheiii  to  use  their  full 
lorrecting  glass  for  all  jnirposes,  and  I  find  that  1  generally  succeed 
if  the  patients  are  at  all  faitliful  in  following  my  instructions. 

I  consider  it  particularly  important  to  corn'ct  myopia,  whether  of 
low  or  of  high  degree,  m  children,  and  to  make  them  wear  llieir 
glasses  constuntly.     1  am  verv  strongly  of  the  belief  that  this  course 


132 

ti'iitls  inon 


TUE  EYE. 


tl.un  anvthinp  ."Is.^  t..  n-tanl  the  further  a..vel..i..M.-nt 


the  myopia 


l.M,  <if  very  fiicat  iinportaiico  ti)  corrof 


It  is  a 
to  insist  upon  tiic  l)atit 


t  fiiUv  the  myopia,  am 


nfs  using  his  glass  for  all  purpos. 


ilior 


a  eonvcr 
ia  wliich  1; 


rgciicc-insutHcicncj 


V.    Tho  .  videnc'cs  < 


wlicii  he 
)f  this  will  1)0  an  cxo- 


mueh  more  ma 


rked  for  .lear  than  for  ilistancc, 


an( 


!:;;,;;;,.;;;.;  ;o"nv:;;sion  .>f  th.  ...ar  point  of  n-morg-noo  .n.li..a^n|g 
\,  ;  ,„,  ai,ili,v  to  n.aintah.  binocular  hxat.on  at  n..ar  pomts  .s  f^^u img^ 
\  \Lh  a  <-iso  the  use  of  fuUv  crreotrng  coneave  glass.^s  foi  both 
!,t,an':.'ana  n.^  by  sthnulating  the  aeeonnnodat.ve  power,  may 

.  , ,  ti„,  (levelonmont  of  a  divergent  siimnt. 

'  \;;;;;,i  .f  ve  hif:h  d.-gree  n.ay  have  to  l>e  under-eorreeted  on 
ac-n  .f   le  annoyance  that  the  very  strong  glas.-s  often  produce. 

Hut  I  believe  that  we  may  generally  prescribe  P'--;;  "I'     ;  ^ J^' 
and  in  certain  cases  mav  give  even  stronger  glasses  with  adxanta^i. 
i    I  correct  all  the  absolute  and  all  the  mamt.'st  hmHropm. 
The  latent  hvperopia  I  umler-correct  according  to: 
,     T  le  .v/r  of   he  pati.Mit.     The  older  he  is  the  less  .n  general   «e 
,,  'l.   ;..  /.ncorrected.     No  absolute  rule  can  be  l''"l ;'---;/ 
,nv  1...  stated  that  in  children  un.ler  twelve  years  of  age,  fn.n 

•>  of  latent  hvperopia  may  often  be  disregarded:  trom  t^^el^e 
to  rw'.ntv-five  years  of  age.  0.75  to  1.25  I).;  ami  from  twenty-hve  to 
fortv  vears  of  age,  0.50  to  <)./•)  U.  ,,  ,      ,        .  i  • 

I,    Th^^nnuUtions   u„.hr    ichich    he   works.     If  he  has  to  use  his 
.ves  ex  .  Js  ve Iv,  especially  at  s,  ni.  trying  kin.,  of  near  work,  and 
V  rticularlv  if  bv  artificial  light.  I  should  give  him  a  stronger  glass 
5,,;,  if    he  were   using  his  eyes   mainly  for  dntance  and    by  da>- 

'""c  '  His  ..,nnptow.^.  A  patient  with  asthenopia,  hea.lache.  and  other 
evidences  of  evestrain,  will  require  a  fuller  correction  ot  his  hyi-er- 
o  i  than  oae-who  has  no  such  symptoms.  So,  also  one  suf  ermg 
om  accommodative  weakness,  .hie  e  ther  t,.  neuras  hema  or  to  le 
effects  of  recent  .lisease,  will  iv.,uire  the  correction  of  nearl>  or  .luit. 
all  of  his  hvpen.pia,  even  if  of  low  .legree. 

,/  Th.'  nn.sJar  co„litin».^.  A  patient  with  esoi)hona.  ami,  still 
,n.,r.>  ..ne  with  an  actual  c.nivergent  squint,  due  t.>  c.nvergenc.;- 
!x,,-s  sh..ul,l  wear  c.mstantly  the  full  c.rrection  of  his  hyperopia 
or  within  0.25  D.  of  it.  lAp.Mi.M.c-  has  shown  that  it  ";  .-"ly  'V  ;«; 
persistent  ami  long-contimu-d  wearing  ot  the  full  c.rrection  that  tht 
he^t  results  are  obtaini'd  in  thi>se  ca.ses.  •     ,    , 

Per  c.ntra,  a  patient  with  mark.".!  exophona  aii.l  particularly 
an  exoplmria  .lue  t..  onvergenc-insuHiciency,  often  d<K>s  letter  if 
his  hvpen.iMa  is  mo.lerately  un.ler-corrected. 

\  -.imple  hvperopia  of  0.25  t,.  0.75  1).,  or.  m  ch.l.lren.  of  even 
1  m  1)  mav  in  most  .-ases  he  left  uncorrecte.l  unless  it  is  producing 
blurring  ..f  sight,  asthenopia,  or  a  converge!ice-exces.s 

In  .Lo,.Li,ia.  whenever  the  sight  in  both  of  the  eyes  can  he 
brought  ui.  to  anything  lik.>  the  normal.  I  try  to  either  give  th.-  full 


BEFIUCTIVE  EKHOna  IS  UEXEUAL. 


V6S 


•     1    ,1      ,r  „i<„  v,..liu-c  the  full  corroction  by  un  tniual 

there  is  /»«"'^,Ve1,a  en    reiK^  «  ^^"^  "'• '"'"  "^'^'^ 

safer  to  have  the  patient  rtpori  loi  (t 

,,.  c;Tec/,s  0/  t;r ^^?  TA  IndS^orLtL^^^^^^^^^^^  tl/cyclo- 

eaoh  eye  the  ful   sphero-rylindnca  <  ""eeuoi  ^^  ^_^^^  ^^_ 

plegic  ancl,havmgthe  i;;:^;;\",tange  tKpherical  glasses  (but.if 
if  he  iloes  not  get  full  Mt'ion,  ^  ,  "t,  ,,til  his  sieht  is  brought  to 
possible,  do  not  change  the  ?jl^'^^l^'^^^^^  .lifference 

between  this  and  t^^  g^a-       prescribe  for  him  will  be  the  manifest 

.,o,  the  amount  of  his  as.       '''"^l^'^^'^^uint.  I  pav  no  attention  to 

If  th.-   patient  has  a  J^^.^^^!    give  the  full,  or  practi- 

'^t'to'iJl:::^^,  no  mlZr^wheth^  the  patieiit  has  poor 

t.„„s.     Persons  with  '^^t.gnjatisnu    I  ^  o     ^  M  -^^  l^  .^ 

whether  low,  moderate,  or  high  ""''  ^7/  ^V; !;  ,„^P,  of  eyestrain. 
sutUeie,.tlyhiglUooccas.onast^H^^orc^h  r   ^^ 

.hould  wear  their  glass.>s  a  ™  J^^,;^  {..^  the  patient  to  use  them 
,hiss..s  are  to  be^vorn  at  '•»";;,/^,  ".;*;;;  .Jt  pn-scribed  simply  for 
,...,..tantly.  P'T?;;;  ;''^;::;r "' c^  -^'I^cll  or  cylindrical  glass 
presbyopia.     \Vhen,  lioweyr.     i  i  ^^i,p„„pia  occurring 

s  of  ^light  amount  an.l  >^  P^''"'';'^  i^rmtte  to  do  without  the 
solelv  in  near  work,  the  patu'ut  may  be  J^^^IJ^^^^  ^he  patient 
ghiss  for  distance.  Y.-t  even  '"  l>  ''"^^J  ;  '^^;Vy  o  doing  he  will 
to  wear  the  glass  con  uu.ous  y  f-'^Ji  f-  ^-  {  ^^^^^\^,,  tell  such 
a..,.„stom  irnnself  to  it  much  -^V^"  t\ ,,  the  time  for  th«.e  or 
.tients  thMt  they  should  ^v™; ''"^^^'^.f '"^.'^f..    j  ^um  f.rr  distance  if 


«^i'i^ 


ji-^^: 


1-34 


THE  EYE. 


own  vulitiim  coiitimic  to  wear  tlic  jihisscs  constantly— wliicli  will, 
on  tlic  wiiolc,  he  a  jrood  tiling. 

A  cunstaiit  wcaiinj;  of  tlic  coiToctinf;  jtlasw  is  particularly  iiulicated 
wlnii  tiMTc  is  [(I)  a  convcrficnco-insuliicicncy  coniluncd  with  myopia, 
or  u  convcrgcnci'-cxccss  (•oinhincd  with  hyiMTopia.  or  (/*)  a  s|)asni  of 
accommodation,  or  {<■)  a  licgiiining  myopia  in  childhood,  or  (d)  a 
pronounced  asliicnoina  with  its  attendant  symptoms  of  cycachc  and 
headache,  or  (c)  ue"  nia  with  eye  symptoms  and  sometimes, 

also,  when  no  eye  i  i     ns  are  jircsent. 

Difficulties  Encou^beied  in  Wearing  Glas&es.  .Many  ])e()))le  (>xpe- 
rience  ililiiculty  when  they  jjut  on  glasses  for  the  first  time,  (ienerally 
speaking,  these  difficulties  vanish  after  the  glasses  are  used  for  a  few 
days,  particularly  if  they  are  worn  constantly.  Hence,  if  a  patient  d(H's 
come  back  two  or  three  tiajs  after  getting  his  glasses  and  complains 
that  he  cannot  see  well  or  comfortably  with  them,  ho  should  be  told 
to  put  them  on  and  wear  them  steadily  for  at  least  a  week,  and  that 
he  .should  not  be  discouraged  if  he  does  not  become  perfectly  ;u-cus- 
tomed  to  them  before  the  week  is  over.  In  fact,  we  should,  as  a  rule, 
not  think  of  changing  a  glass  simply  on  account  of  the  difficulty  ex[X'- 
ricnced  in  using  it  until  constant  use  for  at  least  three  weeks  Iwis 
l)roved  it  unsuitable.  In  the  great  majority  of  cases  it  will  be  found 
at  the  end  of  this  period  that  whatever  trouble  the  glasses  occasioned 
at  the  out.set  will  have  entirely  disappeared,  pre  ided  proper  care  was 
taken  in  prescribing  the  glasses  in  the  first  place. 

The  difliculties  experienced  in  using  glas.-<es  may  arise  from  changes 
they  produce  in  the  .^/^c  of  oiijects.  .Myopes  often  complain  that 
their  glasses  make  objects,  es|M'cially  objects  close  to  them,  look  too 
siuidl,  so  that  they  hnd  difficulty  in  reading,  sewing,  or  doing  any 
tine  close  work  with  the  correction  ])rescribed  for  distance.  I'sually 
this  difliculty  jjasses  away  after  a  while,  and.  in  the  expectation  that 
this  will  take  place,  we  should  always  encourage  the  myope  to  keep 
on  with  his  glas.ses  for  a  week  or  two  at  least,  in  order  to  see  if  he 
will  not  gradually  get  accustome<!  to  them  for  all  purjKJses.  If.  as 
exceptionally  hai)pens,  he  cannot  get  used  to  them,  thei!  we  .shall 
ha\e  to  give  him  .-i  weaker  glass  for  near  work.  How  much  weaker 
must  be  determined  by  experiment:  but  in  any  case,  if  he  is  under 
forty  years  of  age,  wo  try  to  get  his  reading-gla.ss  as  near  to  his  dis- 
tance-glass iis  possible. 

Hyperojies  sometimes  complain  that  their  glas.sos  make  near  ob- 
jects look  too  large  and  co;irse.  This  difhculty  is  prof)ably  always 
remedie(l  by  m<ire  i)rolonged  ns(>  of  the  glas.ses. 

(■lasses  also  cause  trouble  by  altering  the  .v/zo/x'  of  objects  looked 
at.  This  is  i)articiilarly  the  ca.se  with  cylinders,  which  often  make  a 
s(|uare  appear  oblong,  or.  more  fre(|uently  still,  trapezium- haped 
(narrower  at  the  top  than  at  the  Ixittom),  and  mak(>  liorizont  1  sur- 
faces appejir  slo|)ing.  I'rismatic  glasses  have  the  same  eltoct,  and 
so  ;"')  spherical  glas.ses  when  the  wearer  look  il)li(|uely  through  them 
or  sees  through  their  e(|ges.     This  distortion  produced  by  glasses  is 


■'■ ■'  ■  —  -"— ■■ 


IIEFIIAVTIYE  ERRORS  L\  UESERAL. 


135 


iftcii  (luito  iinnoyiiifi,  hut  usually  jjasscs 


;)H'  soon  (within  a  week  or 


two  ill  most  cases 

tlic  strcnfitli  of  tlic  jilasst 


).     X'crv  scKloni  we 


have  to  obviate  it  by  retlueing 


\'.otl.n-  .lisujireetihie  elTeet  pro.luee.l  by  glasses  is  an  alteration  i.i 
,f  „t,jeets  looked  at.     HyiHMopes  often  eoniplam  ot 


the  iliKlindncxx  o 


the  blurring  produe.Ml  by  their  convex  glasses  when  thes<-  over-correct 


even  by  a  v(  ^ 

very  prolongeil  use  of  the  gl 


TV  little/ their  manifest  hyiK'ropia.     Sometime 


even 


;isses  does  no 


t  obviate  this,  as  they  hold 


on  very  teiiacioush 


;lv  to  their  accommodation,  and  so 


do  not  allow 


anv 


furtl 


ler  amount  o 


,f  their  latent  hyi)er(.i)ia  to  become  manifest 


We  should  in  such  a  cast 

three  or  four  \v( 

that  the  excessive  accomnu 


make  the  patient  use  his  glass  steadily  for 
ekl     If  at  the  end  of  tiiis  time  there  were  signs 


xlation  was  giving  way,  or,  m  any  case 
if  the  blurring  was  not  verv  annoying,  we  should  conti.iue  the  glasses 
for  a  further  period  of  three  weeks.     If,  however,  the  blurring  con- 
tinues and  particularlv  if  it  is  causing  the  patient  much  annoyance, 
we  nuist  then  weaken  'his  glass  somewliat,  telling  him  that  later  on  he 
will  need  to  have  it  made  stronger  again.     In  particularly  obstinate 
ca.ses,  where  the  proper  glass  causes  persistent  blurring,  and  where  the 
weaker  gla.ss  that  would  give  better  sight  is  not  sufhciently  strong   .. 
relieve  the  asthenopia,  we  will  have  to  use  a  course  of  atropHie  (1  to 
1  5  mn-  cent  .solution  instilled  three  times  a  .lay,  for  a  week  or  two). 
'  ()uite  the  same  blurring  is  fouiul  in  myoi)es  with  a  spasm  of  acconi- 
modation.     But  here  we  shoul.l  by  no  means  yield  to  the  patient  s 
desire  for  a  stronger  concave  glass,  but  insist  upon  his  wearing  the 
i.roper  correction  as  found  under  a  cydoplegic.     If  the  accommodation 
remains  still  in  a  state  of  spasm,  we  should,  as  m  the  hyperopes,  use 
atroi>ine,  instilled  three  times  a  day,  tor  two  weeks.  . 

Blurring  is  often  noticed  with  convex  glasses  that  have  been  pre- 
scribed for  near  work,  whether  in  liypero,j(>s  or  presbyopes.  I  this 
persists,  we  should  alt(>r  the  strength  of  the  glass  accordingly,  being 
'•areful  to  test  the  patient  as  nearly  as  may  be  under  the  same  con- 
ditions as  those  under  which  he  works.  ... 

Mvows  and  astigmatics  sometimes  complain  that  their  vi.sion 
is  ),;„  ku-n  with  their  glasses.  They  miss  the  mitigating  haze  that 
formerly  invested  all  objects  that  they  saw.  They  soon,  however 
bec.me  used  to  the  new  conditions,  and  learn  to  enjoy  the  increased 
detinitio"  and  clearness  of  everything  they  look  at. 

Vnother  wav  still  in  which  glasses  cause  trouble  is  l)y  altering  the 
ymm-uhir  rdntinn^  of  the  eye.  .V  convex  glass,  by  doing  away  with 
the  necessity  for  using  the  accommodation,  may  cause  a  t<>mporary 
convergence-insufficiency,  which  produces  a  tendency  to  diplopia  and 
con.se.iu(<nt  blurring  of  sight  at  near  points.  If  this  does  not  as  is 
usually  the  ca.se,  soon  disapix-ar  with  the  continued  use  of  the  glasses, 
we  may  have  to  exercise  the  c()iiyerg(>nc.>  with  prisms,  ba.se  out,  or 
i„  ^omi'  eases  even  have  to  .liminish  the  stnMigth  of  the  convex  g  ass. 
Tl.(>  iirescription  of  prisms,  base  in,  for  constant  wear  is  "I'^i'lvis- 
in  these  cases,  since,  although  affording  temporary  relief  to  the 


f** 


mm 


^ 


warn 


i^ipquRi 


v.m 


Till':  KYIC. 


iipt   to  cause  a  progressive  increase  in   the  devia- 


syniptoiiis,  It   is 

tioii. 

So,  also,  a  concave  f^lass,  l)y  compelling  the  us(>  ot  the  accoinnuxla- 
tioii,  which  Ix'fore  was  not  in  use,  may  produce  a  temjjorary  conver- 
gence-excess, and  this  may  likewise  cause  slight  diplopia  and  blurring 
for  near  vision.  This,  if  persistent,  may  be  remedied  by  practising 
the  divergence  at  near  ])oints  vone  foot  or  less)  with  prisms  of  1">° 
or  1()°,  b;i^e  in.  The  prescription  of  prisms,  ba.se  out,  for  constat'* 
wear  is  not  advisable-  in  these  cases. 

If  a  muscular  deviation  is  already  i)resint,  the  troubles  to  whidi  it 
gives  rise  may  be  accentuated  by  glas-ses.  This  is  particularly  the 
(!a.s(  if  the  deviation  is  such  as  to  produce  diploi)ia.  This  diplopia 
may  not  occa.sion  trouble  .so  long  as  one  or  both  of  the  double  images 
are  faint,  so  that  one  of  them  can  be  readily  ignored.  Hut  when  tlie 
glass  makes  both  images  distinct,  they  can  no  longer  Ih>  neglected, 
and  both  obtruile  themselves  di.sagreeably  upon  the  patient  s  notice, 
causing  a  .sen.se  of  confusion  ami  uncertainty  that  amounts  to  abso- 
lute distress. 

Lastly,  a  disturbance  in  muscular  relations  may  be  produced  by 
the  prismatic  effect  of  the  glasses.  All  gla.sses  act  as  prisms  if  their 
we;;rer  looks  through  their  eilges  instead  of  their  centres  or  if  they 
are  decentred.  If  he  looks  nearly  through  the  centre  of  one  gla.ss 
and  through  the  edge  of  the  other,  or,  if  the  glasses  are  of  different 
strengths,  and  he  looks  through  the  edges  of  both,  he  will,  in  effect, 
have  a  different  prism  before  one  eye  than  In^fore  the  other,  and  will 
hence  tend  to  see  double.  If  lie  aetually  sees  double,  his  sight  will 
be  ccmfused:  if  he  overcomes  the  diplopia  by  nmscular  effort,  he  is 
likely  to  suffer  from  a.sthenopia.  This  often  hapjxMis  with  strong 
glasses  which,  owing  to  their  weight,  are  apt  to  .sag  and  get  out  of 
adjustment. 

the  remedy  for  this  is  to  see  that  the  glasses  are  very  carefully 
centred,  or,  if  decentred,  are  so  disjxjsed  as  to  produce  an  ecjual 
|)rismatic  effect. 

These  various  difficulties  due  to  glasses  are,  of  course,  more  a()t  to 
be  produced  with  slromj  glasses  than  with  weak  ones:  yet  it  has 
l)een  my  ex])erience  that  very  strong  s])herical  glasses,  and  in  par- 
ticular, very  strong  cylinders  are  borne  without  much  difhculty — 
in  fact,  ((uite  as  well  as  those  that  are  much  weaker. 

Some  of  the  greatest  ditticulties  are  experienced  in  anisometropia. 
Yet  even  liere.  if  persistent  efforts  are  made  for  a  couple  of  weeks  to 
use  the  glas.ses  ]ir<iperly  correcting  both  eyes.  th(>  ditticulties  will, 
in  mixst  ca.ses.  ultimately  di.sapi)ear.  and  the  sight  will  be  much  better 
and  more  satisiactory  with  the  glasses  than  without  them. 

The  Adjustment  of  Giasses.  It  is  important,  as  we  have  just 
seen,  tliat  gla.-?es,  es})prial!y  if  at  a!!  slvoTtg,  should  bn  .'iccurately 
centred— /.  c,  their  optical  centres  should  lie  oi)p()site  the  centres 
of  the  i)U]iils.     Moreover,  the  nose-piece  should  be  so  adjusted  an 


REFRACTIVE  ERHOUH  IS  OESEHAL. 


137 


,..,t  to  allow  tho  glasses  to  oscillat.-  or  l.e,-onu>  tilt.Ml.     <>thorvvi>.j, 
the  glasses  may  i)ro.luc('  a  prismatic  or  a  cylmancal  i-f.cct  xxhicli 

was  not  ii'ti'iuU'd.  ,    .       .i       i  ..  :ii 

TlH'  frames  should,  in  general,  bo  so  a.ljuste.1  that  the  glass(>s  will 

stan.l  at  the  ant.'rior  focus  of  tlu>  eye-i.  e.,  about  one-half  inch  in 

front  of  till'  cornea.  i      i  1 1     i  i 

( ilasses  inteiute.1  mainly  or  exclusively  for  remhng  should  be  droi)i)e(l 
some  5  or  6  mm.  and  tipi.ed  fonvard  about  15°.  so  that  when  the  gaze 
is  ,lin>cted  down,  as  it  is  in  rea.ling,  tl><'  I""'  "^  '^'Pl't  ""»>'  ;;|"''«^  ^iu 
.rl-iss  at  right  angles  and  pass  directly  through  its  centre.  Moreover, 
?he'  centre  of  each  ghis.  should  Ix'  carried  :i  mm.  in  tovv^ird  the  nose : 
„therwi.se  the  eves  when  converged,  as  they  are  m  n>a(lmg,  will  look 
through  the  inner  edges  and  not  the  centres  of  the  glasses. 

These  are  points  that  the  optician  who  makes  the  gla.-ses  usuall> 
attends  to  carefully.  Vet  it  is  always  well  for  us  to  verify  this  ad- 
tustmeiit  personallv.  ami  satisfy  ourselves  that  the  glass  is  just  of 
h  rength  we  ordered,  that  it  fits  properly,  and  that  it  is  steady. 
Otherwise,  we  mav,  at  times,  be  blamed  for  troubles  produced  by  the 
gla,sses,  but  which  are  due  to  faulty  fitting,  and  not  to  any  error  m 

''"sil.m'times''our  patients  cannot  go  in  per.son  to  the  opticians  to 
be  fitte.l  Then  we  have  to  send  along  with  the  prescription, 
measurements  and  .lirections  showing  how  the  glasses  are   to  be 

""For"jictacles  these  mea.s^rements  and  directions  are  as  follows: 

mThmcf  betw(>en  centres  of  pupils  (interpupiUary  or  pupillary 

Stlwbrilige  (whetherC  bridge,  sa.ldle-bri.lge,  or  snake-bridge). 
Height  of  bridg<-<.  c,  height  of  top  of  bridge  atove  the  line 
connecting  the  centres  of  the  pupils. 

»:;■;;:,:' 'nt'otS.  in  t™,  <•< ..  «„..  *»  .™,„e  <i„ 

ease  the  glasi^es  are  to  be  s(>t  in  or  out  from  the  eyes). 
Style  of  temples  (whether  .straight  or  hooks). 
Length  of  temples.  ,     ,         ■    i  ^n 

Material  of  frame  and  style  (whether  rimless  or  not). 
In  the  case  of  eyegla.sses  there  should  be  indicated: 
Size  of  glass. 

^y?;SS^:"^h"in  general  has  to  be  .lone  by  refen^nce  to 

a  catalogue  or  to  certain  standard  forms.) 
Width  of  nose-'.ip  at  top  and  bottom. 
Distlmce  by  which  ghusses  are  to  be  set  in  or  out  from  the  general 

plane  of  the  frame.  .        -    ,  *\ 

Material  and  ,<tyle  of  frame  (whether  nmless  or  not^ 
Most  of  the  trial  frames  have  scales  marked  upon  them,  by  the 


i:!8 


Till:  EYt:. 


aid  ol'  wliicli  \vc  arc  ciiahlfMl  tn  make  the  iiKirc  imiHirtaiit  of  the 
aljuvc-Miciitioiiccl  iiicasiirciiiciits. 

Analysis  of  Glasses.  In  olficr  woik  we  arc  dl'icn  callcil  updn  to 
examine  the  ^'las.-cs  a  patient  is  wcari  ;:.  and  find  out  wlia*  tiiey  are. 
Tliis  is  Ix'st  done  in  tlic  i'oli()\vin<r  \va\  : 

We  hold  the  j;Iass  to  he  exaniincij  six  or  .•  ."veii  inches  in  front  of 
our  eye-  and  look  throujrh  it  at  a  riKJit-an^lcd  cross  (c.  7.,  that  formed 
l).y  two  intersecfnif;  window  sasiicsi  on  the  otiier  side  of  tlic  room. 
Wc  then  rotate  the  jjiass  al)out  its  centre,  and  watch  the  effect  ])ro- 
diiced  on  the  arms  of  the  cross. 

If,  as  we  rotate  the  j;hiss,  the  arms  of  the  cro.-s  appear  neither 
displaced  nor  distorted,  hut  remain  quite  unhrokcn,  we  know  that  the 
Kla.ss  contains  neither  a  i)rism  nor  a  cylinder.  If  in  this  ca.se  we  move 
the  filass  from  side  to  side  and  uji  and  d<iwn,  and  no  movement  of 
tlie  portion  of  the  cro.ss  seen  tiiroufih  the  <riass  takes  place,  the  Kla.s.s 
is  iiUinv.     If  movement  does  take  place,  the  gla.ss  is  .-ijlurical,  heing 


■I  II  in 

I)i>ti>rlion  prcHliiTOl  liy  a  oyHncler.  I>etermiiiHii.in  uf  the  mis  of  a  c.vlinder.  A  right-angled 
cross.  .1  B  CD.  if  wen  throuKli  a  Ela.«.s  cnntaiuinx  a  cylin.ler.  If  (li  the  axis  of  the  cylinder  dm^s 
not  eoiMcide  with  either  .1  H  or  r  /»,  tlie  eross  will  appear  twisted,  .so  that  the  arms  no  lonRer  make 
a  right  angle  The  cross,  honever,  i  .,t  disi.laced  as  a  whole  either  to  one  side  or  the  other  It 
now  the  gla.s.s  is  rooued  nnlil  the  ax,-  l  the  eylind.-r  eoimides  with  one  arm  of  the  erowi-f  ;;  A  U 
(Mi-thi.  cros.s  will  ap|.ear  riBht-aiiKle.!  and  iinl.rok.n.  The  same  I'jing  will  happen  if  the  glass  Is 
rotated '.M=  more  (III I.  «.  that  the  axis  of  the  cylinder  coincides  with  I  l>. 


convex  fjla 

the  cro.ss  is  aholi 


concave  if  tlu'  cross  moves  in  the  same  direction  as  that  in  which 
we  mi>ve  the  glass,  ami  convex  if  the  cross  moves  the  opposite  wav. 
In  either  case,  we  neutralize  with  glasses  of  opposite  sign,  putting 
"V<'r  concave,  and  cur  versa,  until  all  movement  of 
The  strength  of  the  glass  that  pn'ci.sely  neu- 
tralizes the  movement  will  e(|ual  the  strength  of  the  glass  examined. 

If  the  glass  contains  a  n/Hndir,  the  two  arms  of  the  cross  will  hend 
toward  each  other  as  we  rotate  the  glass,  so  as  to  form  an  ohiique, 
insteail  of  a  right  an>jle.  Th(>  cross  will,  therefore,  he  distorted,  hut 
will  not  he  laterally  displaced. 

If  we  kecj)  on  rotating  the  gla.ss,  we  shall  find  the  ili.stortion  first 
increasing,  then  diminishing,  until  finally  a  position  i>  reached  where 
there  is  no  distortion—/,  c.  where  hoth  horizontal  and  veitical  aniLs 
are  unhroken.  The  same  will  he  the  ca.so  if  we  rotate  the  gl/iss  «M>°, 
so  that  the  vertical  arm  occujues  that  meri.iian  of  the  ghrss  which 


m 


iiEFHArTiVK  r.iiiiiiits  IS  <ih:st:i!M. 


V.VJ 


the  liorizoiitiil  ami  occupied  lu'lorc.  In  citlicr  positinn  of  tlic  pla.s.s 
the  'ixis  of  (lie  cylinder  will  lie  precisely  in  the  line  wliere  either  the 
vertical  or  tiie  iiorizuntal  arm  of  tiie  cr(),xs  traverses  the  glass. 

Now,  holding  the  glass  in  either  one  of  tiiese  two  jMisitions,  we 
move  it  up  and  down,  and,  as  we ve  it  uj),  note  wiiether  the  hori- 
zontal arm  of  the  cross  also  moves  up  or  moves  down.  In  eitJM'r  ca.se 
we  neutralize  the  apparent  movement  of  the  cro.ss  with  the  appropriate 
spherical  gla.ss  ( -r  if  the  cross  moves  up,  and  —  if  the  cross  moves 
ilown).  (Fiir.  (>;}.)  Weliavc  thus  made  one  meridian  of  our  glass  plane 
— /.  v.,  have  converted  the  glass  into  a  simple  cylinder.  Leaving  the 
neutralizing  sphere  on,  and  still  holding  the  glass  in  the  .same  posi- 
tion, we  now  move  the  gla.ss  from  side  to  side,  and,  as  we  move  it 
to  the  right,  note  whether  the  vertical  line  of  the  cress  moves  also 
to  the  right  or  moves  to  the  left.  In  the  former  ca.se  we  neutralize 
with  convex,  in  the  latter  with  concave  cylinders,  the  cylinders  lieing 
lidded  to  the  sphere  we  have  idready  put  on,  and  having  their  axes 
in  the  meridian  we  have  already  neutr.ulized— /.  < .,  in  line  with  the 
vertical  arm  of  the  cross.  The  sphere  and  the  cylinder  together  will 
neutralize  the  gla.-^s  in  all  meridians,  and  will  indicate  the  strength 

of  its  spiioricai  and  the  strength  and  axis  of  its  cylindrical  ( ijxment. 

Thus,  suppo.se  that  the  cross  looks  unbroken  when  we  have  rotated 
the  glass  until  the  vertical  arm  of  the  cross  coincides  with  the 
meridian  of  45°  on  the  gla.ss.  The  axis  of  the  correcting  cylinder  must 
lie  either  at  4.5°  or  VMf.  Now,  moving  the  glass  up  anddown— l  c, 
strictly  in  line  with  the  vertical  arm  of  the  cross — we  see  that  tiie 
horizontal  arm  moves  in  the  ojiposite  direction,  going  down  as  we 
carry  the  glass  u|).  A  — l.(M)  I),  spherical  ijlaced  over  the  glass  neu- 
tralizes this  movement.  Leaving  this  — l.(K)  I),  on,  we  now  move 
ih(>  glass  from  side  to  .side,  still  keeping  it  with  its  corrected  4,i° 
meridian  vertical.  The  vertical  arm  of  the  cross  moves  in  the  same 
direction  that  we  move  the  glass.  We  now  ])ut  on  +  cylinders  with 
the  axis  at  45°—/.  c,  in  line  with  the  vertical  arm  of  the  cross— until 
this  movement  of  the  cross  is  neutralized.  rsui)i)ose  it  took  a  +  L75 
I),  cylinder  to  ilo  this.  The  neutralizing  gla.ss  is  then  — L(M)  .sjili.  :2 
^1.75  cyl.  4.5°.  and  the  glass  examined  is,  therefore,  a  +1.00  >i\A\ 
Z  -L7.5  cyl.  45°. 

We  mighi  in  the  case  cited  have  rotated  the  glass  so  that  the 

meridian  of  L'J5°  coincided  with  the  vertical  line  of  the  cross  (in 

uhich  ca.se  the  cross  would  have  again  appeared  unbroken),  and  then 

iiave  neutralized    this   meridian   first.     Then   this  correciion   would 

h.ive  worked  out  to  —0.75  sph.  3  +  L75  cyl.  1.3.5°,  e(iuivalent  to  the 

ne  given  above. 

If  the  glass  is  a  simple  cyhnder,  instead  of  a  s])hero-c}'linder,  pre- 

i<ely  the  .same  procedure  is  adopted,  only  in  this  ca.se  we  shall  find 

;:it  the  nitivciiifnt  along  meridian  is  already  nil,  ,so  tiiat  we  have 

'  :i|>ply  no  correcting  glass  to  this  meridian,  and  all   that  we  have 

do  is  to  add  neutralizing  cylinders  with  their  axes  hi  this  meridian. 


IIH 


Tin:  i:yt:. 


If  the  s:l:i-s  ciilitiiili 


I" 


iMc  111'  lintli  am 


.f  tl 


ic  en  > 


\M 


II 


!)('  (li>|il:nT,l,  tlir  iKiriziiiital  arm  hciiin 
viTtical  arm  liiiiin  carricii  t  •  "iic  siilc. 
Iis|>laci'mi'iit  uf  niic  arm  will  iiicrca« 


tlirnwii  i.ji  nr  ilnvMi,  ami  tin- 


As  \vc  rotate  tlif  t'la-s.  the 
;,n(|  tliat  of  till'  "itlicr  .liminisli. 
hii't  li'nwi'vi'r  we  ruiatc  the  ^lass.  tli.'  arm-  m'.ii  tlimmrli  it  will  always 
ivmaiii  parall.'l  r<<  fli<-ir  ..riiriiial  ain-ctiKii-tli.'  vcrti.al  arm  n'maiii- 
iiiit  v.nical.  til.'  linri/.nntal  arm  lioriz-mtal.  H<w."  tiif  ir..s.-.  altli'.u>rli 
a^M  .iiiiiir  l-rokcii,  is  not  .listnrtcl.  That  is.  <i  jin.-'m  shijts.  l.iit  « 
oilniilrr  tiri.-ls.      i  rig.  t»4.  i  , 

\Vr  keep  oil  rotatiiia  tin-  gla:--  until  tlir  liorizmital  arm  is  no  lonpr 
.[i'plawl-/.  <.,  until  tlic  |>orti..ns  .-(■.•ii  outsLlf  an.i  iiisi.lr  ol  tlic 
cla-<  form  an  unhfokon  lin.'.  Tli.-  aj-'x  of  tli.'  i-rism  cont  unci  in 
the  glass  will  then  Hi'  in  the  .lin'ctioii  in  wliicli  the  vcrtiral  hnc  is 
(lisi)lanMl;  ami  the  point  which  this  apex  occupies  on  the  circum- 


yi'i.  '"-4. 


"I 


K^ 


X, 


^ 


II 


III 


DlH.laonn.-iit  i.r,.lu,i-.l  bv  u  iTi-ii,  lM>Tiiuuuii..ii  of  the  mis  of  a  pri'-n.  A  nKht-»iitflf<l  rn  s-, 
1  /;  ,  /)  1-  v«-n  thr...,i!h  h  k!.i"  c.T.ia.i.n  u-  k  prism  -I-  Thr  apex  "f  the  l-rism  does  not  lie  .ii 
line  with  clthiT  «rra  ..f  the  rn.-s.  txiiiit  li.  lac-t  .iirectcd  to«8r.l  /;.  B-.lh  arm!.  ..f  the  cr,«  will 
«l.t,-Hr  .liM.lai-i-.l  l».inv  iK.t  wia  ii..t  be  nvi.te.1.  The  amount  of  .li«i'lapement  of  .4«  ii"licate«  the 
lateral  efe.!  an.l  the  .i.sp  «i'«-'ment  ..f  C  l>  the  veniral  elTect  of  the  pri«m  when  in  this  po-iiion  If 
now  the  Kla'S  i-  rotale.l.  l-th  arms  will  a»i.,ar  to  shin,  but  each  will  slill  always  remain  mrallel  lo 
Its  (.riL'iiial  i«»iiion.  .Ill  The  b1.is«  hii>  Uin  rotate.)  until  the  ai*x  of  the  prism  i..iiii«  inwat.l  ''. 
tiJ  ap(«.ars  mihroken.  while  ,1  K  i-  ,li-plawl  'owar.l  r.  an.l  the  am..unt  of  Its  displn.Hiiient  n..w 
in.liratt.spre.i.elv  the  L.tal  s,re.n:th  ..f  the  prism.  .111  The  glass  W  rotated  W)".  The  lin.,- .<  B  m.w 
api«>ar.  uiihr..ken,  an.l  e  /.,.  .i,  Ke.ie.i  t..»ar.l  A  The  ar*i  of  the  iTism  i..ints  t.,w,.nl  A.  an.l  the 
am..unt..f  .lefleeii.m.if  r/i  .■..rre.^i...nds  precisely  t..  the  -trenifth  ol  the  pnsm. 


|!i 


fereiice  of  tile  glass  will  he  indicateil  l>y  the  point  where  the  horizontal 
arm  of  the  cross  cuts  that  circumference.  Thus  if  the  apex  of  the 
pri^ni  was  at  4-")°.  Iioth  arms  of  the  cross  wouM  ajipear  broken  when 
the  gla.-s  was  lieM  in  its  onlinary  position.  When  we  rotated  the 
gla>s  so  that  its  4.")°  meiilian  was  horizontal,  coinciding  thus  with 
?he  horizontal  arm  of  the  cross,  that  arm  wtnild  ajipear  unhrokeii^ 
l)U'  the  vertical  ,irni  would  lie  disiilaced  outward  toward  the  4."r 
]i(iint  on  the  glass's  circumference. 

The  strriiuth  of  the  prism  may  he  mea.<urod  either  hy  measuring 
'lie  ..ctual  nuiximuni  disp!:>cement  of  oiu'  of  the  -ross-arms  on  a 
|)rism-scale,  such  as  Ziegler's  (the  apex  of  the  prism  iM'ing  placed  in 
line  with  the  scale',  or  more  readily  hy  neutralizing  the  displace- 
mont  with  iirisms  i)laced  over  the   glass  with  the  ajiex  directed  tin 


r^T!r?ff"sa?? 


REtU.\<  ri\  !■:  kliUollS  l.\  ll'SKItM. 


141 


nllicr  wav.  Tin-  slri'iitilli  of  ilic  iifiiti-'  ;  iiir  priMii  rentals  lliald'  ilic 
inisiii  ill  llic  >;lass. 

I'stially  the  strcrijtili  of  the  prism  lliat  a  class  cniitains  laii  Iw 
ilctfTtiiiiu'il  only  after  iiciitraliziii};  any  splK-ro-i'viiiiilir •that  il  may 
aisn  contain. 

Ill  llnis  ni'Utraliziii}:  {.'lasses  to  lieleriiiine  the  spliere,  cyrnnler.  or 
prism  liiey  may  eoiitaiii.  it  is  essential  that  we  look  preei>ely  through 
ihe  eeiitre  of  the  (jiass  examined,  ami  also  that  we  slionid  hold  the 
neiitrali/.inn  {ilass  in  close  eoiitacl  with  it. 

HYGIENIC  TREATMENT  OF  REFRACTIVE  ERRORS. 

In  /')(/"/«",  particularly  when  pro^rressiv.'.  aii<l  especially,  therefore. 
ill  children,  we  .should  he  careful  to  jrive  jirecise  rules  as  to  the  amount 


Mu.  tM. 


The  Chandler  »i1jii«lBlile  «e«I  and  <lesli. 


d  kind  of  work  that  the  patior.t  can  <lo,  and  insist  upon  proper 
htinj;,  proper  hours  of  study,  and  plenty  of  sleep,  with  a  jiood 

•  .tint  of  out-<)f-<loor  exercise,  I'se  of  the  eyes  by  artificial  litrht 
ould  he  restricted,  or.  in  the  more  aspravated  cases,  eiiiirely  for- 

Ideii.     It  is  also  a  jjood  plan  to  have  the  pati(!iit  suspend  his  reading 


»«?«a*<i:..«!, 


i;. 


H-2 


Tin:  t:yi: 


or  (itlicr  work  i-vcrv  (il'ttcn  niimiti's  i>r  so.  fi  r  !i  lew  tiinrTiciifs,  aiiil 
iliirini;  llii-  iiittTval  of  ivsl  cillicr  sit  iTirt  or  ii<  tually  sl.iiul  up,  ainl 
look  otT  into  ilic  far  ilisiaiicc. 

Tlic  iPMlicnt's  atfitiiilf  in  rcaWiiiK  or  writing  slimilil  he  can  fully 
looked  after,     lie  siiould  Hot   ije  allowed  to  heiid  over  at  hi.-  work. 


nor.  oil  the  othnr  hand,  should  tho  desk  ho  ."^o  iiigh  as  to  hrinf;  hi.s 
work  unduly  clo.se  to  the  eyes. 

Fijis.  <).5,  <)H,  atid  07  illustrate  a  fonn  of  adiusi:tl>!e  de.-k  we!!  .-.dapte:! 
for  sehool  j)urposes. 

Those  alTecied  with  i)rogressive  myopia  should  he  diseounifted  from 


ui:in.irrivi:  luuious  i.s  ueslum. 


1 4;{ 


iiiMliTtMkiriK  ;iii>  very  fine  wnrk.  siidi  as  IxMik-kfcpiiiK  or  Hwiiij;, 
ii'<|iiirin)t  finsc  Mild  cniitimicil  npiilicatiuii.  It  is  piirticiilarly  imp.ir- 
laiit  to  have  thi-  point  in  iniiHi  ulicii  sclcctiiiK  a  Iwy's  Cutiiri'  life-work. 

In    very   liiyli    myopia,    partiniljiHy    when    tliiTc"  arc   -viii|.t s   of 

retinal  irrilalion.  total  alisteiition  from  near  work  is  often  n  i|iiirei|. 
In  the  trai  'it  myopia  proWueed  hy  ,v/w/,vm  nj  iicntminnila/iiin, 
complete  alisn  on  from  near  wurk  may  Im'  re(|uire<l.  comhined 
often  with  the  instillation  of  atropine  three  limes  a  day  for  sev<'ral 
weeks. 


!3  ' 


Km.  87. 


.\(Jjii^lnieiit  of  seat. 


Ill  all  eonditions  of  refraetion  the  iUuii)in(itiim  should  he  attended 
to  carefully.  Tiie  ideal  ilhimiiiatioii  is  that  alTorded  hy  diiriise  day- 
lisrht.  When  artitieial  lifciit  is  iwd.  this  also  should  be  as  ditl'use  as 
|ios.sil)le.  Hence,  it  is  a  mistake  to  have  a  hriiliant  iiftht,  j»articularly 
:i  shaded  lijrlit  „v,.r  the  desk,  and  have  tlie  rest  of  the  room  in  coin- 
panitive  darkness.  There  should  he  at  lea.st  one  other  light  in  the 
room,  and  more,  if  neces.sary,  .so  that  the  illumination  may  Iw  pretty 
evenly  .listrihuted  all  over  it.  The  hriliiaiicy  of  an  electric  or  a 
Welshach  lifilit  often  needs  tempering,  and  this  is  best  done  by  ;i 
Mfv  light  amber  or  yellowish  siiade. 

I'aticnts  ronipiainiiig  of  iihuloiihoJiin  should  not  be  permitted  lo 
wear  smoked  or  colored  glasses  unless  there  is  actual  di.sea.se  of  the 
lundus,  or  unless  the  photophobia  is  due  to  some  quite  temporary 


144 


THE  EYE. 


cnuso,  ;is  dilatation  of  tho  pupil  from  instillation  of  atrojjino.  Other- 
wise, the  ahiionnal  sensitiveness  to  lij;lit  will  he  afiRravated  by  the 
use  of  the  ^hi'^f^''*.  '""I  t'"'  patient  l)eeoine  more  and  more  ineapable 
of  usinji  the  eyes. 

In  iDjpcropiii  and  (istiffmali.on  we  sometimes,  on  aeeouiit  of  the 
asthenopia  and  other  symptoms,  have  to  diminish  the  amount  l)y 
wliieh  the  eyes  are  used,  and  increase  the  amount  of  open-air  exereise. 
Hut.  in  general,  hyperopia  nnd  astifimatism  furnish  no  absolute  bar 
to  eyework.  and  it  is  usually  a  distinct  mistake  to  yield  too  much  to 
the  patients  complaints.  We  .should  not,  in  tlie  absence  of  orfranic 
disea.se  of  the  fundus,  encourajte  the  patient  to  disu^i  Ins  ctjes  simply 
becau.se  the  use  of  them  is  painful.  Hy  .so  doing  we  may  initiate  a 
vicious  circle,  ami  pro>rre.s.sively  increa.se  the  patient's  di.sability, 
instead  of  removing;  it.  On  the  contrary,  moderate,  systematic,  and 
increasinff  use  of  the  eyes  for  near  work  is  the  rule  in  such  cases. 
The  ophthalmoloftist  himself  shoulil  fiive  careful  and  preci.se  din>c- 
tions  as  to  the  amount  and  kind  of  eye-work  to  be  done,  and  deter- 
mine by  experiment  how  nipidly  the  work  may  be  incn-ased. 

I'inaily,  it  .should  always  be  borne  in  mind  that  in  treating  refrac- 
tive errors  we  must  constantly  h.-ive  r(>j;ard  to  the  ijoicrdl  condition 
of  the  |)atient  ■■md  to  the  state  of  the  organs  other  tiian  the  eyes.  In 
many  cases  in  which  the  symptoms  seem  to  l)e  due  entirely  to  the 
eyes,  treatmeii!  directed  to  the  general  condition,  to  the  nose  antl 
throat,  or  the  |K'lvic  organs,  will  often  relieve  an  a.sthenopia  which 
glasses  ii.iM  f;iile<l  to  relieve,  and  in  not  a  few  instances  will  render 
it  Uiineces.sary  to  u.se  gla.ssf>s  at  all. 


PLATE    111. 


Cii|)sulc  1)1  T. '111)11.     (  Moia 


IS.) 


CHAPTER  IV. 


THE  MOTIONS  OF  THE  EYEBALL  AND  THEIR 
DERANGEiMENTS. 

By  CASEY  A.  WOOD,  M.D. 

Anatomy  and  Physiology.  The  ocular  muscles  are  divided  usually 
into  internal  or  intrinsic,  and  external  or  extrinxic.  Although  it  is 
necessary,  for  convenience  of  reference,  to  speak  of  the  individual 
extrinsic  muscles,  both  the  single  and  a.ssociated  excursions  of  the 
eyes  may  be  regarded,  in  every  case,  as  compounded  of  movements 
due  to  actions  of  all  of  them.  The  iridic  and  ciliary  muscles  com- 
prise tlie  first  class,  while  six  others,  the  external  rectus,  internal 
rectus,  superior  rect  ,  inferior  rectus,  superior  obli(|ue,  and  inferior 
()i>li(|ue,  make  up  the  second.  These,  with  the  single  exception  of 
the  inferior  oblicjue,  form  a  cone,  whose  aj)ex  points  toward  the 
foramen  opticum,  while  its  base  envelops  the  eyeball  in  front  of  the 
eijuator.  According  to  Weiss,  if  the  axes  of  the  orbits  are  projected 
backward,  they  fortn  an  angle  of  from  20°  to  .37°,  depending  upon 
nice,  age,  :.iid  the  fiecuiiarities  of  the  individual.  These  considera- 
tions also  govern  the  conformation  of  the  mu.scular  cone,  affect  the 
degree  of  its  divergence,  and  mav  even  determine  the  shape  of  the 
eyeball.     (Plate  III.) 

The  glolx-  itself  has  a  centre  nf  rotation  around  a  point  in  its  antero- 
poster  >r  axis.  In  the  emmetropic  eye  this  is  about  14  nmi.  ijchind 
the  cornea  and  If)  mm.  in  front  of  the  posterior  surface  of  the  sclera. 
The  prinmrfi  poxilinn  nf  the  ej/e  is  that  in  whidi,  when  the  head  is  held 
erect,  the  gaze  is  directe<l  straight  forward  in  the  horizontal  plane. 
The  vertical  meridians  of  both  eyes  are  then  exactly  vertical  and 
parallel.  It  is  from  this  starting  point  that  the  movements  of  the 
ey('l)all  are  consid(>red. 

The  innervation  of  the  extrinsic  muscles  of  the  eye  is  easily  remeni- 
iH'red.  All  of  these,  as  well  as  the  levator  palpebra-  sui)erioris,  the 
ciliary  muscle,  and  at  least  one  of  the  iris  nuiscles,  are  supplied  by 
the  third  nerve,  except  the  external  rectus,  which  is  sujjplied  by  the 
sixth  nerve,  and  the  sujK'rior  obli(|ue,  which  is  supjilied  by  the  fourth. 

\\hil(>  we  recollect  that  every  excursion  of  the  globe  is  attended 
by  moH'  or  less  contraction  or  lengthening  of  most  of  the  extrinsic 
muscles,  and  .sometimes  by  action  of  the  internal  nni.scles,  we  have 
i<>  s|H'ak  of  the  probiible  action  of  tlie  individual  extrinsic  muscles. 
The  observations  of  Swanzy  apjx'ar  to  give  the  most  satisfactory 
arious  and  comi)licated  movements  of  the  evebalj. 


^P 


ni]) 

10 


the  ey 

(I45") 


146 


THE  EYE. 


both  sp]);iriito  and  associate,  and  conseiiupntly  they  are  adopted  for 
the  purposes  of  tliis  chaijter.  Donders  i)roved  exiM-rnnentally  that 
it  is  only  in  the  primary  position  and  when  tiie  eyes  arc  turne( 
directly  outward  or  inward,  downward  or  upward,  that  the  vertica 
meri.lian  maintains  its  vertical  direction.  When  the  eyes  are  turned 
in  other  directions,  there  is  always  a  sort  of  wheel-motion  given  to 
the  "lobe  and  the  vertical  meridian  of  each  nornially  balanced  eye  is 
inclined  at  about  the  same  angle.  These  various  pos...  .is  of  the 
vertii-al  meridian  can  be  understood  best  by  a  reference'  to  the  actions 
of  the  various  muscles  in  the  associated  movements  of  the  eye  and 
by  a  reference  to  the  figures.     The  author  just  (juoted  points  out: 

Fia.  6«. 


R»  Lp 


^tiowirg  attachment  of  the  orl.i ml  muscles.  K(.  Extenml  rectm.  R».  Superior  reotu..  Ip  Leva- 
t„ri».li«!'>™-  *.  rr.  Si,|«rlor  oblUiue  with  Its  pulley.  Km.  Internal  rwtiu.  Oi.  Interior  oblique. 
/'/.  Inferior  reetus. 

1  III  the  i)riman-  position  all  the  mu.scles  are  ])ractically  at  rest. 

2  Motion  of  tlu'cveball  directly  out  wan  1  is  effected  by  the  external 
rectus  alone,  and  m()tion  directlv  inward  by  the  internal  rectus  alone. 

;{.  Motion  of  theeveball  directly  uinvard  and  directly  downward  is 
effected  mainiv  bv  ai<l  of  the  superior  and  inferior  recti.  At  the  same 
time  these  muscles,  acting  alone,  also  rotate  the  eyeball  directly  inward 
and  give  a  certain  inward  inclination  to  the  vertical  meridian,  which, 
in  this  Dosition.  should  be  upright.  ronse(iuently.  in  rotation  of  the 
globe  .iirectiv  upward  the  inferior  'hiitiue,  which  rotales  the  eye 
sli-rhtlv  outward  as  well  as  upward  and  incline.',  the  vertical  meridian 
ouUvard   must  be  as,so( ".  ,ted  with  the  superior  rectus  in  order  to 


MoriOXS  OF  THE  EYEBALL  ASD  THEIR  DEliAytlEMEyTS.     147 

roiiiitoract,  in  thesse  particulars,  the  tendency  of  its  action.  In  rota- 
tion of  the  eyeball  directly  downward,  the  inferior  rectus  must  be  asso- 
ciated with  the  su|)erior"obli(iue,  which  acts  antagonistically  to  this 
straiftht  muscle,  in  res|M'ct  to  rotation  inward  anil  to  outward  wheel- 
motion.  ,      ,1     1         •  1     r    I 

4  Rotation  upward  and  outward  is  effected  chiefly  f)y  aid  of  the 
superior  nrtus  and  external  rectus;  but  the  latter  muscle  has  no  inffu- 
(Mice  over  wheel-motion,  while  the  former  produces  wheel-motion 
inward:  yet  the  inclination  of  the  vertical  meridian  is  outward  in  this 
position,  and  therefore  a  third  muscle,  which  will  supply  this  inclina- 
tion in  a  high  degree,  is  retiuired,  namely,  the  inferior  obliciue,  whose 
|M)wer  over  the  wheel-motion  of  the  eyeball  is  greatest  when  the 
latter  is  turned  ujjward  and  outward. 

5.  Rotation  downward  and  outward  is  effected  chiefiy  by  the  rectus 
inferior  and  tlie  rectus  externus.  Inasmuch,  howe\-er,  as  the  former 
iiiduies  the  vertical  meridian  outwanl,  while  the  latter  has  no  influence 
over  it  at  all,  a  tliird  force  is  required  which  will  bring  about  the  neces- 
sirv  inward' wheel-motion,  namely,  the  superior  oblitiue,  whose  influ- 
ence in  this  respect  is  most  powerful  when  the  eye  is  turned  down- 
ward and  outward.  .  •  a    ,      ^v. 

()  Rotation  upward  and  inward  is  brought  about  chiefly  by  the 
rectus  sui)erior  and  the  rectus  internus;  but  the  effect  of  the  former 
ui)on  the  inward  wheel-motion  (,."  the  eye  would  be  so  great  as  to  inter- 
ivw  with  parallelism  of  the  vertical  meriilians  of  the  two  eyes,  that  of 
the  (.ther  eye  not  being  inclined  outward  in  a  corresponding  degree.  A 
third  force,"  therefore,  is  retpiired  which  will,  to  a  certain  extent,  ccjun- 
tcract  the  influence  of  the  superior  i-ectus  in  this  resjx'ct,  and  this  is 
found  in  the  inferior  obli(iue,  which,  in  this  position  of  the  eyeball,  has 
Init  slight  power  over  its  wheel-motion. 

7  Rotation  downward  and  inward  is  chiefly  the  result  of  contraction 
of  the  inferior  rectus  and  the  internal  rectus.  The  powerof  the  former 
over  the  outward  inclination  of  th.-  v.-rtical  meridian  would,  in  a 
similar  way,  be  too  great,  and  must  be  similarly  correctt  vl  by  the 
action  of  the  superior  oblicjue.  ,    .       „        ,    ■ -r. 

The  position  of  rest  is  probably  .livergence  and,  in  all  probability, 
even  a  slight  degree  of  convergence,  as  well  as  parallelism  of  the  ocular 
iixes,  is  maintained  by  more  or  less  effort.  _ 

The  internal  rectus  arises  from  the  tendon  common  to  it  and  the 
inferior  rectus,  at  the  inner  aspect  of  the  optic  foramen,  and  runs 
tuAvanl  close  to  the  inner  wall  of  the  orbit,  t"  be  inserted  into  the 
-clera  l>y  a  tendinous  expansion  9  mm.  long  and  UH  i""'-  wide,  6i  mm. 
rioni  the  sclerocorneal  junction. 

The  external  rectus  arises  from  the  greater  wing  of  the  sphenoKl  by 
two  heads  that  become  united  and  form  the  body  of  the  muscle,  which 
!uu^  forward  close  to  the  externa!  w,-d!  of  the  orbit.  It  is  attached  to 
ihe  sclera  by  a  tendon,  3.8  mm.  long  and  9.5  mm.  wide,  about  t  nmi. 
iiotn  the  linibus  cornetB. 


148 


THE  EYE. 


The  inferior  fciau  ari  cs  from  the  tcmlon  (•(Hiiinon  to  it  and  the 
iiitoniiil  rectus,  fin'  runs  foi  "anl  on  the  Hoor  of  tlie  orhit,  and  is 
attached  to  the  ^ilo'.j,-  !■>  an  uponeun.sis  fi  mm.  long,  9  nnn.  wide, 
and  about  71  mm.  from  the  seierocoriieal  junction. 

The  superici  rectus  arises  from  the  upj^er  edge  of  the  optic  foramen 
from  the  "ommon  tendon.  It  jjas.ses  forward  just  beneath  the  levator 
paipebru'  superic-i.s  and  is  inserted  into  the  sclerotic  X  mm.  from  the 
sclerocorneal  junction.     Its  tendon  is  0  mm.  lonp  and  lOJ  mm.  wide. 

The  saperior  obliane  arises  from  the  lesser  wing  of  the  sphenoid, 
passes  forward  along  the  inner  wall  of  the  orbii.  where  it  becomes 
tendinous  and  forms  a  pulley-like  adjustment  which  play.s  within  a 
<il)rous  ring  situated  m  the  trochlear  fossa.     The  direction  of  the 


Rat.  eit. 


Horiamtal  section  of  the  vye  in  the  urbit,  showinR  the  relative  Kitaehnient  of  external  ami 

interiiHi  recti. 

muscle  now  changes,  and  it  proceeds  backward,  downward,  anil  out- 
ward at  an  angle  of  o"j°,  ])asses  beneath  X\w  superior  rectus,  and  is 
inserted  into  the  sclerotic  between  the  cornea  and  the  optic  nerve 
about  17  mm.  from  th(>  corneal  limbus.  The  width  of  the  aponeurotic 
insertion  of  this  curious  muscle  into  the  globe  varies  from  7  mm.  to 
b')  mm.  It  is  one  of  the  principal  factors  in  globar  rotation,  turning 
the  u|)per  part  of  the  vertical  meriilian  inward. 

The  inferior  obliQue  arises  from  the  anterior  third  of  !he  floor  of 
the  orbit,  in  a  pit  situated  in  the  su])eri<)r  maxillary  bone.  It  then 
]>roceeil-i  outward,  backward,  and  upward,  beneath  th"  inferior  rectus 
muscle,  to  W-  inserte<l  into  the  sclerotic  between  the  inferior  and 
external  recti  on  the  [)osterior  half  of  the  globe,  17.i  mm.  from  the 
seierocoriieal  junction. 


W 


M  or  loss  OF  THE  EYEBALL  .\Sl>  THEIR  DERANOEMENTS.     14» 

Tenon's  Capsule.  That  wo  may  tho  bottor  undorstand  the  attaoh- 
iiiciits  of  the  various  cxtriiisic  imisdos,  it  is  'locfssary  to  say  soine- 
tliing  about  the  flowed  sac  iviiowii  as  Tenon's  capsule.     This  luein- 


LCVATOR    FfttPC- 


INT.  RCCTUt 
MUSCLC 
CTHMOID, 
CELLS 


'TtMPORaL  MUSCLC 

.LACHHVMAL  OLAND 
V  <   ICXT.  RCCTUS 


osLiauc 

MUSCLC 


INF.  nCCTUS 


ICTUS        I 
CLC     iN^S 

TAL  NCnVE 

Vertical  section  tbronnh  the  orbit. 


C^")' 


n 


<-..  -:i 


?ihem«llc  repreaentatlon  of  the  Iniertlon  of  the  extisocular  miiKcIen  into  the  globe,  showing  the 
ii-i.iiiiicif  ihc  same  from  the  comesl  llmbus.  I.  SuKriof  aspect  of  the  globe.  IT,  Medial  aspect. 
11.  IiUirior  asptrt.    IV.  Lateral  aspect.    «.  Rect.  sup.    i.  Kect.  inf    m.  H-oi.  int.    /.  Rect.  ext 

■    oil  sup.    oi.  Obi.  Inl. 


(b 


150 


77//;  EYE. 


Kio.  72. 


l)raiu'  oii\  lups  tlic  frrciitcr  portion  of  tho  cychall,  and  is  uiiito<l 
Ih'IiIikI,  as  well  as  in  front,  to  for  i  closed  cavity.  It  is  attached 
close  to  ilic  optic  foramen,  and,  passing'  forward,"  heconics  loosely 
iidliert"'t  to  the  sclerotic.  Anteriorly  it  is  attaclu'd  to  the  conjunc- 
tiva liy  connective  ti.ssiic,  and  extends  to  within  .'{  nun.  of  the  corneal 
junction.  Its  cavity  forms  a  larjje  lymph  space  lined  hy  endothelium. 
The  tendons  of  all  the  extrinsic  muscles,  the  ohliipies  I.ehind  :ind 
the  .-traifiht  muscles  in  front,  pierce  the  capsule  willmut  interfering 
with  its  function  as  a  dosed  lyni|)h  s|)ace.  The  ciliary  nerves  like- 
wise pass  throuj;li  Tenon's  capsule,  which,  let  it  he  noted,  also  com- 
municates throu^li  the  .sclera  with  the  suimu-horoidal  and  perineural 
lymph  spaces.  In  thi.s  way  it  comiects  the  iiitercorneal  Ivmph 
spaces  with  the  exterior  of  the  eye.     When  a  mu.scular  tendon  or 

nerve  trunk  passes  through  this  mem- 
brane a  portion  of  the  latter  extends 
along  its  external  surface,  thus  streiiftth- 
eniiift  their  coimections  with  the  sclera. 
«  We  may  then  rcfjard  the  combined 
tendons  of  the  straight  muscles,  in  con- 
junction with  Tenon's  capsule,  as  fonii- 
inj;  a  complete  envelope  about  the  eye- 
ball, and  tills  fact  nmst  be  reckoned  with 
in  o|K>ratinf;  o!i  the  former.  .\n  incision 
sometimes  fails  to  reach  the  muscular 
tendon,  because  both  layers  of  the  cap- 
sule have  not  been  divided,  and  becau.se, 
al.so,  it  is  not  borne  in  mind  that  pro- 
lonpition  from  the  e.-ipsule  it.self  .•md 
what  are  known  as  the  "  check  li,i;;iments  "  niav  interfere  materiallv 
with  the  results  desired.  (  rijr.  72.)  This  is  e.speciallv  the  ca.-^e  when 
tliesehjiaments  are  abnormally  develoiKMl.  It  is  not"  an  uncommon 
experK'iice  to  find,  even  after  tlu'  most  com|)lete  division  of  the 
tendon,  that  relative  jM.sitions  of  the  globes  are  unaffected  bec.au.se 
ot  these  connections  between  the  mu.scular  ten<lons.  the  capsule  of 
Tenon,  and  the  check  ligiuiients. 

.As  a  rule,  however,  the  .■letioii  of  the  check  lig.'unents  is  a  normal 
one:  they  probably  prevent  or  retard  overaction  of  the  adductors 
and  abiluctors,  as  .shown  in  Fijrs.  7;}  miil  74. 

The  bloo.l  supply  of  the  mu.scles  is  derived  from  the  oi)iithaImic 
artery,  through  the  minute  musciil.ir  branches,  shortlv  after  it  enters 
the  ()rbit  through  the  optic  foramen.  The.ve  capillaries  are  tortuous 
and  loosely  attached  to  their  surrniindings.  so  that  the  movements 
ot  the  globe  und  the  .shortening  and  lengthening  of  the  mu.scles  tliein- 
.-^eives  do  not  interfere  with  their  coiifimiitv.  It  .•sometimes  happens 
that  cuitmg  of  these  small  ve.s.^els  gives  rise  to  i)rofu.-;e  IiemotThage. 
liuf  this  is  rarelv.  or  never,  a  .serious  matter.     Th 


A.  Internal  check  ligament.  B.  Ex- 
tomal  elifcl  ligament.  (Ua.S'seli.  and 
Kkiikk.) 


(laiiied  by  veins  of  the  same  n.uiie. 


ie  arteries  are  accom- 


MOTirys  Of  rill-:  EYEUALL  AXD  TlJEIJi  DEIlAXaEMEyrs.     15] 

Nirve  Supply.  It  is  (Icsirablc  to  say  .something;  fiirllicr  alxmt  the 
iimcrvatidiis  of  the  various  iiuiscjcs.  Tlic  areas  in  the  cortex  asso- 
riated  with  the  iiioveiiieiits  of  tlie  eyelnill  are  not,  as  yet,  preeisi'lj 
located.  Tliey  are  prohahiy  in  front  of  tlie  iarpe  motor  area,  close 
to  the  neuron  that  presiijes  over  the  facial  muscles,  and  undoulitedly 
have  a  near  association  with  Hroca's  speech  centre.  The  basal  nuclei 
are  re<;arde<l  fieiierally  as  lyiiif;  well  within  the  pray  matter  in  the 
aqueduct  of  Sylvius  and  on  the  floor  of  the  fourtli  venlricle,  nio.st 
of  them  just  heneatii  the  corpora  (|uadrijtemina.  According  to  the 
arranjiement  of  Stuelp,  the  subcortical  nuclei  of  the  internal  eye 
muscles  are  situated  in  the  ante-ior  portion  of  the  third  n(>rve  nucleus. 
These  fibres  supply  the  ciliary  muscle  and  the  sphincter  iridis.  Imme- 
diately hehiiid  them  are  the  nuclei  of  all  the  external  mu.scles  supplied 
by  the  third  nerve.  Still  further  back  are  the  nerve  cells  which  con- 
stitute the  nuch'us  of  the  fourth  nerve  that  supplies  the  .suiM'rior 


Flii.  73. 


Flo.  74. 


/.  C.  J.. 


K.  C.   I. 


I.  C  I. 


E.  C.  L. 


Fiii.  7:1  -The  check  ligaments  during  |>ar(ial  inutrai'lion  nf  the  eiternnl  rectus  inuiicle.  the  in- 
tenmt  i-huck  ligament  i  /.  C.  L  )  being  in  a  state  of  maximum  relaxation,  and  the  external  (A',  f,  /..) 
somewhat  stretclied.    (Motais.) 

Fk..  71— Diagram  intended  m  show  how,  during  full  eontraction  ot  the  external  rectus,  the 
cMernal  check  llijament  (f.  C.  L.)  is  stretched  to  its  maximun.  lenulh,  and  the  Internal  (/.  f  /.  ) 
i>  slightly  stretched  also.    (Motais.) 

ublii|iie;  and,  finally,  .still  behind  the.se  are  the  nucleoli  of  the  .si.Vth 
nerve  that  jroverns  the  external  rectus.  .Ml  of  these  nerve  centres 
are  connected  with  one  another  by  nerve  fibres  that  run  from  one 
nucleus  to  the  other.  It  should  not  be  forpitteti  that  minute  ner- 
vous connections  probably  exist  between  the  motor  neurons  govern- 
iiij;  the  various  eye  muscles,  and  all  the  other  nerve  centres. 

That  the  individual  may  fix  both  eyes  with  ease  ujion  objects  dis- 
tant and  iu>ar,  and  ohtdin  liiiinciilar  n'sinn  in  (til  juirts  of  thv  jivkl  oj 
visit, ti.  it  is  necessary  that  a  certain  balance  exist  between  the  forces 
that  rotate  the  eyes  in  various  directions.  Moreover,  both  eyeballs 
must  be  xkwHvd  in  their  fixation.  We  must  l)elieve  con.setpiently 
that  all  the  external  muscles  are,  during  the  waking  hours,  in  a  ,state 
i:f  imconscioiis  tonic  contraction,  .-uid  th:if  every  act  of  sight  is  acc<>m- 
paiiied  by  more  or  less  exiieiiditure  of  nerve  force. 

Convergence.  A  state  of  divergence  of  the  visual  axes  being  the 
linibable  condition  of  res',  parallelism  and  convergence  recpiire  more 


m 

a?? 

»  : 


ili 


152 


TllK  EVE. 


or  lt's.s  luTVdUs  cffDrt.  Tin-  axes  inay,  however,  he  made  tn  cross 
uiitii  they  form  a  very  wiile  alible,  estiinaletl  to  vary  in  indiviiluuLs 
from  45°  to  ().")°.  When  the  eyes  converge  there  i.s  not  only  con- 
traction of  tile  internal  rectus,  but  of  the  superior  and  inferior  recti, 
I  of  the  iridic  and  ciliarv  muscles.     It  is  very  likely,  also,  that 


am 

other  nmscles  of  the  i-ye,  as  iM-fore  noticed,  take  part  in  this  act  of 
convergence  liy  a  sort  of  mi>diHed  contraction,  so  as  to  steady  the  eye. 
One  method  of  measuriu};  convergence  is  hy  means  of  a  prism,  ap<'X 
in.  placed  before  eithiT  eye — prism   convergence.     (See   page  159.) 

Divergence.  It  is  very  likely  that  in  a  state  of  absolute  rest  tlu; 
visual  axes  diverges"  to  10°  from  parallelism,  and  this  may  lie  <lemon- 
strated  by  making  use  of  prisms,  apex  out.  Ilideed,  it  may  with  truth 
bo  artirmetl  that  convergence  .^ihould  be  regarded  as  beginning  at  this 
point.  Hence,  we  have  the  term  uvijtttitT  loiinriidirc,  becau.se  from 
a  state  of  divergent  rest  we  proceed  to  parallelism  and  then  to 
convergence.  The  nearest  point  at  which  a  very  small  object  can 
be  .seen  singly,  with  both  eyes,  constitutes  the  fusion  near  ]x)iut. 
The  divergent  power  in  any  individual  may  be  measured  by  finding 
the  higlx'st  prism,  apex  out,  that  can  be  held  before  eitiier  eye 
without  imxhicing  double  images  of  a  candle  fiame  G  m.  distant — 
prism  divergence. 

DeoTsumvergence.  When  the  eyes  are  turned  downward  it  is 
mainly,  as  we  know,  through  the  contraction  of  the  sujierior  obliipie 
anil  the  inferior  rectus,  and  this  act  is  termed  deorsumvergence. 

Sursumvergence  refers  to  the  act  of  turning  the  eyes  upward. 

Associated  Movements.  So  far,  refer;M,t:'  h;is  only  been  made  to 
the  fact  that  it  is  neces.sary  for  binocular  vision  that  both  eyes  be 
rotated  in  precisely  the  same  direction.  With  properly  balanced 
imisdes,  every  movement  of  one  eye  is  as.sociated  with  an  instant 
and  e<iual  rotation  of  the  other  eye.  Thus,  it  is  impos,sible  to  turn 
one  (\ve  up  and  the  other  <lown,  or  both  eyes  outward,  as  that  would 
produce  an  amioying  double  vision  and  interfere  with  binocul.-ir  sight. 
On  the  other  hand,  owing  m.-iinly  to  an  arrangement  of  the  nerve 
fibres  in  the  central  neurons  |)residing  over  the  various  (>ve  muscles, 
the  associated  movements  of  the  eyes  are  so  arranged  as  instantly  to 
fix  corresjxinding  retinal  points  upon  images  perceived  by  the  brain. 

Accommodation-convergence.  With  every  effort  of  convergence  there 
goes  a  certain  amount  of  acconmiodation.  .Mthoiigh  within  reason- 
;ible  limits  accommodation  and  convergence  are  constant,  o?ie  may 
be  increased  or  diminished  a  little  with  n'fereiice  to  the  other  with- 
out disturbing  symptoms.  For  example,  before  the  normal  eye 
of  an  individual  a  concave  glass  may  be  placed,  and  yet,  with  a 
slight  effort,  an  object  at,  say.  thn-e  feet  ilistance  will  be  readily  and 
distinctly  i^een.  In  the  «atn<'  way  a  convex  glass:  still  c!i;ih|(";  m 
person  before  whose  eve  it  is  ])lace(l  to  sec,  with  both  eyes  togethe:, 
the  same  ol)ject  distinctly  and  at  the  sanie  distimce.  For  the  more 
di'finite  measurement  of  convergence  eiforts  the  term  metre  anqle  is 


MoTioMi  OF  rut:  kyehm.l  ash  their  i>Eii.\.\GEMf:yTs.   ir^i 

used.  This  is  the  alible  whirli  the  victual  litic  makes  with  the  niofliaii 
line  of  tlic  face,  tlit-  latter  \)f'inii  lirawii  at  riglil  aiiRles  U>  the  base 
line  (iiiteroeular  ha.se  line)  joining  the  centres  of  rotation.  The 
anjrie  formed  hy  the  median  line  and  the  visual  line  at  a  |>oint  1  ni. 
distant  from  the  base  line  is  termed  I  metre  ancle.  An  ol)jerl 
si'cn  '  metre  distant  from  the  eye  would  re(|uire  twiee  as  much  con- 
vcrp-nce  as  th't  seen  at  I  lu.:  convergence,  therefore,  at  this  point, 
would  he  2  metre  aiiRles;  at  \  m.  distance  it  would  Im- 3  metre  anjlles, 
at  J  m.,  or  25  cm.,  it  w(mld  l)e  4  metre  angles,  etc.  On  the  other 
iiand,  an  object  .seen  at  L'  m.  distance  would  re<]uire  only  one-half 
the  amount  of  convergence  to  fix  it  at  1  m.;  convergence  here, 
tilt  II.  ('(juals  J  metre  angle — in  other  words,  V.  =  J  m.  a.  Where 
litith  rjii's  (ire  normal  and  emmetnipie,  as  many  metre  uncles  of  con- 
venience are  reijiiired  as  there  are  dioptres  of  aecammodatum. 

The  anijle  finrnmn  is  that  formetl  at  the  centre  of  rotation  by  the 
optic  axis  anti  the  line  of  fixation.  It  should  not  be  confused,  as  it 
sometimes   is,  with  the  antjle  alpha  formed  at  the  noilul  point   by 


A' 


Flo.  75. 


Antflr 


r>i.ltni  liiii'  indicate*  direction  which  tlie  projected  beam  Hikes.    (UaKSEtL  and  Kpber  ) 

the  visual  axis  and  the  major  axis  of  the  corneal  ellipse.  In  meas- 
uring the  angle  gamma,  it  is  well  to  make  use  of  the  |)erimeter.  The 
patient  is  placed  in  the  primary  position,  with  his  chin  on  the  chin- 
rv<\  and  gazing  at  the  fixation  point.  A  small  candle  is  moved  along 
the  perimeter  arm  until  it  is  reflected  from  the  exact  centre  of  the 
cornea  into  the  eye  of  the  oh.server  gazhig  at  it  iiiimediately  behind 
ilie  llame.  This  point  is  read  off  in  degrees  ii])on  the  perhneter  arc. 
Tiie  angle  varies  from  1°  to  o°. 

Prisms.  One  cannot  pniKrly  und(>rstand  the  contractile  or  rotary 
power  of  the  eye  nmscles  without  having  a  proper  idea  of  the  effect 
of  ])risms  upon  beams  of  light  and  upon  the  position  of  the  images 
(•a>t  upon  tlie  retina.  .\  ])rism  is  a  piece  of  glas.-  whose  refracting 
~url'aces  are  inclined  toward  each  other  so  as  to  form  an  angle  whose 
'liiircc  is  commonly  emjjloyed  to  ilesignate  its  particular  prism.  This 
■a\^"  !'"nns  its  (>dge  or  apex.  The  angle  sul.'tends  the  thicker  portion 
•n-  liasi'  of  the  pri.sm.  A  ray  of  light,  instead  of  i)a.ssing  through 
uiichaiiged  ill  direction,  is  bent  in  its  course  from  the  j)erpendicular 
•iwanl  the  ba.se  of  the  pri-m,  and  if  the  eye  be  placed  in  the  path 


154 


riii:  i:vi 


"%• 


H 


ihf  li'.'lit   I'.iv  Miter  it  li 


~-ril  ilirmi^li  ilic  priMi! 
liicli  ii  ciiiMii;!!!'.-  uill  ni'i  lie  <('("   ill  it-  In 


li'd  III 


•Villi  tin 


lici  l\  frmii  will 

ill  till' (lircciii>ii  (if  iiic  vi>u.il  line  I 'I']''! 

ill  ;i<'('<iiil,iiici'  willi  the  1,1  '    III'  |ii       . 

niv  of  li'^lit  til  ;i  r.'ilsc  pu-iiiiiii  nil  'lie  nliiia,  .•iim  tln'  i     in  il  e'cifscsft^ 

|i(Tcci\c  the  tilMi'<'t  :is  cuiiini 


'li 


1.11- 


'•     llllllll!ill|-i 

.<itiiifi,  lull 

-      Tlii,  is 

iriijcfli  til-- 


iiuiii  a  straii'lii   liiif,  th 


•iitini:  itiofi 


f  till'  vi>'iial  a\i>.     \\  lien       |iii-iiii  i-  iilariij  in  trout  nf  mii'  I'Vc   iti-i 
till'  '.  isual  iiiiaj;!'  i-  tlnw  | 


11    ;i  'Inl  upiiii  al.  illilis 


II n  I  i  iirr   i 


h, 


•ilnr 


III   iiiirr 
II 'inn  inn  II  n     i 


III/    Ihl     III 

II.'     If  r 


II  iitri'.-'   <ii  III  iiiliiis 


iial  "art  "I    j 


ic  rc  na. 

'/(  I  III     -'11' 


■\   of    li 

ilislr 


'  i-^ll      lie    ilificfcil 


iiiiiiiciiialfly  iiiwanl,  ti''  ta.-K  oi  ::,  i  .n  iilisliiiijr  tl.  -  i.-  Ian      ii  .'h  t 
iiiu-fli~   tiiat    rotatr     Uc  <  \c   iiiwai'l     :lii     iiltiii      -i-,  lli'     iliicf 
whii'li  I-;  til"'  intcriiai   ..clii-. 

\\r  know  fi-'Wii  rxi'i'ricitfi'  iliat  aftci  a  I'l  •  -rials  ilii  ni  '  =-tors  of 
iiiriiiai  I  ye- i-aii  ovi'i  iiiii- in  lis  ^  av  tin- ili|.:'|iia  thai  voii  ntlicr- 
wisc  iic  |iroiiii('C(l  !iy  iirisms  ,,  hi^in  as  411°  or  .'id  N'l  n  il  <  m-liiiii 
1-  tliu- sail!  to  Ix' a!"iiit   |n"or.")(P.     ( »ii  the  co!  iraiy.  wi    n  ii  .  ■< 

of  till'  iirism  is  uiicri   -I  iimiii  Jiati'Js-  oiitwani  li'      ri'  ■  '  n       yes, 

till-  task  of  ovi  I  ■omiiju,-  till-  ili|iio|iia   iimst  Im-  in     !'•  -rlcs 

that  nitato  ill"  I'M  iilwanl,  iliii'tly  the  cxtcrnai  ■■(•tii-  AIh  kHiih 
iiica-iirc'l  'i\  |irisiii~  is  in  the  iioiiiial  cyi'  alioii'  ■-foiir'^  it  '»f 
aililiu'tioii,  ^  iiiii'l,>  .  )<•"      I'i   til'  -  iiiif  \va\   wi- Il         !iat  '■•'■ 

aii'l  siiiii-iiiliii-i  ri  iprisiiis    ii|'    'ir    .lo'    '    !     ori'    ■  i'_\       in    .    i 

iiicasiin'il   i'l  ■    I  'IS  of  ilic  [11       r  n'i(i..icil  vcrcoiii-    i' ■    ilii  lop 

thai  wmilii  '     isn  l)c  prodiii  .'(1.     This  van  uirJ"       4°. 

AlMlucti'-!.  .1-      iiinlat  thclir-t  oi'irccxaiiii;      mii.      'm..  v  constan' 
.iMil  in  iioiiiial  r>    -  will    rari'lv    fall  lii'liiw  7         Tii'      alio    ixtw^ 
ai  luctioii    III, I  aliilni  tioii  iprism  li        l'cih'I'    |i      \\\  h't  ' 

friiiiS:!    ■      1\:\.     No    arliitrary    -'aiiilah     r:       In     iixn 

simply  lii'i-a  I-' the  liiiun  -  thus  lai -ri'il  ha   i' l-'-i-ii  larfii'lx  ■  i- 

of  pcrsonni  i-.|iiaii.'ii. 

Field  ot  Fixation.     An ''xainiiiat      •  il   il     iiio\' •  ■  nts  o: 


'       i-    -llnlljil    ili'liTililin    'li-  !alill-       -     ' 

(•■-..'        When    tlll'Si     ■■Xtiv    ir         'illls    li  ■' 
limy  1  iiiistituti'  th.    iiiiiiiiir  /'- 

yi'ars  au'o.  ailjustcit  tin-  p<"     "tiT  ' 
of   haviiij;   an   nliji'i'l    alt'  I 

ill   iln-  usual   way,   lir    i  -imp 

of   till'  iilolii'  ill   aiiv  iliii  i-    rapi 

strips    .if    iin"la/i>ii    par.  '11.     tit    paper    \ 

■f  twi    ii'tti'i-  r'.rr('s])oiiiliin    'o  .iacs;<'r  .\  ^ 
:.s  wi'i     IS  Im'Ii.u    tiiruri-  rri  iiliiijc   ilic 

[K-ritii.  ti'r  arc-     These  striji-      re  toifi  t' 
am:     -f  the   j-^'riiiu'ter    ''i;r.     ''-.  '''•■ 

prill  posilioii,  and  he  i-  a-i^ed      '  I'l 

frm  -  eel;     e  MS   possili-  rin 


f    ti  isele      n!       ach 

t'liUli'i  I   ei.iii       led, 

Tl  ler.'        eral 

Il  .ry.     Instead 

il  I  ill.         rimeter  -trm 

•li\-        .■   ro';     ioll 

\  me'        il.     lour 

'lined    .  ■•!  Is 

i  .VI  I'lii.,  plai  ''II 

I.  ^re.  -  of  latil'  the 

plai'i'd  in  posit  II  a  i  -ii   the 

;..t.t',,      l>,,.j,j       Ijcjjiir      It;       the 

le  lower  line  as  far  away 
ijisheil,  he  is  reiiue'-ted   to 


..  Awim'iiitiou,  I'^'Jil. 


.t/"/7o.\^  III   ri!'  h:\iuM.i    i.v/>  Tiiiii:  hi:t:AS'.i:Mi:\  r^    \:,-, 


i  iieiii'-  ft»r  till-  mea?«uivnient  .^t  tl--^   n.^nwulHr  •!.  i.|  ut"  ii\atu)p  ■  v  iiu-flMs  o(  ih-   !«Tiineter, 


156 


TUK  E  YE. 


flivc  tlic  fifiurc  iil;u'0(l  iihovo  tlio  word  just  rorojinizcd,  and  to  try 
to  rcail  fartlicr  out  additional  letters  on  the  fifjure  line.  Karii  word 
beyond  repn-sents  about  one  def;ree  on  the  scale,  and  the  numlHT  of 
words  so  read  added  to  the  previous  tifiure  fjives  tiie  limit,  in  desrws, 
of  the  field  in  that  direetion.  As  each  (piadrant  of  the  circle  is 
passed  over,  a  slip  of  paper  is  removed,  revealing  the  next  pajjcr, 
whose  lettering,  being  (hfferent,  suggests  nothing  to  the  person 
under  e\amiiiatio:».  After  many  perimetric  examinatioi  -  with  this 
device,  the  limits  of  the  monocular  fixation  field  were  fomul  to  corre- 
spond closely  with  the  figures  of  Landolt : 


IHrfctly  out  4 
IiirtTtly  in  i- 
Dirucily  (iuwu  frf 
liircctly  up       43 


Out  ami  down  47°  I  ,|.„ 
In  mill  up  1"'°  ►  '  " 

m»vvn  nntl  in    :i>  '  (    -« 
I'pand  out       47°  > ' 


Fig.  ■ 


Stevens'  tropometer. 


The  binocular  field  of  f\xntinn  is  by  no  means  identical  with  the 
field  of  binocular  .singl"  vision,  alihimgh  its  borders  are  about  the 
same.  Duane  finds  that  the  upward  limit  of  the  monocular  field  to 
be  about  45°,  downward  about  70°,  right  and  left  55°.  The.se  rota- 
tions vary  with  age  and  with  the  form  and  positiim  of  the  globe. 
[)iiiibtless  the  Ix'st  method  of  measuring  the  rotations  of  the  eye, 
and,  conse(|uently,  the  field  of  fixation,  is  by  means  of  Stevens' 
tropometer.  (Fig.  77.)  .\s  we  shall  hereafter  find,  it  is  neces- 
sary to  know,  s(j  far  as  it  can  be  determined,  whether  a  particular 


MOTIoy.S  OF  THE  KYICIiALl.  ASh  THEIR  nEUASCEME.STS.     157 

muscular  iinbalance  is  due  to  weakness  or  spasm  of  some  |)articular 
muscle  or  muscles.  For  this  purjjose  the  rotation  power  of  the  glol)e 
ill  all  directions  as  measured  by  the  methods  just  described  will  Ix' 
found  of  extreme  value. 

.Vnother  u.s«'ful  instrument  for  the  meosureinint  0/  rimvenjence  and 
Us  relation  to  dircrnriice  is  the  Landolt  ophthalmodynamometer. 
In  it  we  [losse.ss  a  method  comparable  to  the  measurement  of  the 
amplitude  and  range  of  accommodation  by  noting  the  relative  posi- 
tion of  the  punrtiim  proximum  and  the  punchim  nniotum  of  conver- 
gence. This  device  consists  of  a  black  metal  case  fitted  overa  candle. 
Tliis  cylindrical  case  is  pierced  by  various  openings,  the  most  valuable 
of  which  is  a  narrow  slit  through  which  the  candle-light  can  be  seen  as 
a  streak  of  light.    .last  below  each  one  of  the  openings  is  a  hook  to 

Pig.  78. 


Ijiiiilnlt's  opIillmlmiHlynnmometcr. 


wiiich  is  attached  a  tape-measure  marked  in  centimetres,  anil  on  the 

wilier  side  the  metre  angles  corresponding  to  them.     The  candle  is 

iicld  directly  in  front  of  the  patient's  face,  graiiually  approaching  it. 

until  the  light  streak  becomes  doubled.     The  tape  indicates  in  ceii- 

liiiii'li-es  this  di-stance  (which  is  the  punctum  proximum  of  conver- 

u'liice)  as  well  as  the  amount  of  convergence  in  metre  angles.     We 

have  seen  that   the   number  of  centimetres  distant    from   the    in- 

!i  idculiir  ba.se  line  to  the  point  of  doubling  divided  into  100  give.* 

ilie  number  of  metre  angles  of  convergence.     If  the  double  vision 

"icms  ;it  10  cm.,  we  know  that  the  patient  i)o.s,sesses  10  metre  angles 

1   ronvergence.    The  punctum  remotum  of  convergence  may  be 

■':.t;iincd  by  having  the  |>atient,  with  his  head  in  tlie  primary  \nm- 

i'lii,  lix  a  point  of  light,  say,  a  candle  flame,  at  6  m.  and  find  the 

I  longest  prism,  apex  out,  before  one  eye,  that  can  be  overcome 


158 


witlioui   pnuluciiifi  iliplopi 
piisin   ill  (Icf^rci's 


rUi:  EYE. 

,„i„,,, \Vc   tlicil   divide   tilc   llllIulHT  of  tllilt 

1)V  seven,  and   tluis  olitain   in  metre  an},'ies  tiie 


aniouiit  ni  iwiititiir  eiinverjuent 
has  O.S.)  iiK 
aiisiles,  and  so  on 


com 


of  eaeli  eve.      If  tlie  prism  be  H",  lie 


trc  allele;  if  7°,   1   metre  aiisle,  and  if  'J°,  1.2S  metre 
-I'l — .  •■■•")uiu  of  eonverf!;enee  in  tiie  norma! 


ri 


le  averap'  aiiH 


litioii  is  about  10  metre  angles. 
Maiiv  are  tlie  devices  tiiat,  in  addition  to  tlu 


ineiitioned,  have 


been  (Miii)loyed   for  estiniatin-;  tlie  exeiii-sion  powers  ( 


if  the  ocular 


mil: 


isde 


l'robai)lv  the  best  of  these  are  the  itisley  rotatiiif;  prisii 


the   Maildox   ro( 


Is,   tl 


le  mo 


nocular  phoroineter  of  Savajje,  am 


1  th 


Could  and  Noyes  prism  batteric 
Heterophoria,  Heterotropia 

of  the 
mention  / 


uw..»,  — r Deviations  from  the  normal  balance 

mus('''les  ha%-e  nwived  various  names,  and  we  have  only  to 


ii'iiilfi 


Hrii'iini  or  wrakncss  <>/  tiinirrijnivt 


to  indicate  one  phase 
ibalance.'' 


f  what   (ioiild   has  verv  properly  termed  '   muscular  mi 

■lature    of    Stevens    has    been    most    widely    accepted 


The    iioineiu 

Normal  muscle  balanci 


he  terms  orthojtiutrw :   abnormal    balaiu 


or   111 


ibalance,    heterophoria.      lliipcrplnn-m    is   a    tendency   < 


i 


_^_ _  if    the 

visuHlaxirof  one"eve\o'd(>"viat(-  above  tli;it  of  the  other;  linpoplioria 
is  -i  teiideiicv  of  the  visual   axis  of  one  eye  to  deviate  below  that  of 
the   aihi'V.  '  isophoriii,    a    tendency    of    the    visual    axes    outward; 
rvopAnnVi,  a   tendencv  of  the  visual  axes  iiiwanl;  hmirnxophorKi.  a 
tendencv  of  the  visual  axis  of  one  eye  upward  and  outward ;  hifpo- 
cvophor'in.  a  K'lidencv  of  the  visual  axis  of  one  eye  to  deviate"  down- 
ward and  outward;  'l,iip<-n:-<„phnn,i,  a  tendency  ot  the  vi.sual  axis  of 
„iic  evi'  to  deviate  outward  and  inward;  hipinsi.plmnn,  a  tendency 
of   the   visual   axis  of   one  eye   to   deviate  downward  and   mward. 
^\\^   this    list.   Sav.i<ie    has   added    iiisuiliciency     ''    the   (.bh(|ue    eye 
muscles,  or  ciirloph.n-u'  ;  and  Diiaiie,  a  defect  of  |     ,>-er  of  some  jmr- 
ticular  eve  muscle— A(//x*/./'H'.-'^- -excess    in   action   ot    a  particular 
,.vc~/(///i'r/,/)/CNM— while  irrejiular  action  of  an  individual  muscle  is 
^[yU^i\' piiniLinrsis.     Where  th.'  visual  axis  exhibits  somethinp:  more 
than  a  Ifwkncii  toward  abnormal  excursion,  the  terniination  "  tropia 
is  used    instead  of  "iihoria;"  thus,  in  (.votrnpin  the  visual  axis,  as 
compared  with  that  of  the  ..pposite  eye.  does  visibly  turn  outward, 
It  somfliines  happens  that  in  the  same  individual  there  maybe,  for 
example,  a  hyperphoria  for  near  Hxation,  aii<l  a  manifest  hyjiertropui 
Alien  he  nazes  in  the  distance. 

The  term  "  iiisulficieiicv  of  the  ocular  muscles  "  corresponds  to  v(m 
(Iraefes  <hp,',nur  .•.■lmhi.'<nni.'<.  Tli.>  test  which  in  v  •  Craefe's  tiiiio 
was  commonlv  made  of  the  convergence  i.ower  is  ■  i  ,  le  one:  The 
i.itient  is  asked  to  fix  an  object  held  directly  in  fn-  •  -\  is  face,  at  a 
.listaiiceof  1  ni.  This  is  gradually  •ipim.ache.l  to  wit,  ^  .or  15  cin.  of 
the  r-yes  If  there  be  weakness  of  converneiici',  the  eye  \>  ith  the  weaker 
internal  reclus  usuallv  turns  out.  .\r.othtT  well-known  and  useful  t.-st 
is  to  ask  th<'  patient  to  fix  a  dot  upon  the  card  held  a  little  below  the 
horizon  :'■)  cm.  from  the  ev<-s,    ( )iieeye  is  then  covered,  and  the  other 


MUTJOys  OF  THE  EYEBALL  AM)  THEIR  DERAXilEMESTS.     I59 


eye  is  wiitchcil  to  (Icti'rniiiic  wlictlicr  it,  bcliiiid  the  cover,  dcviatc's 
i)\it\v;inl,  inward,  upward,  or  downward.  If  there  be  no  deviation 
after  first  one  eye,  and  tlien  the  other,  has  Ikhmi  covered  and  uncovered, 
one  may  decide  that  there  is  little  or  no  imbalance  of  the  rnu-scles. 
For  testing  the  ftmctions  of  the  muscles  that  produce  Tertic' J  ezcui- 
sions,  a  10°  or  15°  prism  is  placed,  base  in,  before  either  eye,  taking 
care  tiiat  the  prism  axis  is  exactly  horizontal. 
If  the  double  images  thus  produced  at  20  fu:.  79. 

feet  or  (i  n.  are  on  the  same  level,  there  is 
no  hyperphoria.  In  nmch  the  same  way, 
//)(■  jinictiniis  of  the  lakrnl  muf:chs  may, 
iiniier  similar  conditions,  be  tested.  A  7°  or 
S°  prism  is  placed  base  up  or  down,  before 
one  eye.  This  produces  vertical  diplojjia. 
If  one  image  is  seen  (hrectly  over  the  other, 
there  is  no  excess  of  divergence  or  conver- 
gence. 

There  are  several  methods  of  testing  the 
hdhmrc  i)f  the  musclcx  at  the  near  junnl  or 
ordinary  working  distance,  which  varies  ac- 
cording to  the  occupation  from  '25  cm.  to  40 
cm.  l"or  all  practical  purjxises  we  may 
employ  it  at  :{<)  cm.  A  card  having  a  small 
dot  and  a  fine  line  drawn  through  the  latter 
is  placed  at  this  distance,  just  below  the 
horizon.  N'ertical  diplopia  having  been 
indduced  in  th(>  manner  just  mentioned,  the 
double  images  will  be  found,  in  e(|uilibrium, 
to  stand  directly  above  the  other.  When 
crossed  or  homonymous  deviation  is  pro- 
duced, we  know  tha*  th.re  is  insufficiency 
or  excess  of  convergent  power,  and  the 
prism  that  restores  the  images  to  their 
normal  position  represents  the  amount  of 
imlialaiice. 

.Viiother  useful  method  of  determining  the 
pinrrr  t)j  ailditctioi)  or  ])rism-convergence, 
.iliduction  or  prism-divergence  and  sursum- 
duction,  is  by  finding  tb"  strongest  prism 
which  the  lateral  and  vertical  muscles  can 
"vcrcome. 

.hhlttrlinn  is  tested  when  the  patient,  with  his  heu'  in  the  primary 
position  0  m.  from  a  candle  or  other  flame,  endeavors  to  overcome  the 
double  images  produced  bya  pri.sm,  aiK>x  in,  placed lx>fore one  or  1  he 
■  ii  her  eye.  ( )ne  shouM  begin  with  a  weak  prism,  and  gradually  increase 
ii  unti!  the  diph>pia  is  such  that  no  effort  on  the  part  of  the  [)atieiit 
Micceeds  in   fusing  the  double    image?.     It   should  Im'  remembered 


Could's  )   .  m  battery. 


1«0 


THE  EYE. 


c- 


tluit  the  ailductive  power  is  often  greater  by  several  degrees  when  the 
prism  is  placed  before  one  eye  than  wlien  it  is  held  Ix^fore  the  other; 
that  the  images  should  always  be  kept  in  the  same  horizontal  line;  and 
tiiat  the  eye  should  be  encouraged  to  fuse  them  by  bringing  the  candle 
fiame  to  within  2  or  3  feet  of  the  patient's  face  and  gradually  carry- 
ing it  U)  infinity,  or  20  feet  distant.  Another  method  of  inducing 
fusion,  and  thus  measuring  the  tf)tal  adducting  power,  is  to  ask  the 
patient  to  fix  the  end  of  his  finger,  heiil  20  cm.  in  front  of  his  eyes,  and 
then,  immediately  afterward,  to  gaze  at  the  more  distant  candle 
flame.  The  average  of  adducting  power  at  the  first  trial  varies  from  30° 
to  50°,  in  patients  with  normal  eyes.  Gould  and  Lippincott  have 
described  the  space  between  the  least  and  greatest  power  of  adduc- 
tion as  the  "region  of  iliplopia." 

The  power  of  abduction  is  in  the  same  way  tested  with  a  prism  hori- 
zontally placed;  it  will  then  be  found  that  in  normal  eyes  a  prism 
of  from  G°  to  8°  will  be  overcome.  In  measuring  sursumduction, 
a  prism  is  placed  with  its  base  up  before  one  eye;  the  highest 
degree  that  can  be  overcome  is  noted.  In  all  examinations  made 
at  6  m.,  the  ametropia  should  be  corrected  for  the  distance,  and,  in 
the  same  way,  when  a  near  test  is  employed,  reading-glasses  should 
lie  used. 

A  very  convenient  and  useful  method  of  gradually  increasing  the 
strength  of  the  prisms  in  measuring  the  power  of  rotation  po^,- 
sessed  by  the  extrinsic  muscles  in  aparticularca.se,  is  the  prisrn  fmt- 
tery  of  (iould,  modified  from  the  one  first  suggested  by  Noyes.  (F'ig. 
79.)  A  series  of  prisms  increa.ses  on  each  side  of  a  central  slide  by 
1°  up  to  20°,  then  by  2°  up  to  40°.  The  prisi.is  may  be  revolved  upon 
a  pivot  so  as  to  present  bases  up,  down,  in,  or  out. 

Red  Glass  Test.  If  a  red  glass  be  placed  Ix'fore  one  eye,  binocular 
vision  is  overcome  in  most  cases  of  heterophoria,  and  two  images, 
one  rod  and  the  other  yellowi.sh,  of  a  candle  or  other  flame  are  ob- 
served. The  n'lative  positions  of  these  lights  is  a  fairly  reliable 
indication  of  the  form  and  amount  of  the  imbalance;  indeed,  it  fur- 
nishes an  easy  though  rough  test  of  the  heterophoria  present.  The 
prism  needed  to  fuse  the  two  images  furnishes  the  degree  of  the  latent 
deflection.     (Plate  IV.) 

Instruments  u.sed  in  testing  the  balance  of  the  extrinsic  eye  muscles 
are  based  mainly  upon  the  foregoing  methods  That  is  to  say,  the 
impulse  for  binocular  fixation  is  imllified  as  far  as  possible,  so  that 
each  eye  may  be  rotated  to  a  point  which  represents  the  strength 
of  its  nmscles  with  other  factors  eliminated. 

The  Phorometer  of  Stevens.  Double  vision  is  produced  by  a  prism, 
base  down  or  up,  liefore  one  eye,  for  the  examination  of  the  power 
of  the  lateral  nmscles,  another  prism,  base  in  or  out,  being  used  for 
measuring  the  |(ower  of  the  vertical  muscles.  It  is,  in  effect,  a  more 
accurate  application  of  the  prisiri  tests  just  described,  and  may  be 
emploj'ed  for  examination  both  for  the  distant  or  the  near  point. 


PLATE    IV. 


n 


fl 


XL 


n 


n 


n 


n 


n 


ft 


n 


ned  Glass  over  Right  Eye. 

Exophori.i  5      Left   H  yper-esophoriii. 


E-.ophorin, 

LeH   H  y  perphtiriH, 

Rii)Iit    HyperphoriH, 


H.  Right  hyper-e-'ophoriii 
7.  Rinht  liyper-ex<)()hiit  11 
8      1-efl   hypet-exophririii 


ic 


MOTIONS  OF  THE  EYEfiALL  AND  THffR  DIPANO-ML^rs.     161 

Knowine  its  limitations,  and  allowing  for  its  !iabi;»y  t<)  cm.  it  is 
probably  the  best  instrument  that  we  possess  for  mepsunng  netero- 
phoria. 

FlQ.  80. 


Stevens'  phorometer. 


The  Risley  Prism,  consisting  of  tw..  supcrimiwscd  prisms  with 
ti," ba«>s  in  opposite  .lircctions,  may  be  ascd  with  the  rial  frame, 
-n  is  is  ^v  application  of  Herschers  plan,  who  show..!  that  by  rotatmg 
tvo  prisms  n  opposite  ilin-ctions  we  can  produce  the  effect  of  a 
S;;iri.™sing\lrisn.  With  this  device  the  amount  of  ad.U:  t.on, 
abduction,  and  sursumduction  may  readily  be  measure.1. 


Flu.  «l. 


FiO.  82. 


Risley'a  roUry  prtani. 


Maddoz  TnulOple  rod. 


tnrou) 
when 


tiKrffluSluT,;^ £:u,^r;.y.  u o„h„phoHa, 


U'2 


rUE  EYE. 


the  ciiiiillc  flame  (s<>('ii  as  a  streak  of  linlit  l>y  tlie  eye  In-fore  which 
the  ro<i  is  phu'etl)  piisses  tliroujili  •!"'  caiiilie  Haiiie  seen  by  the  other 


Vw.  H3. 


Mad'lox's  nid-ttitt  fur  borlsDntal  deviation;  tlie  nxl  is  before  the  right  eye.  A.  Ttie  line  ikkscs 
through  the  flame--<>rthophoria.  8.  The  line  paHses  to  the  riu'ht  of  the  flatne  latent— convergence  or 
esophoria.  c.  The  line  paiKex  to  the  left  nf  the  ttame— latent  d'.Tergenre  or  ezophorla.  (dc 
StHWKINIT/.  anil  Randai,!..) 

Fl«.  M. 
ABC 


TO  5 


Maililiix'ii  n»l-te«t  for  vertical  deviation  ;  the  rod  is  ln'fore  the  riRht  eye.  .1.  Tlie  line  p^^»e!. 
thmngh  the  fianu'— ortho|ihoria.  H  The  line  )*»ses  Vielow  llie  ijiiine  ;  llie  upper  iniiiKe  tielunKS 
to  the  left  eye  -ristit  iiyr>erphoria.  C.  Tlie  line  |W!«e«  alnive  tlie  (lame ;  the  npi^^r  image  belongs  to 
the  rlRht  eye— left  liyiicriiiioriii.     (he  Si  HWi;:MTznri<i  Kandai.l,) 


MoTIoys  iiF  THE  EYEUALL  ASP  THEIR  JiERASOEMEyTS.     ]«.•} 


vyr.  Ill  tsoplioria  wo  have  hoinonynious  diplopia,  the  streak  l)oiiig 
oil  the  same  side  as  the  eye  fixing  it:  in  exophoria  it  is  on  the 
opposite'  side:  and  in  hyperpiioria,  either  i)ei()\v  it  iir  al)(>ve  it,  as  we 
have  to  deal  witii  a  right  or  left  hyix'rjjhoria.  Assuming  that  the  rod 
he  ))laeed  before  the  right  eye,  Figs.  N;{  and  S4  show  the  position  of 
tlie  light  streak  and  the  candle  Hanie  in  normally  and  almonnally 
halaneed  eyes. 

.\nother  well-known  test  is  tiie  so-ealled  ixinillitx  kst.  This  is  made 
at  the  usual  (i  in.  distanee,  and  is  carried  out  with  a  light  on  a  dark 
liackground.eaeh  eye  being  covered  alternately,  so  as  to  remove  the 
desire  for  binocular  Hxation.  As  the  cover,  plao'd  first  before  one 
eye,  is  being  carried  liefore  the  other,  the  patient  is  a.sked  whether 
tiie  recently  uncovered  eye  notices  any  movement  of  the  distant 
tiame.  If  he  does  not  after  a  few  trials,  one  may  Im-  certain  that 
there  is  no  marked  heferophoria.  When  ajJiiarent  motion  of  the 
candlo  ihime  is  noticed,  the  patient  will  siiortly  be  able  to  describe 

Fig.  bii. 


(>rtho|>boria.  Heltrophoria. 

The  convex  «pherical  tt^t. 

its  direction  and  its  extent.  Kxophoria  is  indicated  if  the  light  moves 
ill  the  same  direction  as  the  cover  is  carried  from  one  eye  to  the 
nther:  if  in  the  opposite  (Urection,  esophoria.  If  the  light  moves 
downward  wlu-n  tiie  right  eye  is  unco.ereil,  there  is  a  right  hyper- 
phoria; if  it  moves  in  an  upward  direction,  we  have  to  deal  with  a 
left  hyperphoria.  The  prism  that  neutralizes  the  movement  measures 
tlie  degree  of  the  heterophoria. 

The  Convex  Spherical  Test.     A  strong  convex  glass  do  D.)  is 

covered,  except  at  its  optical  centre,  and  iilaced  before  one  eye.     The 

distant  candle  image  api)(>ars  in  the  shaiM-  of  a  blur  of  light  with  a 

-eeond  image,  that  of  an  oniinary  candle  flame.     '     .he  muscles  be 

nnnnallv  balanced,  the  clear  candle  flame  will  ...    situated  m  the 

i;i.ldlc  of  th.'  blurred  image.     In  heteroi)horia  the  clear  image  wi  1 

MMx^ar  in  various  parts  of  the  blurred  image  field,  or,  m  the  high 

Iru'ives,  will  he  separate.l  from  it.     The  relation  U-W.nHi  the  tw;, 

i'-LMges  and  1h-  prism  re(iuired  to  bring  the  clear  miage  into  t tie 

■  rntre  of  the  blurred  one.  deteniiines  the  measurement  of  the  heteni- 


164 


THE  EYE. 


phoria.  Hansoll  and  UoIkt  holicvo  tliat,  when  [jroiM-rly  rarried  oiit, 
tl»is  U'st  i.^  sii|MTior  to  tliost'  in  which  |)risins  ahmc  arc  usi-d,  anil  tluit 
it  |)()ss<'ss<'s  all  till'  advantaRcs  of  the  Maddox  hmIs. 

Symptoms  of  Heterophoria.  Thcrt-  can  Im>  no  douht  that  a  marked 
dcKiw  of  almost  every  form  of  muscular  imbalance  (as  measured 
l)y  one  or  mori'  phorometers)  may  exist  without  giving  rise  to 
siM'cial  symptoms.  The  state  of  the  nervous  system,  the  habits 
of  the  patient,  the  condition  of  the  dig<'stive  and  other  organs 
influence  the  symptomatol< igy  in  tl.ese  muscular  anomalies.  On 
the  other  hand,  Ijoth  local  and  general  symptoms  an-  commonly 
I)resent  in  the  majority  of  ca.scs  of  heterophoria.  Inasmuch  as  ame- 
tn)pia  is  intimately  a.s.sociated  with  heterophoria  and  with  hetero- 
tropia,  and  since  we  know  that  the  correction  of  the  one  may  greatly 
n'lieve  the  irritation  proiluced  Ity  the  others,  it  is  not  strange  that 
one  has  ditficulty  in  differentiating  the  eyestrain  symptoms  of  ame- 
tropia from  those  of  heterophoria.  We  shall  consider  these  nmscular 
anomalies  separately. 

Fio.  8«. 


ImagiMnovement  In  heterophoria,  ezophorla,  and  e»)phoria.    (Coi.Bi  rn.) 

Ezophoria.  The  tendency  of  the  visual  axes  outward  is  generally 
a  passive  condition,  and  is  commonly  the  result  of  lossof  convergence- 
power  or  convergence-impulse,  and  it  may  range  all  the  way  from 
an  insignificant  defect  to  a  true  and  almost  constant  exotro|)ia.  It 
may  be  due  to  structural  defects  in  the  insertion  of  the  recti  interni 
or  their  opponents  in  the  too  divergent  orbits  of  wide  skulls,  or  to 
.some  other  anatomical  anomaly.  .Moreover,  an  insutHcient  innerva- 
tion of  the  interni  may  have  something  to  do  with  this  condition; 
occasionally  a  developmental  defect  in  one  or  other  internus  may 
bring  about  an  undue  tendency  to  divergence.  The  exophoria  may 
be  paretic  from  the  beginning,  or  the  nerve  supply  having  been  par- 
tially restored  in  an  exotropia,  the  remaining  iml)alance  is  not  notice- 
able unless  tests  are  applieil.  It  will  thus  be  .seen  that  both  exophoria 
and  esoi'horia  are  the  resultant  in  m.-my  c,i.ses  of  iHspusos  of  the  most 
oi)posite  character,  affecting  one  or  more  of  th(>  nuiscles  that  take 
part  in  normal  divergence  and  convergence.  .Anything  which  affects 
the  tone  of  the  nmscular  system  generally,  but  in  particular  those 


MOTIOys  or  THE  EYEBALL  AND  THEIR  DERASUEMESm.     165 

imiscli's  fiij<iiji<''l  '"  potivorjtfncc,  is  likely  ti>  prixluce  an  cxophoria. 
We  iviiow  lx)th  fnun  ()l)^<orvati()n  aiul  exixTieiicc  tiiat  the  most  active 
(•(incoiiiitant  of  exophoria  is  myopia.  In  this  fonii  of  ametropia 
till'  coiivergcmc'  muscles  are  not  frecjuditly  calietl  into  play;  the 
hcailiis-  impuls*'  to  converge  is  usually  lacking.  In  time  loss  «)f  the 
convergence  im|)ulse  takes  place,  and  thus,  iiulin'ctly,  e.xophoria  is 
produced.  The  symptoms  caused  by  cxophoria  do  not  ditTer  from 
tluw  that  accompany  the  ametropic  condition  .md  the  accommo- 
dative anomalies  with  which  it  is  so  intimately  associated.  These  arc 
(•(iiinected  nearly  always  with  attempts  to  do  near  work— blurring  of 
ilic  print,  pain  in  and  alM)ut  the  eyes  on  attempting  t<<  read  or  write, 
confusion  and  running  together  of  print  or  of  the  notes  in  nmsic, 
h(>adache,  fatigue  of  the  eyes,  and  a  sleepy  fe«*liiig-  all  these  may 
accompany  a  pure  exophoria,  even  after  a  correction  of  the  refractive 
errors  that  accompany  it. 

Treatment     We   know   that   in   many  instances  exophoria  gives 
very  little  trouble  and  produces  no  .symptoms  after  the  correction  of 
a  simple  or  compound  myopic  astigmatism.    It  sometimes  ceases  to  lie 
an  irritant  when  an  acute  or  chronic  disease  has  been  cured.     It  is  the 
belief  of  the  writer  that  the  condition  of  the  general  health  and  the 
correction  of  all  fonns  of  ajjtigmatlsm,  and  esfn-cially  of  a  concur- 
rent   myopia,  should   be  the  first  consideration  in  this  condition. 
de  Schweinitz  advises,  as  a  routine  of  practice,  tincture  of  nux  vomica, 
fifteen  drops,  three  times  a  day,  increasing  the  dose  by  five  daily 
drops  until  forty-five  are  taken  or  until   toxic  effects  are  noticed. 
When,  after  this  hai  been  done,  exophoric  symptoms  still  remain, 
attention  .should  be  directed  to  a  permanent  relief  of   the  condi- 
tion.   The  most  important  of  the  non-operative  procedures  is  regular 
prism  exercise,  either  bv  means  of  the  Noyes-(iould  apparatus  or  by 
means  of  ordinarv  square  prisms  set  in  spectacle  frames  and  placed 
before  the  eves.  "  The  strongest  prisms,  ba.ses  out,  should  be  used. 
The  patient  fuses  the  double  images  while  standing   four  or  five  feet 
Irum  the  ix.int  of  illumination.     He  then  slowly  backs  across  the 
r.H.m.  fifte...,  or  twentv  feet  away.    This  exercise  is  to  be  performed 
for  from  thrw-  to  five  minutes  at  a  time  three  times  a  day.      1  he 
strength  of  the  pri,sms  is  gradually  increased,  but  in  no  case  .should 
the  patient  make  use  of  such  strength  as  to  cause  pam,  vertigo, 
ur  other  disagreeable  svmptoms.    This  ealisthenic  performance  may 
alsu  be  cmducted  bv  ordering  square  prisms  with  whici,  the  patient 
luav  exercise  his  conve  ,'ence  at  home.     If,  for  example,  the  conver- 
ireiit  power  be  15°  an.l  the  adduction  7°  or  8°,  three  s<iuare  pn.sms 
inav  be  prescribed,  of  respectively  15°,  h'.  and  3°.    The  patient  uses 
the"  hrst  for  a  couple  of  days,  until  fusion  of  the  double  images  at 
twentv  feet  is  easv  when  it  is  placed  l)efore  either  eye.    The  next  day 
i,e  .....piuvs,  f..r  the  .same  purpose,  the  15°  wd  the  3°  prism   and  so 
.ni.tinues  until  he  can  overcome  the  compound  IS    pnsm      l-maiiy, 
all  three  are  together  used,  and  this  combination,  which  is  about  equal 


IM 


lllk   KYU. 


to  ;i  siiijjlc  2'i°  prism  is  cxr.liaiigi'il  for  nnothcr  series,  -iiv  2.'i°.  l(i°, 
ami  .")°.  In  this  way,  ilii'ciiii\cr>j<'nt  |M>\ver  iiiav  Ik' iiu  n  ,-i-.l  until  the 
patient  can  readily  overcoine  at  least  a  ()U°  prism,  t  aiTl'iil  ilirec- 
tions  tor  their  i.se  shoiihl  always  Ix'  jiiven,  aii<l  eontr^l  e\|M-rimentH 
sli;>ulil  Im'  maile  from  time  to  time  in  tiie  surjieonw  olliee.  No  opera- 
tion s!i;<iil(|  '»■  thought  of  until  the  mejisun's  just  alluuiil  f"  havf 
iM'en  sullii'ienliy  tri'-<l.  ((utijoor  exercise-,  a  nutritious  cjiel,  and  as 
litt'e  nr'ar  work  as  pir-silile.  slmulil  .ilways  Im-  incule;iteil  in  connection 
with  fhi-'  "I'-neral  treatment. 

Alliiou'ih  the  constant  wearing  of  prisms  occasionally  ^ives  rr'lief 
to  the  symptoms  iinl'iceil  by  an  i-xophoria.  the  writer  cannot  con- 
scientiously advise  them,  except  is  a  ti'inporary  ex|)eclient.  If  worn 
for  some  tiiiit',  tl."  effort  of  conveiijence  is  mon-  and  more  lelt  in  ahey- 
iince,  ait(i  there  is  no  re;il  attempt  at  a  cure  of  tin   conditions  that 


Kl<i.  «7. 


Imo^-movenient  In  liyiKW-toi-tK-ria.  hyitvrphorin.  uid  hy^<,<viio|>horta.    iCoLBrRN.) 


uiidi-rlie  the  exojihoric  sl:i!e.  When  a  prism  correction  is  attempted, 
not  more  than  two-thirds  of  the  total  amount  (divided  hetween  the 
eyes)  should  he  presented.  Three  or  four  de,iri'<'.'s  of  exoplioria  rarely 
iv'iuire  any  correction,  and  as  it  is  usually  durins;  ne:ii-  work  tli;it 
symptoms  are  set  up,  ;ind  since  (he  exoplioria  is  most  marked  at 
liiat  time,  it  may  he  advi.sahle  to  f;ive  a  stronjjer  |)risni  for  readinp 
or  desk-work. 

When  all  means  fail,  an  operation  upon  theeyp  mus  ■'•  i-  iiulicated. 
In  this  ,-':ise  the  surgeon  may  teiiotomize  one  or  tmih  externi,  or 
advance  one  or  both  interni.  The  writer,  while  syiiip;ithizinji  with 
Liiiidolt's  preference  for  advancement  in  all  cases  of  weakened  con- 
vergence, has  not  been  able  to  obtain  the  best  results  with  it  a 
section  (partial  or  complete)  of  the  opj)osin>:  external  rectus.  \\  neve 
the  apparent  exoplioria  is  really  deiiendent  upon  the  presence  of 
hyp«Tphoria  or  a  hypertropiji  (as  Stevens  affirms  is  frequently  the 


Muiioys  (If  Tilt:  i:)i:iiM.i.  .i.\h  riiEiR  pkuasi  tMtsTN.   i67 


•!i.M«'),  lie  "inrnic.'il  iiitorlVn^       svitli  the  cxniiliMria  i-  .iu>tituil)l( 


until 


VlTtlC 


aiKiiiia 


Iv   lia-       I'll   corrected.     Whetlier  uiir   or   Iwitli 


til 

imeriii    reiiuire   ailvanceiiii         ami   wlidlier  acciiiiii>aiiyiii):  sections 

~lioiilil  l>e  .lone  on  ilie  CN    ■mi.  will  .l<|M'n(|  upon  tiie  n-Miltf  i>f    « 

not  relieve.  1  hv  glasse^.  nie.l,    ili.i 


i^je   oiK'raiion.     I'mlial)!     an  e\.)plioria.  jiymptoni.-i  ..I    "liii-li  a 


sli..nlil  1m'  corrected  !>>  the  a.iva 


n,  liyjii 
icemen 


and  prism  ex.Tcise, 
t    .f  hoili  inlernal  recti,  wiiii- 


.iiit  tenotomy 

the  loriner  tail,  the  operator 


irtial  or  coinl^lete)  of  one  ( 


)r  hoih  externi.     Hut,  if 


I  not  hesitate  to  have  recourse  to 


he  additi.mal  ..peratioin.     Tli'   ticliiii.|iie  of  all  these  o|)erations  will 
ideied  under  the  allied  coiiilitioii— stral>i.«mus 


)i8opboria 


As  ill 


the  cas<'  <'t'  ex.>iihoria,  tiiis  coiuliti.iii  .I(K's  not 


jlive  rise 
other  ..rr.iun. 
(•arsici<nes-  ; 
.li-tnrliancer 


to  .listinctive  symptoms.     I'liotophohia.  not  i^i'laine.'  on 

Is,  iilurriiiKof  the  juint."  pan.iraimi"  vertipo  and  naus<'a, 

-,  with  headache,  nervou.snes-.  aii.l  .iigestivo 

fcrre.!  I.i  it.     As  Han-ell  .in.l   U<'l)er  have 


lid 


seasicknes 
re  I  Hen  n 


is  the  ner^dUs 


pointi'd  out.  a  curious  symptom  ii.itice.l  i)y  esophoru 

irritation  pr.xluced  hy  the  patient's  seeinjj  his  iioi^e,  not  ..nly  v  hen 

r.'.idinii  or  writing,  hut  when  lookinji  in  the  .listani 


•1   I  ule, 


p.itients  ^u^■erillp  from  esop 
t.inis  lint  III  iiroliiiuivil  "-* 


ihori 


a  are  much  more  likel>  to  have  .syin|(- 
c/yc^  in  ijiuniii  nl  disiatd  nhjt'cl.^.  as, 


tor  exaini)le.  in  atten.litif;  the  theatn',  t'oiiiK  lo  church,  in  riiliiif:  on 
ilev.ite.l  trains  or  in  lookiiiK  out  of  the  win.low  of  a  nioviiift  car. 
A  small  amount  of  esophoriti  may  give  rise  in  susceptible  in.livi.luals 


sym|it.>m~  w 


hen  the  same  or  a  larger  amount  is  W( 


11 


hv 


)atieiit  with  a  stable  m 


■rvous  svstem  anil  good  iligesti.m.     The  neu- 


su 


tt'er  fr<  111  insoiiiiiia 


rotic  anil  the  neurasthenic— i)articularly  if  the; 
.ire  much  more  likely  to  complain  of  esophoria  pure  ami  simple 
1  ,11  the   healthv  individual,     hi^t  as  exoi)horia  is  coininoiiiy  asso- 


,ted  with  myopic  stat 


in'sciit  III  al 


)  w 


e  fin  1  esophoria  more  fre(|uently 


legrees  of  !iyp(i..pia  and  hyperopic  astigniatisn 


Treatment.     Kirs! 


■ill 


con 


•ectioii  of  anv  refractive  error 


uld  he  made,  ami     I  f-    i'.^sary,  gla.sses  (usually  convex 


shouid 


III'  worn  con 


<tanth 


Willie 


if   atropine    for   severa 


tl 
1    .lav 


lie    eves 


s   or   weeks. 


are  kept    under   the  influence 


At    tl 


le   saiiu'  time,  anv 


.^•ct  ill  the  general  health  should  l)e  renuMlied.     Tlii'  habits  of  the 
,tieiit  should  ha-.-  attei.tiim,  as  these  are  imi.ortant  in  dealing  with 

it  from  work,  can-ful  dieting, 


"]: 


form  of  heterophoria.     Tdiiics,  re 


change  o 


f  air.  will  often  help  to  effect  a  cun'.    In  the  writers  ex]ieri 


.'III'.' 


,  p-.isni  exerci.se  has 


t  that  value  which  it  pos.sesses  in  exoi 


ihoria. 


trea 


nervous 
hvoscvam 


t  it  should  he  prescribed  in  conjunction  with  the  foregoing 
the  etTect  of    soothing  the  irritated 


ti:      t.     Reni(><lies    having 


•em   are 
in  anv  o 


of  value,  and  of  these  the  most  important  is 
if  its  forms.  When  it  is  impossil)le  or  not  con- 
-,d.M.Mrde..^;rai.le  t."-  instil  atn.piiu-,  a  .single  drcp  '-.f  a  one-  or  t\«>-2rain 
M.lution  of  homatropine  should  be  dropiM'd  into  the  eye  an  hour  or 
two  b'fore  bedtime.    Cydoplegia  produced  by  this  agent  passe'^  off 


168 


THE  EYE. 


;'•:< 


(] 


befire  the  next  morning,  while  accommodative  quiet  is  reflected  In 
esophoric  relief.  Prisms  for  con&tant  wear  may  be  of  occasional 
value,  but  as  their  tendency  is  to  coddle  the  weak  muscle  or  muscles, 
instea!d  of  strengthening  them,  this  plan  ought  not  to  be  encouraged. 
As  a  means  of  bridging  over  a  temporary  (lifticulty,  or  to  allow  time 
for  improvement  of  the  patients  health,  their  use  may  be  justified, 
but  for  a  permanent  cure  they  are  inadmissible.  When  other  means 
fail,  a  market!  esophoria,  say,  of  10°,  for  the  distimce,  is  a  defect 
pn)per  for  operation.  As  the  operative  treatment  of  heterop!ioria  is 
practically  the  same  as  that  of  true  strabismus  and  other  forms  of 
heterophoria,  a  description  of  the  tenotomies  and  advancements 
proper  to  the  latter  condition  will  be  found  under  the  appropriate 
heading.  There  is  one  exception  to  this  statement,  in  that  jtartial 
tenotomy  and  partial  shortening  are  restricted,  by  those  sur^-eons  who 
employ  these  means,  to  heterophorics  ami  to  cases  exhibiting  minor 
ilegrees  of  heterotropia.  The  writer  has  occasionally  had  patients 
who  were  benefited  by  partial  operations  alone,  after  non-operative 
means  had  faithfully  been  tried. 

Partial  Tenotomy.  This  may  be  either  central  or  marginal,  the 
purpose  of  the  fonner  being  to  lessen  the  tension  of  the  muscle  operated 
on,  while  a  marginal  tenotomy  is  done  both  to  moderate  the  tension 
and  to  influence  the  action  of  the  nmscle  upon  the  rotation  of  the 
eyeball.    Savage'  thus  describes  the  two  operations: 

The  instruments  needed  are  the  same  as  those  nnjuired  in  doing 
the  complete  operation.  To  do  a  central,  partial  tenotomy  the  lids 
most  be  well  separated  by  the  speculum.  The  patient  .should  look  as 
far  as  possible  in  the  direction  opposite  the  muscle  to  be  operated 
on.  The  conjunctiva  over  the  insertion  of  the  tendon  should  be  lifted 
in  a  meridianal  fold  with  the  forceps,  and  this  should  be  snipped  with 
the  scissors.  Through  the  cut  in  the  conjunctiva  the  forceps  should 
be  made  to  grasp  the  capsule  of  Tenon,  which  in  turn  should  lie 
snipped  throvigh  the  ojiening  in  the  conjunctiva;  the  central 
fibres  of  the  tendon  should  then  be  grasped  with  the  forceps  and 
slightly  raised  from  th''  sclera,  so  that  they  may  b(  caught  with  the 
•scissors  between  the  forceps  and  th>"  attachment,  as  close  to  the  latter 
as  possible.  Thus  the  tendon  is  buttonholed.  If  the  ofx-rator  is 
certain,  from  the  resi.stance  he  feels  with  the  forceps,  that  he  is  not 
too  near  either  margin  of  the  tendon,  he  may  divide  a  few  more  fibres 
in  both  directions,  while  still  holding  the  tendons  with  the  forceps; 
but  in  doing  so  he  takes  some  risk  of  doing  too  much.  Now  the  for- 
ceps shouM  be  laid  down  for  the  small  (Stevens)  hook,  which  should  be 
passoil  through  the  buttonhole  in  the  tendon,  first  in  one  direction, 
then  in  the  other,  beneath  the  uncut  fibn>s,  so  as  to  determine  the 
resistance.  Guided  by  the  hook,  the  operator  now  divides  fibre  after 
fil>re  with  the  scissors,  until  the  lessened  resistance  warns  him  that 
he  hius  gone  far  enougli  in  that  direction;  he  then  repieats  this  step 


Prom  the  advance  sheeU  of  '■  Ophtbalmlc  MyoI(«y." 


MOTIOSS  OF  THE  EYEBALL  AND  THEIR  DERANGEMESTS.     169 

toward  the  other  margin,  in  the  same  careful  way.  To  get  the  full 
ftfect  of  a  partial  tenotomy,  the  capsule  of  Tenon  must  be  cut  coex- 
t('U-;ively  with  the  <livi.sion  of  the  tendon.  The  cut  in  the  conjunctiva 
m:iy  or  may  not  be  of  the  same  extent.  There  is  no  necessity  for 
inaking  either  a  very  small  or  a  very  large  conjunctival  incision;  but 
for  those  just  beginning,  a  large  conjunctival  incision  would  make  the 
t(>notomy  both  easier  and  safer.  In  a  marginal  tenotomy  the  initial 
cut  of  the  conjunctiva,  capsule,  and  tendon  Ls  made  as  for  a  central 
tenotomy,  care  being  exercisetl  that  the  buttonhole  in  the  tendon,  if 
not  in  the  centre,  shall  be  nearer  that  margin  which  is  to  be  com- 
pletely severed  later.  Still  holding  the  tendon  with  the  forceps,  the 
srissors  may  be  passed  in  the  direction  in  which  complete  divisioA  is 
indicated,  and  be  made  to  cut  all  the  fibres  at  once. 

Hyperphoria.  In  this  anomaly  there  Ls  a  tendency  of  one  Wsual 
line  to  project  itself  higher  or  lower  than  that  of  the  other.  Hyper- 
phoria i«  by  no  means  a  rare  condition,  and,  although  it  may  be  present 
to  a  marked  extent,  it  iloes  not  always  excite  symptoms,  particularly 
if  the  individual  possess  a  sound  nervous  system,  a  good  digestion, 
and  does  not  abuse  his  eyes.  The  principal  symptom,  not  only  in 
hyj)eri)horia,  but  to  a  greater  or  less  extent  in  all  the  muscular 
anomalies,  is,  in  the  writer's  experience,  sensitiveness  io  light.  In  the 
case  of  hyperphoria  we  find  also  the  usual  reflex  symptoms:  hj^per- 
icniia  of  the  lids  giving  rise  to  smarting,  burning,  and  a  sensation  of 
heat  in  the  eye;  confusion  of  images,  particularly  when  the  patient 
is  walking  along  a  crowded  street,  looking  out  of  the  window  of  a  car 
ill  motion,  ascending  in  an  elevator,  etc.  It  happens  not  infrequently 
that  hy|)erphoria  of  slight  degree  produces  more  ocular  and  other 

nervous;  symptoms  than  one  would  crpect.  Not  only  in  this  form 
"f  hot(>roph'»ria,  but  in  all  the  others,  the  sjTiiptoms  are  not  in  direct 
proportio'i  to  the  amount  of  the  defect;  indeed,  just  a«  it  is  impossible 
to  say  liow  much  hypermetropia  or  astigmatism  is  required  for  the 
Iii(KK:>ti')n  of  syniptoms  in  a  particular  individual,  so  is  it  difficult 
to  iiidicate  the  amount  or  kincl  of  annoyance  likely  to  accompany  a 
irivfii  amount  of  hyperphoria  '"i  a  certain  patient.  This  defect  gives 
rise,  not  only  t<i  what  liennett  has  termed  "panorama"  symptoms 

-as  shown  by  headaches,  vertigo,  and  occasionally  vertical  diplopia— 
liMi  also  evidences  of  ne^^•ous  irritation  on  attempting  to  use  the  eyes 
I'll-  long-continued  near  work  are  rarely  absent.  These  are,  in  par- 
lif'iilar,  dizziness,  ocular  pain,  and  photophobia.  The  patient  is 
.'ivcii  to  .stiuinting  his  eyes  during  both  near  and  distant  fixation; 
!uiro-.vs  or  ridges  may  be  usually  detected  alM)ve  one  or  both  eye- 
liriiws.  or  the  eyes  may  present  a  st.,.i.ig  appearance,  or  there  may 
-'  (111  to  he  an  apparent  ptosis  of  oni  lid,  with  a  wide-open  condition 

I  the  other.  This  peculiar  wrinkling  of  the  brow  is  .seen  in  its  exag- 
,(iatcd  form  in  true  oculomuscular  paresis,  but  its  meaning  is  the 

itm   in  hyix-ri)horia.    Thf  head,  also,  is  verj'  often  carried  with  a 

iU  away  from  the  hyperphoric  eye.    If  the  vertical  defect  be  not 


(> 


I 


170 


tup:  eye. 


PKces^iv.".  this  parriasc  of  the  luvul  nuty  h.'  sutf.ci.M.t  to  ..vom.mo 

.h..  wliolo  of  th..  l.viu.rphona.  un.l  it  is  a  oomn.on  ^YT^'Z  ^1 

any  lu-iMTl.h..nc.s    .hvsi.-ally  vv.ll  .lev.>lo,,.Ml  succh-I  ,h.nng  tia  r 

Xiv  om.,.ati...J  in  ..l.taiuinfi  <-o.ufort  by  thus  ,..utrai./.ng  all, 

r  ^  r  V  all.  of  an  ..tlu-rwis.  intoK-ral-l.  l.y,K.r,.hona.     Lxophorm   s 

^m-    n' ,,-.  tlv  a.-ociat..a  with  hyiH-rphoria,  ami   as  S  .vons  ,H.u,ts 

ou?    onv  tio.i  of  the  on.-  n.ay  issue  in  cure  ..f  the  other.     I.ulm 

the  writer  is  eonvinee.!.  fro.n  an  exan.inat.on  of  a  larg.-  nun.be      f 

IJ'  ases,  .hat  hvperex..phoria  a.ul  hyix-resophoru.  -re  often    esult« 

.,n  ...te.iDt  on  the  part  of  the  lateral  muscles  to  relu  .-e  Mie  \er- 

th-:^  .Sn     -rhis  point  shouhl  always  l.  .leci.:..li.et..re  a.| 

!.^,t    M,  t  is  nuule  to  correct  either  anon.aly.     Both  -supraduct.on  and 

;;i;;:;iuction.  as  wen  as  abduction  and  -|''--»'"";^'>;;;  '  ,^;:;f  "i^ 
measured  with  an.l  without  correctn.g-gla.s.«es  .  the  lateral  d  vm 
;.„.  are  found  to  be  in  nornml  relat.on  t..  one  another  an.l  the 
v'.'Iical  ex.-ursiuns  are  abnonnal,  ..ne  n.ty  conclu.le  that  the  case  is 
csseutiallv  one  of  hvix'rphoria.  i  »  i  ... 
Tests  for  Hyperphoka.  Th.-se  have  aln-a.ly  be.M.  referred  to  bu 
it  is  well  t..  sav.  in  .i.l.lition.  that  sin.-  sn.all  .l.-gnH-s-.i  this  .lefoct 
•m-'of  greater  inip..rtance  than  minor  am..unts  of  .>xoi)horia  or  eso- 
'phoria,  care  shoul.l  be  .-x.-n-is.-d  in  .-liciting  its  pr<>s.>nce  or  abpice. 
Tl  ,'  mrallax  or  the  scr.H-n  test  will  be  h.un.l  of  i.art.cular  vahu-  m 
the  .iVt.'ction  of  this  an..maly.  A.-c.rding  t..  Duan.-.  .•ynstant  prac- 
tice will  .-nabl.'  on.,  to  d.'t.rt  as  little  as  a  .[Uart.M-  ot  a  d.-gr i 

''■'Treitmlnt.'     First  ..f  all.  tlu-n-  sioul.l  be  a  tlu.r.mgh  .•..rr.-ction. 
nnd,>r  a  cvclopl.-gi-  (wh.-n  that  is  n.H-ossary).  ..f  al'r..fract. v.- errors. 
Thi<  willbe  fomid  suth'-ient,  in  many  cas."s,  t..  make  th.   pati.-nt  so 
,.„,nfortabl.-  that  further  interfen-r..'.-,  for  the  tnn.-  at  l.-ast.  is  uncalle. 
fur      If  r.,„T.M-ting  leiu.'s  are  foun.l  to  b.-  insuHicu'i.t,  prisms  shoul.l 
1„.  worn.     It  must  bo  .•.mtVsse.l  that  it  is  not  ..a.-<y  in  th.'  hrst  instance 
to  <,v  what  proi)<)rti.)n  ..f  the  .l.>viati..n  sh..ul.l  !..•  irpivsent...!  by 
„ri<!n'<       V-^  a  rule,  most  pati.'Uts  will  not  tolerat.'  moi.-  than  oi.>-hall 
,|„.  full  .-orn-ction,  divi.l.-.l  betw-.-n  the  tw..  eyes.     Tl..-  writer  .s  exp<- 
rien->  is  that  it  is  b.-st  to  ..rd.T  the  prism  .M.mp.um.h'.l  with  the  cor- 
ivcting  glass,  an.l  lu-  d...'s  not  Hn.l  that  fn.nts  ar.;  comfortably  worn 
It  i.  bett.T  t..  have  tw..  pairs  of  glass.-s  if  it  i>  d.>ci.l.>d  tu  use  different 
I.ri^-matic  -tn-ngths  for  distant  and  n.-ar  w..rk.     Th.-  iH.w.-r  ot  mfra- 
,|u.ti,.n  and  sui).aducti..n.  as  n..-a.sure.l  from  tmi<-  to  Urn.-,  shoul. 
,!,.cid.-  wh..th.'r  tl...  i.risms  thus  constantly  w..m  are  t..  ae  docrea.so. 
,„   in.-r.'is,.,l.     Th.'  constant  w.v.ring  of  prisms  is  ..f  greater  iH-neht 
an.l  mon-  justitiable  in  hyperphoric  .-on.litions  than  m  t iios.'  of  .-so- 
l.l.oiia  or  ..x.mhoria.  an.l  th.-y  often  pr...iu<'.'  brilliant  r.'sults.     rviyag.' 
;„lvis,.s  ..x..rcise  with  vertical  prisms,  aft."  the  mann.-r  sugg.'st...l  for 
prism-training   in   weak-'iu'd   .■onv.-rg.-nce   an.l   .liv.-rgence.   but    the 
ri'sults  ar."  not  satisfactory. 
The  sam.'  rul("s  a|.i.iy  in  tlu-  ..p.'rativ.'  treatm.'nt  ..f  liyiH'rphoria 


MOTIuyS  OF  THE  EYEBAIL  AXD  TUEIR  DEBAyOEMESTS.     n\ 


that  wore  lai'l  down  for  esophoria  and  exophoria.  After  all  otlur 
|.l;ins  (correction  of  ametropia,  attention  to  general  health,  etc.) 
liMve  failed,  tenotomy  of  the  overstrong,  or  rather  overworked, 
muscle  is  indicated.  Can-  should  Ih-  ol)s<'r%'ed  not  to  o[M'nite  in  pan-tic 
cases.  When  in  doubt  the  tropoineter  or  any  of  the  other  means  of 
tncasuring  tiie  rotating  [jower  of  the  individual  nm>cles  will  lie  found 
of  great  value,  it  is  not  always  easy  (owing  to  the  si'condary  con- 
tractions following  even  a  slight  paresis  of  a  vertical  nni.scle)  to  decide 
whether  we  have  to  deal  with  a  non-paretic  hy{)er])horia  or  not. 
When  the  latter  is  constant  in  amount,  and  Ls  found  to  be  due  to 
insuHicient  powei  of  one  of  the  vertical  mu.sclps,  the  proper  procedure 
is  an  advancement  or  a  mu.scl"-shortening:  where  the  defect  is  due 
til  overaction,  tenotomy  is  indicated.  If  there  he  a  field  for  partial 
tenotomies,  it  is  in  low  degrees  of  hypen'^i'Tia  due  to  overaction  of 
■1  particular  muscle.  But  the  sjime  objection  to  the  tenotomy  of  a 
muscle  is  as  pertinent  in  hyperjjhoria 
MS  in  other  muscular  anomalies;  it  is 
always  Ix'tter  to  strengthen  a  weak 
muscl'>  than  to  weaken  a  strong  one, 
i\cn  when  balance  of  all  the  muscles 
is  the  ()bj(>ct  sought. 

Cyclophoria.  This  is  an  uisuifi- 
rjrncv  of  the  oblii|ue  muscles,  .ir  a 
'Irfcci  (if  til  normal  torsion  or  wheel- 
iiMilion,  which  occurs  when  the  ob- 
liiiuc  muscles  es]K"cially  are  called 
iiiii)  action,  we  are  indebted  for 
iiiiist  that  we  know  of  this  subject  to 
S.ivage.     He  attributes  a  muiiber  of 

-\!iilitcin'.s  (commoM  in  .ametropia  and  other  forms  of  heter(ii)hor'a) 
i'>  this  condition.  It  may  be  detected  by  co\  Ting  (iiie  eye  and 
placing  over  the  otii  "r  a  Madtlox  double  pn.-m. 

Tlie  patient  fixes  a  horizontal  line  drawn  <;n  a  white  card  eighteen 
isirhes  from  his  face.  He  sees  two  lines.  The  second  eye,  the 
HI'  being  tested,  is  now  unco'-eivd  and  a  third  line  will  be  seen  ha!f- 
vay  between  and  |)arallel  to  the  others,  if  all  the  niiiscles  are  properly 
■alanced.  In  imbalance  of  the  oblicpie  mu.scles  the  central  line  is 
'lied,  in  n'ialioM  to  the  others,  cither  up  or  ilowii.  If  the  middle  lire 
"■  nearer  the  bottom  than  the  top  line,  or  riir  nrs<i.  there  i>  a  hyp(  r- 
!;'>ria:  <ir.  if  the  middle  line  extend  more  to  the  right  or  to  the  left, 
'"luction  or  ;idduction  is  at  fault. 

Treatment.  Hhythmic  exercise  of  the  insufficient  obliin'.e  muscles 
iicdniplislied  by  the  method  of  ."^aNage.  This  consists  of  the  rota- 
■II  ot  convex  or  concave  cylinders  before  the  eves  of  the  patient 
li".  meantime,  looks  at  a  distant  candle  flamiv  \\'e  have  had  .so 
Mje  experience  of  the  results  of  o|K'rations  upon  the  obliiiues  for  the 
lief  ipf  cyclophoria,  that  it  can  only  be  .said  that  the  matter  is  .still 
'I I  inilirc. 


Maddox  double  prhm.    a.  Front  view , 
6    Sectional  view. 


172 


TIIK  EYE. 


Strabismus.  Squint.  Heterotropia.'  In  this  cnmhtion  the  vL.ual 
■xxo.  an-  so  .lirect.-l  that  tho  hnago  ..f  tlu-  ..hj.>ct  .loos  not  fall  ui^n 
th..  fov.-a  of  1.0th  CVS  at  the  sa.no  tnno.  Th.;n>  ,s  an  al.sence  of  bin- 
ocular vision,  although  tlu-  rotating  powor  ot  the  uulivulual  nuiscles 
is  not  to  anv  great  extent  iinpaire<i 

Internal  or  Convergent  Strabismus.  ("'•Ny^-«''^-^7  ,^f '^ij,  j'^""; 
TKdiM  V  The  visual  axis  of  one  eye  is  directed  toward  that  of  its  fellow , 
so  that  the  image  falls  uix.n  some  portion  of  the  retina  m  the  deviating 
or  s.,ui.iting  eve  outsi.le  th-  f.m>a.  Convergent  strabismus  may  be 
n.on'eular  or"  constant,  binocular  or  alternating.  In  the  former 
.ase  one  .v."  is  c.mstantly  us<h1  for  purp..ses  of  hxati^.n.  vdule  the 
secolul  eve  turns  in.  In  the  s<'cond  ca.se  either  eye  is  used  indiffer- 
entlv  for  fixation,  and  the  opposite  eye  S(iuints. 

There  is  pricticallv  no  definite  line  of  demarcation  between  .sciumt 
and  heterophoria.  Some  f<.rms  of  heterophoria  may  represent  an 
(.■iriv  <:m^  of  strabismus,  or  the  same  inu-scular  imbalance  may  at  one 
time  be  properly  called  .s.,uint,  and  at  another  time  a  mere  insufh- 

ciciicv  of  the  muscles.  ,     •    .1        •  •         t 

Monocular  Squint  or  Coustant  Squint.  Not  only  is  the  vision  of 
the  strabisnic  eve  def.n-tive.  but  ihe  amblyopia  generally  dees  not 
orrespo.id  to  aiiv  ophthalmoscopic  .lefect,  although  the  visua  held 
tVe(|u.'nllv  is  c.n'tracted.  The  error  of  refraction  of  the  amblyopic 
j.  often  much  tli.'  same  as  that  of  the  fixing  eye,  so  that  the  ametropia 
alone  cannot  account  for  the  lowered  visual  acuity.  Probably  there 
i<  a  true  nmhhiniiia  ex  oitopsin:  although  in  the  majority  of  cases  the 
vision  of  the  non-fixing  eve  is  not  to  any  extent  improved  '>y  correc- 
tion of  the  refractive  error  and  cure  of  the  squint.  Whatever  be  the 
ori.'in  of  tlie  d.-f.'et  in  sight,  it  is  probably  the  main  cause  of  the 
het'^Totropia.  Without  discussing  the  various  theories  from  time  to 
lime  put  forward  to  explain  s<iuinting  eyes,  one  may  say  that  the 
brain  centres  hav.-  a  disUke  for  th<'  vision  that  results  from  an  eye 
that  sc.-  plainlv  and  one  that  h<m's  indistinctly,  and  that  in  the  effort 
to  rid  the  nervims  sv-teni  of  this  source  of  irritation  Ihe  defective  eye 

j.;  tinned  in  the  directi md  kept  in  the  jxisition  easiest  to  obtain 

•iii.l  maintain  If.  however,  we  are  enabled  by  any  m.-ans  to  improve 
the  vision  of  the  s.juintiiig  eye,  we  to  the  s.-une  extent  remove  the 
ubjectior.  on  the  part  <.f  the  nervous  sy>i<'ni  to  eyes  of  unecpial  vision. 
If  in  addition  to  this  d.-sirable  result,  there  goes  a  restoration  to 
parall<-lisHi  of  the  visual  axes,  we  may  obtain  not  (mly  binocular  .sight, 
bul  also  (  .inii'ortalde  vision  with  both  eyes. 

Diagnosis.  In>pection  of  the  eyes  will  generally  show  an  abnormal 
direction  of  the  visual  axes,  aiul  the  sclera  wili  be  found  more  exjiosed 
in  one  s<'gment  than  in  the  corresixinding  portion  of  the  opposite  eye 
The  eorn.-a  will,  in  most  ca-^es,  be  seen  to  be  dcfh'cted  toward  tlu' 


1  snme  H.nhnrliK*  pMVr  the  cxi.n.«.lo.i  Mrrni,„i,ia  for  »11  f..rm...f  lMil«l«n<«  of  the  mawl.- 
in  »lil.h  liliLKiiUr  (Ixation  Is  lo»t.  discarrtliiK  the  tirins  •  slrablnmu.,"  "  p«ralylio  squint,  etc 
DniiliiU'w,  In  linu'.  Shi"  niiinTOCltttMri-  will  prevHii 


MOTIOSH  OF  THE  EYEBALL  AND  THEIR  DERASGEMEXTS.     173 


Fia.  8». 


iioso.     This  apparent  deviation  of  the  visual  axes  is  noi  always  to  be 
relied  upon;   the  angle  alpha  may  be  abnormally  small,  so  that 
although  there  is  no  muscular  imbalance,  there  is  an  ap|)arent  eso- 
tropia.  The  best  means  of  diagnosis  in  cases  of  doubt  is  the  cover  test. 
If  the  fixing  eye  \yi?  excluded  by  a  screen,  the  cornea  of  the  deviating 
I  ye  will  be  seen  to  make  an  excursion  outward.     The  eye  that  Ix'fore 
turned  toward  the  nose,  now  attempts  to  fix,  and  in  doing  so  the  cornea 
is  rotated  so  that  the  rays  of  light  may  pass  through  ami  fall  upon 
the  foveal  region.     Owing  to  the  high  grade  of  aniblyfi|)ia  in  some 
eyes,  it  is  not  easy  to  measure  the  amount  of  scjuint  with  j)risms,  and 
for  the  same  reason  the  use  of  the 
double  images  of  a  diplopia  in  the 
various  phorometei*s  usually  fails 
to  furnish  any  information.     The 
false  initi()e  is  .sH/j/wc.s.ved  ■•'n  nwst 
ruses  (if  coHverijent  and  other  forms 
of  siiuinl.    The  amount  of  exces- 
sive convergence  in  sfjuint  may, 
accoriling  to  the  method  of  Lan- 
(liilt,be  measured  on  the  perimeter. 
The  patient  fixes  with  the  better 
lye  while  a  eand  e  is  carried  along 
I  lie  arm  of  the  perimeter  until  its 
ii'flection  is  sei'U  by  the  obser\'er 
fruni  the  centre  of  the  pupillary 
.Ilea  of  the  opposite  cornea.     The 
angle  thus  subtenile<l  is  read  off  on 
I  he  arc  of  the  jierimeter.  (Fig.  89.) 
Treatment.     Since   convergent 
-tnihismus    usually    is  a.ssociated 
with,  and  is  by  some  said  to  de- 
pend in  most  cases  ujkju  the  |)res- 
'■nceof  hyiM'rmetroi)ia  fas  an  indi- 
rect lesult  of  abnormal  accommo- 
l.ilive  etTort,  we  have  increased  attempts  at  convergence),  paralyzing 
ilie  accunnnodation  with  an  effective  cyeloplegic,  like  atrc.jiine,  is  in- 
licated.    M  first  the  s(|uint  is  usually  relieved,  or  it  may  not  undergo 
Miy  sensible  dimimition  for  some  days  or  weeks.     When  the  patient's 
■iiiiiiiiiiodation  is  thus  thoroughly  paralyzed,  a  full  correction  of  the 
■  yperopic   error   should    lie    ordered    and    worn    constantly.      The 
lect  of  glasses  may  Ik*  much  increa.sed  by  the  continued  u.«e  of 
tropine.     Th,'  writer's  plan  is  to  instil  a  single  drop  of  a  1  per  cent. 
"luliun  of  atropine  sulphate  into  each  eye  after  breakfast:  this  is 
'iitimied  for  two  weeks  after  the  glas.ses  liave  been  ordered.     The 
Miopiegic  is  then  stopix-d  for  two  weeks,  or  until  the  patient's  pupils 
'■f  no  longer  <|i'ated.     If  the  glii.s.ses  are  not  fully  accepted,  or  if 
iTc  IS  no  impn)vement  in  the  stpiint,  the  atropine  cydoplegia  is 


Meuurement  of  squint  with  a  perimeter. 

(Lanijoi.t.) 


174 


TJIJC  EYE. 


ciitinucl  for  anotlicr  fortiiinl.t.  and  so  on  altcrnutoly  every  fort- 
nijilit  fur  from  tlinr  to  six  months,  durmp  winch  tnn«>  additional 
attempts  sliouiil  l)e  made  to  I'ducate  th<'  faculty  ol  tusion  and  to 
promote  binocular  vision  l)oth  for  distance  and  near.  One  ol  the 
iM'st  nieaus  of  accomplishinj;  these  hnportant  results  is  the  use  ot  the 
Mcreusrnnr,  usinfi  with  it.  for  example,  the  pictures  ol  Kroll.  Ihe 
meth(.d  (.f  Landoit,  in  which  lh.>  vision  of  the  better  eye  is  dulled, 
.so  that  it  more  cl..selv  ai)proacli.'S  that  of  the  s<iumtmn  eye,  i.s  t he 
one  pref.'rred  bv  the  writer,  and,  alliioufjh  much  patience  will  be 
reiuiired  bi.tli  on  the  part  of  the  surj^eon  and  of  the  dnld.  fjood  results 
are  often  obtainabh'  by  the  use  of  this  simple  histrument.  As  con- 
ver'-eat  strabismus  usually  sets  in  during  childhoo.l,  several  tpies- 
tions  arise  in  connection  with  this  fact.  In  the  hrst  place,  how  early 
shall  weattem|)t  medication?  The  answer  is  that  atro|»ine  .sliouhl  1h> 
used  as  soon  as  the  S(inint  apix'ars  and  attemi.is  at  monocular  fixa- 
tion an'  made.  The  writer  has  fre(iuently  bejiun  to  triMt  a  conver- 
fjeiit  strabisiims  in  children  two  years  of  ape,  and  has  had  them  wearinj; 
glasses  with  benefit  Ix'foro  they  were  thire  years  old.  If  we  shouhl 
fail  in  obtaining  paralleli.sni  of  the  eye,  or  should  so  far  succeed  in 

our  efforts  ;is  to  convert  the  monocular  s'luint  into )l  occasional 

<-sotiopia,  an  operation  should  l)e  done— the  (>aiiier  the  better.  In 
monocular  squint  that  h:us  defie.l  milder  measures,  advancement  of 
the  (>xteriius  with  tenotomy  of  the  internal  rectus  is  the  o|H'ration 
that  will  gent>rallv  be  recjuired  and  that  will  usually  be  successful. 
( )ne  often  finds  ainipward  (U'viation  combined  with  the  inward  s(piint. 
and  it  is  usually  necassary  in  such  case.s  to  tenotomize  also  the  superior 
rectus  of  the  .s(iuinting  eye. 

Alternating  Convergent  Strabismus.  In  this  form  of  convergent 
stiuint  th(>  nerve  centres  .seem  indifferent  as  to  whether  vision  is  con- 
ducted by  one  eye  or  the  other;  sometimes  one  eye  fixes  and  the 
other  .s<iiiints:  sometimes  the  hitherto  scpiinting  eye  sees,  while  the 
fellow  eye  turns  in.  \ision  is  usually  about  the  same  in  each  eye. 
and  it  is  usually  easier  to  restore  binocular  vision  than  in  constant 
s(|uiiit.  It  is  sometimes  dilficult  to  explain  tlie  origin  of  alter- 
nating strabismus,  especially  examples  of  it  where  the-r  seems 
to  be^an  objection  on  the  part  of  the  cerebral  centres  to  binocular 
fusiim.  One  mav  at  least  postulate  a  congenital  defi'ct  of  co-ordina- 
tion in  the  fusioii  centres.  These  patients  invariably  have  a  hyper- 
metropia  of  mon-  than  1  IX,  and  we  may  ass-nne  that  the  incentive 
to  accommoilalive  <"ffort  and  the  .•ibiiormal  us(>  of  the  convergence 
have  something  to  do  with  the  scpiint. 

Diagnosis.  This  is  practically  the  same  as  for  the  constant  form. 
It  is  easier,  however,  to  induce  dii)lopia  with  prisms  or  otherwise, 
and  so  n-cogni/.i>  thi<  relation  of  the  fals(«  to  the  true  image.  This  is. 
of  course,  much  more  dillicult  in  children,  but  with  a  little  coaxing 
and  the  exercise  of  p.atience,  it  can  often  be  demonstrate(|.  Hyper- 
esotropia  is  a  coimnon  variety  of  alternating  .s<iuint,  ju.st  as  it  is  m 


MOTWSa  or  THE  EYEBALL  ASD  TllEtll  DEHAXdEMESTS.     17-) 

the  constant  form,  and  in  the  imx-cdun's  undertaken  for  its  pure  this 
lunu  of  the  defect  should  not  !)<>  overlooked.  The  tr  'atnient  of  alter- 
nating esotropia  is  practically  that  of  the  constant  variety,  and, 
although  the  writer  does  not  entertain  the  enthusiastic  ojunion  coin- 
iiionly  held  as  to  the  higii  |)rop.>rtion  of  cures  in  l)inoeular  strabis- 
mus convergens,  then-  is  no  doubt  that  j)arallelisni  and  binocular 
fusion  nioH'  fnHjuently  result  from  juiUcious  treatment  than  they  do 
in  the  constant  form. 

External  or  Divergent  Squint;  Divergent  Strabismus;  Ezotropia. 
This  is  the  antipodes  of  esotropia,  and  is  usually  a.s,sociated  with 
myopic  eyes.  It  is  an  ac<iuired  condition,  often  dependent  u|M)n  tlie 
same  causes  tliat  brin>?  about  myopia,  such  as  asymmetrical  orbits, 
lonft-eontinueil  near  work,  insutiiciency  of  the  internal  recti,  etc. 
The  etiolopy  of  many  cases  is  t)b.scure,  but  the  lessi'iied  demand  on 
;ii'((>mmodation  ami  convergence,  and  tlie  consecpieiit  relaxation  of 
the  interni  nm.sdes  that  accompanies  the  ac(|uisition  of  axial  myopia, 
,ire  largely  respcjusible  for  them.  The  eye  turns  out  constantly  in 
the  monocular  form,  and  alternales  in  this  position  with  the  fellow 
eye  in  binocular  exotropia.  Proi)ably  the  diseas«'  Ix-gins  with  a  ten- 
dency to  <l«'viation  (exophoria)  and  emls  in  a  true  exotropia.  For 
tills  reason  divergent  S(|uint  is  rarely  se<ni  in  children,  but  is  an  anom- 
aly of  adolescence.  The  tendency  of  myopic  eyes  toward  divergence 
is  |)artly  due  to  tiie  enlargement  and  comsecjuent  elongation  of  the 
1  yeball,  rthich  ad<ls  to  the  weakness  of  the  adducting  muscles.  This 
train  of  causes,  with  the  decreasing  convergent  i)ower,  brings  about 
a  true  divergence.  Small  degrei -i  of  <!ivergence  are  readily  detected 
l>y  the  cover  test,  while  a  high  degree  i.s  re.;dily  seen  on  insjiection. 
Occasionally  the  si|uinting  eye  in  constant  exotropia  is  amblyopic, 
Imt  the  deviation  itself  rarely  sets  up  symptoms,  because  the  image 
if  the  divergent  eye  is  suppressed  and  diplopia  is  not  a  sy.mptom. 

Treatment.  The  optical  treatment  of  divergent  strabismus  con- 
-ists  chiefly  in  the  correction  of  the  accompanying  myopia,  with  or 
svitliout  the  ])rescri|)tion  of  prisms.  As  full  a  correction  of  the  myopia 
I-  liie  patient  will  tolerate  .should  Ix'  given,  and  the  accommodation 
-hdiild  be  further  stimulated  by  instilling  a  weak  solution  of  pikicar- 

iiie  into  each  eye  three  times  a  day.     If  the  exotropia  be  associated 

ilh  hypennetn  1'  I,  the  latter  shoulil  either  not  Ix- corrected  at  all,  or 

'ii'  we.ikest  workiiig-gla-ss  should  Im-  u.^sed.    In  this  way  ()n<'  may  hojK' 

•  ■  ixcite  the  action  of  the  ciliary  muscle    and  amuse  a  concomitant 

nnuiation  of  the  adductor  mu.sdes,  and  thus  lessen  the  divergence. 
luw  degrees  of  exotropia,  or  in  those  cases  where  the  af;iremen- 

'iied  treatment  is  successful  in  converting  the  <>xotropia  into  an 

■■;ili<)ria,  prism  and  stereoscope  training  sli<iuld  be  iriiide  use  of. 
\fter   a    fair    trial    has    Im-cii    given    these    remedies,    and    par.'il- 

'i-in  or  binocular  tixa'ion  is  not  attaineil,  u|H'rative  measures  are 
I'd  for.  The  remaining  deviation  shouKl  be  overcotii-  by  ;idvance- 
iit  of  till'  internal  rectus  of  one  or  both  eves,  not  forg«'tting  the 


176 


Tim  EYE. 


|i  ! 


vertical  deviations  that  soinetimps  accoiiipiiiiy  this  form  of  wiuiiit. 
Whfii  the  patient  has  onco  possessed  the  ik)W.t  ol  l.ii.oruhir  v.si,.i. 
the  oiH'rative  tn-atnient  is  n.ucih  more  likely  to  Ik-  successful,  although 
aperi.Mlof  stereoscop..  training  may  properly  occupy  several  montlis 
both  before  and  after  oi)eration. 

Hypertropia.      \ertical  deviation  iimountmn  to  sciumf  is  u>uaU\ 
associated,  as  has  b«M.n  mentioned,  with   ex<.phona  or  .snj.horia:  in 
anv  event  it  n.av  l)e  tt-garded  as  a  late  sta^.  or  exagp'rated  forn.  o 
hvix-rplioria.     Viany  i.atients   exhibit    a   deviation    in    the   vertical 
hue  which  mav  at  one  moment  present  a  liyi)erpli<.na  and  at  anothe.  a 
hvpertropia.  "As  long  as  th.'  patients  fusion  iK.wer  is  sutficieni  a 
aiiv   tune   to  brhig  about   bhiocular   vision,   the   former  condition 
obtains;  the  moment  this  fails  one  eye  turns  up.  and  we  have  a  ver- 
tical s(iuint.     What  has  been  said  cf  hypoi.horia  is  largely  true  ol 
hvwitronia,  both  as  to  causation  and  •reatment.  _ 

Anaphoria,  Anatropia.     Oataphoiia.   Oatatropia.     ht.  ..us   wa-s 
the  first  to  describe  a  class  of  ca.ses  in  which  l)oth  visual  ax.-s  deviate 
either  above  or  b,-l.,w  th.>  horizontal  plane.     If  the  condition  be  pn^ 
nouncMl  and  re.,uirv  careful  te.sting  to  prove  its  exist.'iice.  he  desig- 
nates the  anomalv  mmphnrin,  when  there  is  a  deviation  ot  both  axes 
UDward.  or  mUiphma  in  deviation  of  both  ax.^  downward.     If  the 
uiibalance  Ih'  more  mark.-d.  we  have  an  anatropia,  or  a  catatroj.ia 
Wlnteser  be  th<'  nature  of  tliis  unusual  condition,  it  is  .liscover.>d 
bv  means  of  the  .screen  or  cov.t  test.     In  anatropia  the  right  eye 
turns  ui)  behind  the  scn-en.  while  the  left  eye  fixes,  th<-  left  ey.-  rotating 
UDWird   and  not  .lownward  iis  in  hyi)ertropia,  the  moment  the  cover 
is  transferred  to  the  other  eve.    In  catatropia  a  downward  excursion  is 
noted  inboth  eves  with  thec.ner  test.    Stevens  attnluites  a  numlH-rof 
evil  conse.iuences  to  these  coiiditions.which  he  remove^  bv  ..|.«"ration. 
Paralysis  of  the  Eye  Muscles.    .Mthough  for  the  purpose  ot  mves- 
ticution  it  is  desirable  to  .-on-^idei  lh.>  -ular  palsies  apart  Inim  b(  tero- 
iroi.ia  and  the  various  forms  of  s<iuint,  it  is  often  .lithcult  t=.  ditleren- 
ti-itc  <me   from   th  ■   otlKr.     .lust    where    f-inctional   weakness  of    a 
muscle   emls   and   paretic   insufficiency    In-gins   is,    uiK>n    occasions 
impossible  t.  ^  demon.strate.     Muscular  paralysis  may  lie  of  mtr:;.  ranial 
or  orbital  origin:  in  .)ther  wor.ls,  tlie  nerves  and  nerve  centres  upon 
which  th.'ir  function  depends  may  be  attacke<l  in  the  cortex  (cortic:i, 
nirilv^'-t    hi  both  cortex  and  nuclei  (cortico-nuclear).  in  the  nuclei 
aione  (nuclear),  within  the  cranium  and  along  the  p."riphery  icranio- 
periph(M-ai),  or  within  th-  orbit  (orbital).     The  c.-ntral  causes  (>f  these 
ormnic  lesions  are  conrnonly  constitutional,  especially  lues,  rheum:.- 
tisMU  and  tulKTculosis.    Thev  are  often  associated  with  talx-s,  paralysi> 
of  th.'  insane,  brain  tuin.)rs,basil;ir  m.-ningitis,an.l  .ith.-r  proc."s.ses  m 
herent  in  the  vari.)us  forms  .if  intoxieaiion    Uiberculosis,  diphtheria, 
hvsfria,  nei.hritis,  diabetes,  din-ei  anu  ii.dir.-.-t  iniury,  <>tc.   /"/<;"- 
genital  paralysis,  /</<»>-•/.-  is  th.'  most  .oiaiuon  sign,  while  paresis  .>!  tn.' 
e.xternal  rectus  alon."  is  frciuently  ^'ncountered. 


MoTIoyS  OF  THE  EYEUAl.L  A.\D  TIIEIR  DERASUE3tEyTS.     m 

gymptonu.     ( )cu!ar  paralysis  sets  in  without  warning,  I'.ulcss  it  be 
hcii'lachc,  or  ilv,'  syiiiptoias  of  disease  (r^enerally  of  the  nervous  sys- 
tem), or  liauinatisni  with  wliieh  it  is  so  often  ass«(eiate»l.     Double 
lisio'n  if  usually  the  first  indieation  the  i>atient  has  of  an  attaek. 
It  is  extf^inely  annoying,  particularly  if  it  \v'  ohli(iue  or  vertical.    The 
iliplopia  persists  (luring  the  attaek,  and  is  often  iussoeiated  with  ier//;/o. 
,iiiii.-<e(i,  iKrnsioiKil  vnmitiiKj,  mintul  nmju^wn,  uncertain  yait.  and  a 
,v,  H.vr  of  insf.uritjj  while  walking  alM»ut.    The  eve  under  the  iiifluenee 
uf  pan-lie  niu-eles  do«"s  not  see  objects  in  their  proper  (wsition,  and 
to  tills  jnlse  proki-lion  are  due  the  uncertainty  in  walking  and  grasping 
lijects  anil  other  disagreeable  eonse(|ueiices  of  the  jjaralysis.     The 
iiMial  innervation  effort  put  forth  to  assist  the  disabled  eye  to  Hx  is 
till"  source  of  the  error.     It  was  employed  by  Craefe  under  the  name 
■  luuch  test"  in  testing  for  the  |)aralyzed  m-Lvles.    The  patient  covers 
ilir  sound  eve  with  one  hand  and  with  hv."  forefinger  enileavii:-s  (luiekly 
to  touch  the  tip  of  u  l)eneil  held  In-fore  him  with  the  other.     He  will 
direct  the  fiiigiT  tip  to  the  side  of  the  pencil  corresponding  'i  the 
paralyzed  muscle.     In  time,  however,  the  jjatient   learns  Dy  expe- 
lienee  to  make  allowance  for  this  error,  and  for  him  the  test  is  value- 
less.    After  a  time  the  patient  learns  to  close  one  eve,  so  as  U:  s'mt 
uiit  the  confusing  second  image;  or  if  i>tosis  set  in,  the  same   •'■>    < 
served.     Ilventuallv,  also,  the  head  is  turned  toward  tlu  side  (,:      • 
paralyze.!  muscle  (iipward  in  elevator,  downward  in  d<t)ri<s„r  m-    ■> 
p,iralysis),as  this  action  corn-cts  or  at  least  duiiini.shes  the  double 
vision.     These  unnatural  [Misitions  of  the  head  as.>*i.st  the  surgeon  in 
making  a  diagnosis,  although  it  shouUl  not  Im>  forgotten  that  .similar 
poses  are  seen  in  heterojthoria  and  in  some  other  forms  of  hetero- 

Diasnosis.     When  a  single  muscle  in  one  eye  is  recently  paralyzed, 
it  is  easy  from  the  svmptoms  and  by  in.spection  to  say  at  once  where 
till' t rouble  lies.     Mon"  frr'iuentlv,  however,  a  careful  insiM'ctimi  of  all 
\hv  excursions  of  both  glolies  is  neces.sary  before  a  correct  diagnosi.s 
1-  ,i.  he  made      In  anv  event  the  i)atient  should  be  placed  with  his  head 
ill  tile  i)rimarv  position  and  asked  to  follow,  first  with  each  eye  sepa- 
i:i!elv  and   tlien  with  both  together,  the  poiiii  of  a  pencil  while  it  is 
.MvriiMl  in  various  .lirections  in  front  of  his  face      Many  an>  the 
M  lirmes  that  have  beiMi  devised  for  detecting  the  character  o.  p.".ra- 
Iviic  s,,Mint  l.v  making  use  of  the  double  images  invariably  pn-iluced 
11.  some  i.art  of  the  field  bv  even  a  slight  muscular  i)aresis.    ( )l  lli.-s., 
i.r.bablv  .\Iautli.ier-s  (Fig:  00)  pictorial  table  of  single  muscle  paresi.s 
:-  the  simplest      There  are  several  reasons  why  it  is  so  often  dithcult 
.  determine  bv  means  of  tiie  dil.lopia  test  alone  what  mu.srle  or 
iiiiscles  are  affected.     ( >no  does  not  always  have  intelligent  patients 
.  deal  with:  the  pare.sis  niav  affect  more  than  one  muscle,  or  i    ma> 
-  omplete  in  one  eve  and  incomplete  in  the  other:  or.  wiiee  one 
ve  alone  is  affected," a  single  muscle  may  Ik-  completely  pan.lyze.l 
.  liie  others  are  only  partially  affecte.1      Moreover,  when  the  cr.>e  is 

12 


178 


TllK  KYE. 


of  limR  -^t^indiiiK,  ciitrartums  of  tho  aiitnsonist  iiiiisrW  aro  prntty 
miP'  In  -t  iii.an.l  tli.-r."  inaviilso  Im-  in  such  (•as«"s  a  sur.-rwful  .•ffort, 
ina.k  in  the  interests  of  ti.e  n.  rvoiw  system,  t<.  suppn's-s  <-i|tirely  the 
iinane  in  the  .leflecte.1  eve,  v  i.reviotisly  existuip  miisele  inibalam-e 
or  I  inarke.l  .litTen-nee  in  the  visi-M  of  the  two  ey.-s  also  acts  as  a  dis- 
im.infr  factor.  There  niav  h..  n..  -quint  wh.-n  tlie  eyes  an-  turned 
away  from  th.-  paralyzed  nuisele,  hut  it  is  readily  |)rodu.-e.l  when  they 

Fill.  '.«• 

Belatioss  of  thb  Double  Images  in  Pasalysis  of  the  Otplar  MrscLEft 
(The  True  Imajre  i*  Barred.) 


KiUTmU  Kectut. 
rioublt  TUlon  on  looklnu  i"W«nl  the 
iwrnlyzed  ililf.     The   lmiwf-'*'ii«r»tl<>n 
Increue*  with  »bdafUon  of  the  panlywd 
eye. 


^ 


I  Hternal  Rectut. 
Donble  virion  on  looking  toward  the 
unaffecteil  side.    The  iiei«ratlon  of  the 
imagea  Increases  with  the  adduction  of 
the  paralywil  eye. 


Supfrior  Xeeliit. 
Double  vision  on  rotating  the  eye  ui>- 
warl.  DUtance  between  the  Imagea  In- 
creaf  ■•<  when  the  paralyzed  eye  1»  ralscil 
and  abducted.  The  obll.iuliyof  ihelalae 
image  U  Increased  by  adduction. 


i>  f 


11     ; 


Intrriw  Rfctut. 
Double  vWon  on  rotating  the  eye.lowB- 
wiird.    IHslauie  between  the  Image!,  in- 
crca.«e«when  tlie  i«ralyaedeyc  is  lowere 
and  gWucL-i.    Tlieohlliiuityof  the  liiNe 
image  Inoreases  on  adduction. 


\ 


Mauthner-s  scheme  f.r  ilie  dele.' tin  .     f  tl"-  ""cctol  muscli*  in  ocular  p«l»y. 


MOTUISS  OF  TllH  EYEBALL  ASlt  THEIR  DERASnEMEyTS.     179 


Doable  vtRi'm  nnnitattiigrxiMlownuiiril. 
l)lt>tjtiic«  betwei'ii  liiiflKi'H  iiirri'ue*  when 
the  |«ralyn*tl  eye  bt  Uiwi-rvil  and  vldtirteil. 
The  i>hli<|iiliy  of  tb*  Atlie  linage  lnrre<«e« 
wltb  tbductloo. 


Ir\tfrior  Ohlique. 
Double  TlaloD  on  rotating  eye  upward. 
Dtstance  between  Iniagea  Incrcaiea  when 
tbe  eye  Is  imiiie<l  and  aililucle)!.  The  ob- 
liquity of  the  falte  imatce  lnrreaic«  with 
abduction.  TV  lateral  'littanre  between 
the  Images  Increases  as  the  icralysed  eye 
Is  ralml  and  abducted. 


Mauihner's  wheme  tor  the  detection  of  the  atftcted  mnsdea  in  ocular  palsy. 

an'  nitiitctl  towani  the  scat  of  paralysis.  The  deviation  is  more 
marked  tlio  wider  the  attempted  exeursioii,  while  the  hniitation  of 
iiiuvciuent  notieed  can  usually  l)e  referred,  without  ditticulty,  to  the 
\>ii>\H'T  muscle  or  set  of  muscles.  //  the  affected  eye  fix  an  object 
ilirectli)  in  front  of  it  and  the  .sound  eye  be  covered,  the  latter  xrill  dei-iale 
In  a  qreater  extent  in  the  Kame  direction  than  the  jHiralyzed  eye.  This 
^viimditni  squint  is  an  overaetion  result  arisiriji  from  the  excessive 
iiiiicivat'ioii  effort  needed  to  allow  the  affected  eye  to  fix.  This  fact 
i'^  to  lie  remembered  in  the  differential  diagnosis  between  functional 
.uid  (.rtranic  esotropia;  in  the  former  the  primary  and  secondary 
'lcviati'iii.«  Mil' eipial. 

Unilateral  Paralyses  of  the  Orbital  Muscles.    Paralysis  of  the 

External  Rectus.   Abducens  Paresis.    Paralysis  of  the  Sixth  Nerve. 

\'W\<  \>  llie  cmiiiionest  form   of   the   individual   palsies.     The   long 

■uiir.<e  .,1    the  .sixth  nerve  through  its   bony  canals  renders  it   jx-cu- 

!i;,rlv  11  d.le  to  diseii.se  from  the  various  meniiifiitic  and  other  proces^ses 

•l,,,i'  niav  oc.'iir  during  its  pa.ssape  to   the  external   rectus  ma«cle. 

!i   i<  often  round  as  a  part  of  rheumatic,  syphilitic,  an.l  traumatic 

.nditioiK   as  well  as  in  ilisease  of  those  central  neurons  with  which 

i.r  sixth  nerve  is  a.ssociated.     Wood  says  that  wh.-n  the  paralys's 

MHM-ipheral  it   is  likelv  to  he  due  in  adults  to  syphilis  when  not 

ri^iiii.tly  of  rheumatic'origin,  but  that  it  is  generally  tulx-rcular  in 

liildreu. 


MICROCOPY    RESOLUTION    TEST   CHART 

.ANSI  and  ISO  TEST  CHART  No    2: 


^     ^'^PLIED  IM^GE 


^^.  '"^-^    i:.j5'    Uij.n   SN*et 

— _»        Rochester.   fv*w  roftt 
li^a         t'"6)    *8^  -  C300  -  c- 


180 


THE  EYE. 


( 


Third  Nerve  Paralysis.  This  is  next  in  order  of  frequoncy  of  the 
one-sided  i)areses.  The  most  common  sign  is  paralysis  of  the  levator 
palpebru'  causiii<;  pUms,  with  a  loss  of  the  normal  skin-wrmkhng  of  the 
affected  lid,  although  the  latter  can  he  partially  raised  by  contraction 
of  the  frontalis  muscle.  When  other  branches  are  implicateo,  the  plobe 
is  defective  in  all  its  excursions  except  the  downward,  upward,  and 
outwanl  movements.  The  eye  deviates  outward  and  downwanl  owing 
to  contraction  of  the  unaffected  superior  obluiue  nm-cle,  and  the 
upper  end  of  the  vertical  meridian  will  be  plainly  seen  to  turn  towanl 
the  pose.  There  is  cxoiMialmi>s  from  relaxation  of  so  many  recti 
muscles;  dilatation  and  immobility  of  the  pupil,  as  well  as  jwralysis 
of  acconimodiition  from  *he  uivolvemeiit  of  the  iruhc  and  ciliary 
fibres.  The  mijdrnms,  which  may  be  further  increased  l)y  atropine, 
is  unaffected  h\  lif!;hl,  converfjence,  or  the  consensual  test.  ^  ision 
both  for  distance  ••md  the  near  point  is  affected  about  as  it  would  be 
if  a  cycloplejiic  were  instilled  into  the  .-ye.  The  dii)l()pia  is  crossed 
the  false  imajte  being  higlier,  and  its  upper  end  is  inclined  towanl 

the  i)aralvzeil  side. 

Paralysis  of  the  thinl  nerve  is  often  incomplete,  and  it  may  be 
associated  with  the  same;  affection  of  other  nerves.  If  the  ciliary 
inuscle  and  iris  aie  alone  involved,  we  have  an  iiiternnl  ophthnlnw- 
pleijin:  if  the  (>xtrinsic  nmscles  are  all  affected,  an  cxUmal  ophlhiil- 
mopk'fiia:  if  both  external  and  internal  muscles  are  paralyzed,  a  total 

op'ithnlmopletjia.  .         „    ,  ,      ,„         +      j  ij    ; 

.\  form  of  recurrent  oculomotor  paresis,  calle.l  by  (  harcot  optitlwl- 
nvmhjic  mlqmim',  attacks  children  and  young  adults  who  suffer 
fr.m  seven;  headache  (atteiuled  by  nausea  and  vomiting)  on  the  side 
of  th;"  paralvzed  muscles.  In  the  intervals  of  the  early  attacks. 
which  last  from  a  few  days  to  a  few  months,  the  muscles  regain  their 
normal  functions,  but  the  paresis  l)econies  more  marked  and  at  last 
it  ni:iy  be  perman -nt.  The  disease  affects  both  sexes  e(|ually, 
and  is"  accompanied  t)y  ccmtractiim  of  the  field  of  vision  and  lowering 
of  th(>  central  aoiitv.  '  Its  real  natun'  is  obscure;  some  writers  believe 
it  to  be  hysterical, Others  attribute  the  symptoms  to  a  lesion  of  the 
nerve  n)ot  at  the  base  of  the  brain.     No  treatment  is  of  avail. 

Paralysis  of  the  Superior  Rectus.  This  is  not  an  uncommon 
unilateral  paialvsis.  With  it  there  is  Hmited  movement  upwanl  and 
towanl  the  unatTecteil  eve,  accompanied  by  diplopia  in  the  up])er 
hall'  of  the  tield  of  vision.  When  the  patient  looks  in  this  direction 
divergence  is  the  result.  The  face,  in  fixation,  is  turned  up,  while 
liothU  and  the  head  are  incliiie<l  towanl  the  sounil  side.  The  n'la- 
tive  position  of  the  true  and  false  images  will  be  seen  on  consulting 

tlie  chart  (pagi-  17S).  _.      ^.       .    „  ,  -     _iu 

Paralysis  of  the  Superior  ObUque.  Trochleans  Palsy.  Fourth 
Merve  Paralysis.  Thi -  mu.scie  is  rarely  panilyzed  alone.  The  diag- 
Mosis  p^n  u-u:i!lv  W  luMde  in  n-cent  cases  by  the  diplopia-scheme  test 
(page  170),  or  bv  n'membering  that  there  is  homonymous  diplopia  on 


MOTIOSS  OF  THE  EYEBALL  AND  THEIli  DERAHOEMESTS.     181 

lookingdown,  that  the  false iiiiagf  is  lower,  with  its  upper  eii-l  iiieliiied 
toward  the  healthy  eye.  It  is  a  very  troiiblesdine  form  of  paralysis, 
and  the  patient  is  comjx'llod  to  close  one  eye  to  avoid  the  double 
vision  in  the  lower  half  ol  the  field. 

Unilateral  ami  v<olaled  paraly.sift  of  the  inferior  rectitu,  inlirnal  rectus, 
(ir  inferior  oblique  is  extremely  rare.  \\'hen  any  of  these  does  occur, 
it  can,  especially  in  recent  cases,  he  diagnosed  by  the  symptoms  and 
a  study  of  the  positions  and  relations  oi'  the  diplo])ic  iinapes. 

A  fairly  large  percentage  of  ocular  palsies  afi'ect  the  associated 
movements  of  the  two  eyes,  and  while,  as  before  stated,  almost  any 
or  every  combination  of  paralysis  of  the  muscles  of  the  two  i\  <s  may 
occur,  there  are  particular  examples  that  call  for  mention. 

Paralysis  of  Convergence.  This  may  result  from  true  nuclear  or 
supranuclear  disease.  It  is  not  necessarily  followed  by  diplopia,  but 
the  patient  is  unable  to  fix  with  either  eye  at  the  near  point :  the  optic 
a.xes  remain  i)arallel  in  all  movements. 

Conjugate  Paralysis.  Inability  to  move  both  eyes  toiri'ther,  either 
to  the  right  or  to  the  left,  while  the  convergent  jjower  is  jjreseryed, 
is  not  hifre(iuently  seen.  The  lesion  in  this  case  is  probably  cortical, 
although  it  is  also  claimed  to  be  near  the  sixth  ne;-e  nucleus— s;i id 
by  some  observers  to  Ix"  the  centre  for  the  a.ssociated  lateral  moti.  iis 
of  the  glok'.  It  Ls  often  a  distant  symi)tom,  as  in  hemorrhage  into 
or  disease  of  the  cortex,  pons,  internal  cajtsule,  etc.  It  usually  lasts 
but  a  short  time,  because  disturbance  of  the  centre  in  one  side  of  the 
brain  is  soon  ((uelled  y  the  unaffected  second  centre.  In  deMructire 
lesions  with  this  symptom  the  ejes  turn  from  the  paralyzed  side 
(Swanxy)  when  the  cerebrum  Is  the  seat  of  the  disease,  but  toward 
the  i)ari!lytic  side  in  pontine  disease:  the  eyes  turn  toward  the  con- 
vulsed side  in  irrita'ire  lesionx  of  the  cerebrum,  but  away  from  it  in 
irritation  of  the  pons. 

Conjutiate  parah/sis  of  both  ujnrard  and  dovmvard  morement,  due  to 
disease  of  the  thidamus  opticus  and  the  corpus  striatum,  has  also 
been  recorded. 

Prognosis.  As  a  rule,  the  periph  Tal  paralysis  (due  to  exj-osure  to 
cold,  rheumatism,  injurv)  gets  well,  but  where  the  cause  of  the  palsy 
is  intracranial  the  prospect  of  a  cur(>  Is  necessarily  more  remote. 
The  first  attack  of  ocular  j.aresis  that  heralds  the  api)roach  or  forms 
a  part  of  talK's  dorsalis  mav  disappear,  only  to  recur  and  become  per- 
manent. Indeed,  it  may  well  be  remembered  that  an  attack  of  ocular 
paresis  occurring  in  a  man  over  thirty-fivr  years  of  age— particularly 
if  he  has  had  earlv  syphilis— should  arouse  susi>icions  of  a  prob- 
ai)le  posterior  spinal  scl(>rosis.  Probably  the  paretic  cerebral  com- 
plications of  syphilis  (gumma,  local  periostitis  and  the  like)  are  as 
am.'uable  to  treatment  as  anv  paralysis  of  central  ongin.  In  most 
cases  manv  weeks  or  months  mav  elapse  before  uni)rovement  or  cure 
rrsults.  the  longer  a  paralysis  has  existed  (with  or  without  treat- 
iiuiit)  the  less  the  hope  of  eventual  cure. 


K 


182 


THE  EYE. 


So  far  as  possible  the  cause  of  the  paralysis 


shoulil 


Treatment. 

be  removed.    Where  tlie  .     'iii  ol  tne  xroume  i^  „,-.. ........ ■••-•;. 

^  lici  Ten  t.)  twenty  g  .in.^  thre..  tinu-s  daily,  has,  in  the  writer  s 
h.  u  b  n  ouml  inore  .lesirable  an.l  more  rea.iily  borne  than  the 
sXvhtes  This  shoul.l  be  oomi.ine,l  with  an  antirheumatic  regimen 
V  ,7r  baths,  and  copious  .Iraughts  of  lithia  water.  Injuries  should 
ha  e  the  ca  e  proper  to  them.  All  the  other  cas..s.  unless  there  i.s 
s-mie  contraindication,  should  at  once  ho  ordere.l  a  -u-' "f -*^^  <^ 
p.,tassic  iodi.le  (or  both  together)  in  increasing  i  oses.  to  be  gn  n 
'between  meals  and  in  a  large  .,uant  ty  (pmt  '>^.;;7' "f  7^*' ',  •  ^,  ;^. 
patients  will  tolerate  M)  or  4(M)  grains  .ally  with  beneht.      lli>     .> 

,  supplemental  by  mild  me.rurial  inunctions,  and  -  I «  "  ^ 
should  neantime  take,  three  or  four  times  every  week,  the  Turki.sh 
o     he  o   liurv  sweat  bath.     For  the  b,-nefit  of  the  ..hange  (as  well  as 

the  hot  vat,.-)-  patients  .lo  well  at  various  h..t  springs  hen>  and  abroad. 

Coincident  with  this,  the  treatmeiit  i-I-"V'\'"  ui  ^th' 'b  m^:^' 
tubercle,  and  brain  neoplasms  is  ">'li<-ate.l  altlu.ugl  m  m  .^ 
instances  it  will  not   be  followe.l  by  any  good  result   so  far  a^  th. 

''":;ISi?v;V";"':k'n!rn.nt  ,2  to  o  milliamperes)  of  the  interrupted 
ga  vane-  -urrent  will  br  found  of   use-the  eathode  over  the  dose, 
Hd  ,;r  on  th..  eo,.ainiz,-.l  seh-ra.  n.'ar  th.-  ius..rtioii  ..t  the  paralyz,>,l 
muscle,  the  an,)de  at  the  nape  of  the  n.'.'k.  ,       i... 

Michel's  plan  ,.f  grasping  the  cncaimz.'.l  CMiijunctiva  an.l  scl  i. 
will   a  pair  ..f  HxatiV.n  t'.rc,>ps,  an,l  f.)rcibly  ..xercismg  tlu-  ,.nfe,^bl.-.l 
uHc le  bv  n.tating  th.-  glolM'  back  an.l  forth  in  the  .lirecti.m  ..f  its 
^^  .MLut  ;  mhiute  'ich  .lay,  is  ,.f  s,.me  value.     Other  forms  .. 
cx,-rcis..,  with  prisms  ..r  Hxi.ig  a  n.-ar  obj.-ct  f..r  a  few  nunut.-s  at  . 
time  s..v..ral  times  a  .lay  in  all  p.issibl..  .lirect.ons,  nu.y  hn-..>  the  eff.>ct 
of  i.rev.-nting  s.coii.larv  c.ntractuivs  an.l  of  stiniulating  dm  periph- 
Z\  n.-rv..  lilm-s.     SomVtim..s,  when  the  paresis  is  slight,  correcting 
pr'isms  reliev.-  th.-  .liplo,.ia  an.l  the  vertig...     In  chn.mc  paralysis 
I,ft..r  the  foreg..ing  tn-atiiK-nt  has  b.-en  ai)l.lie.l  with..ut  success,  when 
■the  pairtic  muscl.-  r.-tains  son.,,  cntractile  pow.-r  a.lvancem,.nt  of 
lu-  w,.ak  musd..  with  Tenon's  capsul..  may  be  tri,;d.     N>ction  of  the 
antagonist  will  always  be  iie,-.le.l.     If  th.-  paralysis  be  c.mpl.-t.-.  no 
oi(.-rati.)n  sIduI.I  be  un.lertaken.  ri»,„K«.i 

Paralysis  of  the  Extrinsic  Muscles  in  the  LocaUzation  of  Cerebral 
Diseases.  Third  Nerve  Paralysis.  H..aring  in  mm.l  the  nucl..ar 
an.l  corti.-al  centn-s  of  the  ,-y.-  musd.s.  unilaUral  ,>los,.i^oiH-  is  n,-arl>- 
alwavs  ,lue  t,.  impli,-ati..n  ..f  the  ,-,.rtical  (associat,-.  )  centr,.  m  th,. 
opp„Vito  upper  ,.xtr.-nnty  of  the  ascen.ling  fn.nta  cnvlution- 
,i!.,.  th,.  arm  centr.-.  Is.,lat.',l  pt..sis  is.  h.-nc...  <-all.-.l  cen-br',1  ptos>. 
\\rr<\<  of  th.-  l.-vator  palp.-bra-  .occurring  ,-/*  the  saw,  ./c  as  the  le.iu,,, 
whhout  implL-ation  of  th..  oth.-r  hranch.-s  ..f  th.;  »>''>' V;?'^'';:"'^;'  „' 
dis,.-,.,.  .,1  the  po.is  Varulii.  Iii  d,-tn.<-t.v.-  1,-sions  of  the  .-n  s  «lu  r, 
there  is  crosse,'  -paralysis,  pt..sis  is  usually  present  as  part  of  a  totiil 


MOTIoyS  OF  THE  EYEBALL  AND  THEIR  DERAyOEMEXTS.    183 


third  nerve  paralysis.  If,  under  these  circumstances,  only  the  branch 
supplied  to  the  levator  be  affected,  one  may  diagnosticate  a  lesion 
of  the  peduncle.  When  oculomotor  pare.sis  is  found  on  the  same  side 
and  alxjut  the  same  time  a.s  a  central  lesion  shows  itself,  with  loss  of 
sensation  and  motion  (including  facial  and  sometimes  hypoglossal 
paralysis)  of  the  opfMisite  side  of  the  body,  we  have  a  "  crossed  hemi- 
plegia" that  almost  invariably  means  destructive  disease  of  the  crus. 
Lesions  affecting  the  basal  neurons  are,  however,  the  commonest  of 
the  oculomotor  paralyses,  and  these  are  usually  comitlcte.  It  is  not 
always  easy,  from  the  character  of  the  |)aralysis  alone,  to  differentiate 
between  disease  of  the  crus  and  purely  basal  disease.  If  there  is  no 
other  paresis,  or  if  there  is  an  incomplete  hemiplegia  with  the  third 
nerve  })aralysis,  the  changes  are  almost  certainly  at  the  base  of  the 
brain.  Om''  must  not  forget  that  oculomotor  jKiralysis  may  occur  as 
u  distant  (pressure)  .symptom,  especially  in  brain  tumor  and  tlirom- 
l)osis  of  the  cavernous  sinus. 

Paralysis  oi  the  Sixth  Nerve.  Owing  to  the  many  connections 
formed  bv  the  abducens  during  its  long  course  from  the  liain  to  the 
external  rectus  muscle,  it  is  subject  to  jjaralysis  in  lesions  not  directly 
reaching  its  nuclear  origin.  Cerelx'Uar  tumor  is  an  example  of  a  dis- 
tant lesion  especially  prone  to  affect  the  sixth  nerve  in  this  way,  and 
one  or  both  nerves  "mav  lx>  compromised.  \\'hen  abducens  paralysis 
appears  as  the  onh/  focal  sign,  it  usually  means  basal  disease,  and, 
apart  from  fracture  of  the  petrous  portion  of  the  temi)oral  bone,  is 
likely  to  be  due  to  svphilv  .  particularly  if  it  be  bilateral.  When 
iiara'lysis  sets  in  with"  an  opjmslte  hemiiilegia  and  other  evidence  of 
cerebral  disease,  the  lesion  can  be  referred  with  confiilence  to  the 
pons.  A  hemiplegia  due  to  a  lesion  in  the  cortical  motor  area 
furnishes  much  the  same  symptoms,  except  that  the  i)aralysis  is  on 
the  same  side.  Owing  to  the  close  relations  of  the  nuclear  centres 
for  the  sixth  and  seventh  nerves  we  often  have  facial  and  abducens 
paralysis  occurring  together.  When  these  an-  associated  with  a 
crossed  hemiplegia  the  lesion  is  in  the  pons. 

Paralysis  of  the  Pourth  Nerve  alone  is  a  very  rare  occurrence  in 
cerebral  disease:  when  associated  with  i)aralysis  of  other  oculo- 
motor nerves  it  is  practically  impossible  to  separate^  it  as  a  localizing 
■<i.'n  In  the  former  case  it  is  the  result  of  a  basal  lesion:  when  it 
s.^s  in  with  third  nerve  paralvsis  it  indicates  a  lesion  of  the  peduncle. 
\s  Prevost  has  pointed  out,  and  as  we  have  iust  seei',  m  conjunnte 
deviation  of  the  globe  due  to  paralvsis  of  the  as -"i:.ted  muscles  th<- 
cy.'s  ar(>   turned  toward  the  sitle  upon  which     lie  central  lesion   is 

-ituated.  ,  ,  i  *i 

Spasm  of  Accommodation,  The  constant  demands  made  ujion  the 
•  iliarv  muscle  and  the  habit  so  engen.lered  are  such  that,  in  young 
p.rs„ns  esiH'ciallv.  relaxation  of  the  nmscular  contractions  does  not 
alwavs  take  place,  so  that  the  true  state  of  the  refraction  is  masked. 
If  the  patient  Ix'  hvperopic,  he  may  apjjcar  emmuUopic  or  myopic;  it 


l64 


TUE  EYE. 


or  somt 
wise  \V( 


(Miiinotropic  invopic,  ami  if  myopic  the  myopia  may  seem  to  he  Kmitcr 
than  it  really  is.  This  fact  "furnisiit's  the  reason  why  a  patient  may 
pri'sent  perfect  distant  vision  iis  measured  i)y  test-tyi)es,  and  yet 
have  a  fairlv  hif^ii  degree  of  hyperopia  or  astigmatism,  or  both.  In 
other  cases  the  spasm  is  so  marked  that  a  hyperope  may  have  greatly 
diminished  distant  vision  and  ai)]3ear  to  be  myopic  three,  four,  or 
five  dioptres,  ('oncave  lenses  may,  in  such  instances,  be  accepted 
and  aiJi)arently  restore  the  lost  v;  'in  for  a  time,  but  visual  acts  will 
i)e  painful,  and  all  the  other  signs  of  eyestrain  (heatiache  especially) 
are  liki'ly  to  b<>  present.  The  occurrence  of  acconunodative  spasm 
teaclies  us  the  n<ed  of  paralyzing  the  ciliary  muscle  with  atropine, 
other  cycl(jplegic,  before  measuring  the  refraction;  otlu-r- 
cannot  be  certain  of  the  condition  we  have  to  ileal  with, 
unless  the  patient  be  past  forty  years  of  age.  .Mon-over,  it  is  wise 
to  assist  in  breaking  off  the  spastic  habit  by  ordering  the  patient 
to  wear  the  glas.ses  bef<jre  the  effects  of  the  cycloplegic  have  passetl 

away. 

Spasmodic  or  Spastic  Heterophoria.  Just  as  spasm  of  the  accommo- 
dation occasionally  arises  from  strain  of  the  ciliary  nmscle,  so  may  we 
have  oveniction  and  cramp  of  the  straight  mu.sdes.  In  their  efforts 
to  overcome  a  nmscular  imbalance  some  particular  nmscle  may  be  s.) 
stimulateil  to  overwi  '<  that  the  real  nature  of  the  heterophoria  is 
completely  masked,  fhis  is  the  reason  why  a  complete  correction 
of  the  refractive  error  should  be  made,  preceded  or  followed  by  mus- 
cular rest,  before  dealing  with  the  heterophonc  defect.  It  often  hap- 
pens that  an  apparent  heteroi)horia  disappears  and  the  patient  is 
made  comfortable  after  glasses  are  ordered.  The  relief  afforded  the 
ciliary  muscle  is  reflected  upon  the  tasks  of  the  orbital  muscles.  For 
exampU",  an  apparent  esophoria  for  near  may  bc'comean  orthophoria 
to  tests  when  convex  working-gla.sses  areem])loyed:  or  a  right  hyjier- 
phoria  may  dissolve  into  a  left-sided  vertical  defect  after  the  use  of 
prisms,  or  >f  leases  correcting  the  ametropia,  or  from  the  employ- 
ment of  both. 

Certain  forms  of  manifest  hyptwxophoria  and  hypoesophoria  are 
either  pure  hy|)eri)horias  or  pure  horizontal  deflections,  the  impulse 
for  binocular  vision  so  affecting  tiie  related  muscles  that  they  come 
to  tlie  aid  of  the  defective  ones  and  bear  most  of  the  burden.  It 
beh()ov(>sthe  surgeon,  therefore,  to  n)ake  a  number  of  tests  at  hiter- 
vals  before  deciding  in  doubtful  cases,  and,  if  possible,  to  keep  the 
patient  for  a  week  or  more  under  the  influence  of  a  cycloplegic. 
When  persistent  contraction  of  a  mascle  has  lasted  for  months  or 
years  a  form  of  timic  cramp  arises  that  may  retpiire.  in  adtlition  to 
these  measures,  tenotomy  of  its  tendon  with  or  without  shortening 
or  advancement  of  the  op|)osing  nui.scle. 

Operations  on  the  Eye  Muscles.  When  milder  means  are  found 
insuin  ■ietit  to  restun*  binocular  fixation  or  to  r<-lieve  spastic  str.ijn, 
operative  interference  is  indicated  in  most  cases.     The  chief  point 


MOTIOyS  OF  TUE  EYEBALL  AXD  TUEIR  DEBASOEMESTS.     185 

to  be  borne  in  mind  is  the  need  of  conserving  the  rotating  force  of 
tiie  ocular  muscles.     It  is  conseciuently  better  for  the  future  of  the 
patient  to  strengihen  a  weak  nmscle  in  our  attempts  to  bring  about 
the  necessary  balance;  of   power  than  to  accomplish  it  by  reducing 
the  effectiveness  of  the  stronger  muscle,  even  if  we  know  that  its 
overuction  is  ilue  to  spasm.     The  kind  of  operation  suitod  to  the  case 
in  hand  is  important,  and,  although  it  is  not  po.ssible  to  foinmlate 
precise  rules  for  every  contingency,  the  following  aphorisms  may  be 
of  value:     1.  A  simple  tenotomy  of  any  one  adilucor  or  abductor 
muscle  alone  is  rarely  useful  anil  seldom  recjuiied;  as  a  rule,  rist 
under  a  cydoplegic  combined  with  a  full  correction  of  refractive  errors 
will  relieve  the  spa.vn  of  a  single  nmscle,  and  so  avoid  the  necci^sity 
U ir  a  solitary  tenotomy.    2.  Tenotomy  of  a  single  sursumductor  alone 
is  freijuentlv  of  value.     3.  Advancement  or  shortening  of  a  tendon, 
with  or  without  tenotomy  of  the  chief  opposing  muscle,  should  b(> 
done  in  most  caot-s  of  abnormal  deviation  in  the  horizontal  plane. 
4.  Where  advancement  (or  tendon-shortening)  on  one  side  is  insuf- 
ficient to  correct  the  error  the  same  operation  on  the  other  eye  is 
preferable  to  tenotomy.     5.  When  possible,  operations  should  be 
done  under  a  local  amesthetic,  ami  that  method  chosen  in  which  pro- 
vision is  made  for  increasing  or  diminishing  the  operative  effect  both 
during  and  after  the  operation.    6.  The  probable  effect  of  the  opera- 
tion should  be  tested  (red  glass,  cover  test)  during  its  progress. 
7.  Whether  an  overcorrection  or  a  partial  correction  of  the  deflection 
is  preferable  will  largely  depend  upon  the  refractive  condition  and 
the  occupation  of  the  patient.    8.  The  more  the  cajisular  attach- 
ments, check  ligaments,  and  muscular  fibres  are  disturbed  or  in- 
cluded in  the  tenotomy  or  advancement,  the  greater  will  be  the  effect 
upon  the  rotation  of  the  globe. 

Duane  lays  down  the  following  rules,  that  differ  m  some  respects 
from  the  foregoing:  (a)  In  convergent  sijuint  due  to  overaction  of  one 
or  hv\  interni,  tenotomy  of  one  or  both  interni:  when  due  to  weak 
extt  nn,  advancement  of  one  or  both  interni,  with  tenotomy  of  the 
latt'r;   ib)  in  exophoria  due  to  overaction  of  one  or  both  interni, 
tenotdmv  of  the  extend;  when  due  to  insufficiency  or  paresi.«  of  one 
or  both  "interni,  advancement  of  the  latter,  combined,  if  necessary, 
with   temitomv  of   the   externi;    (c)  in    non-conutant    hyperphoria 
(whore  the  angle  of  the  two  visual  lines  constantly  varies)  due  to 
weakness  of  the  superior  or  inferior  rectus,  advancement  of  the  weak 
muscle:  when  due  to  overaction  of  the  superior  or  inferior  rectus, 
tenotomy  of  the  overacting  nmscle:  when  due  to  insufficieii<y  or 
l)aresis  of  the  superior  oblique,  tenotomy  of  the  inferior  rectus  of  the 
other  eye:  when  due  to  overaction  of  the  superior  dhlique,  advance- 
ment of  the  inferior  rectus  of  the  other  eye:  when  due  to  weakness  of 
the  inferior  oblicine.  tenotomy  of  the  superior  rectus  of  the  other  eye; 
.„„1  when  due  to  (!ver.iction  of  the  inferior  obli(iue.  advancement  of 
th    superior  rectas  of  the   other  eye.     When  the  deflection  of  the 


■'Mm: 


186 


THE  EYE. 


!(i 


noii-fixiiig  eve  has  constant  relation  to  tlu-  fixing  eye  (coniitant  hypcr- 
phoria),  tlu'"l)cst  ronicdy  is  generally  tenotomy  of  the  superior  -ectus 

of  the  higher  eye.'  ,      ,,  ,      ,  . 

Every  operation  on  the  eye  muscles- should  be  done  under  aseptic 
conditions.  A  2  per  cent,  holocaine  solution  or  cocaine  (4  per 
cent  )  is  the  ideal  local  aiuesthetic,  while  adrenalin  (1: 1000)  or  somi' 
other  suprarenal  capsule  preparation  will  give  an  almost  bloodless 
tield  of  operation.  It  is  as  yet  undecided  whether  these  agents 
favor  a  post-operative  hemorrhage  that  may  interfere  with  the 
success  of  the  operation. 

Tenotomy.     A  speculum  (or  two  '"     retractors  held  by  the  assist- 
ant) is  iiLserted  and  a  fold  of  cor'  va  and  capsule  imnH>diat<'ly 
over  the  central  insertion  of  the          c-le  firml'j  grasjjed  by  fixation 
forceps  having  at  least  four  tcH'th.    I'he  underlying  structures  are  now 
drawn  sligiitlv  awav  fioin  the  globe  and  an  incision  is  made  with  \\w 
tenotomy  sci.ssors,  care  being  observed  not  to  cut  through  the  tendon 
itself.     Sufficient  space  should  be  given  to  enable  the  surgeon  to  pass  a 
strabismus  hook  above;  or  below  the  exposed  tendon,  so  that  ita  point 
presents  at  the  oiiposite  border.     A  snip  of  the  sci.s.sors,  one  blatle  of 
which  is  also  passed  Ix'iieath  the  muscle,  now  severs  the  tendon  as  near 
its  insertion  as  i)ossible.    If  he  prefers  it,  the  operator  may  proceed  as 
for  partia'  tenotomy  (making  a  'Hnitton-holo"  or  entirely  central 
opening  in   the  ten.lon)  and  complete   the  central   incision  toward 
each  in:irgin.     If,  on  testing,  the  first  result  Is  deemed  insufficient, 
the    wouiul  in  the  capsule   and    conjunctiva  is  enlarged   and   the 
supplementary  fibres  on  both  sides  of  the  tendon  arc  carefully  and 
gradu'dly  divided  on  the  hoak,  several  deviation  tests  being  mean- 
time II,  itle.     .As  a  rule,  5  to  10  prism  tlegrces  of  deviation  (or  less) 
are  obtained  by  a  simple  tenotomy    where    the  retaining  lateral 
fibres  an;  undisturbed.     If  the  capsular  attachments  and  check  liga- 
ments are  undermined  and  divided,  a  greater  (and  unknown)  effect 
follows  even  to  marked  limitation  of  the  excursions  produced  by  the 
muscle  o|)erated  on.     It  is  not  neci-ssar\'  to  suture  the  wound.     The 
after-treatment  consists  of  cold  applications  every  two  or  thr(>e  hours, 
followed  bv  a  simi)le  coUyrium.  such  as  two  gratnmes  each  of  boric  acid 
and  borax  in  100  grammes  of  a  1 :  10,000  solution  of  mercuric  chloride. 
If,  not  later  than  forty-<'ight  hours  after  the  operation,  an  oyercor- 
rci'tion  be  found,  a  suture  in.-luding  the  cut  end  of  the  muscle,  Tt  ;on's 
capsule,  and  the  conjunctiva,  should  be  so  placed  that  the  over-defect 
is  reme<lied.     If  excessive  bleeding  occur,  it  is  better  to  iwstpone  the 
operation,  chieflv  becatise  it  is  then  difficult  to  estimate  the  final  effect 
of  the  tenotomv.     Bandages  are  objectionable  since  they  prevent  the 
use  of  the  (\ves  in  binocular  fixation— an  exercise  that  should  begin 
iinmcdiatelv  after  the  operation. 

Advancement.    The  tendinous  insertion  may  Ije  brought  fonvard 
with  or  without  resection  of  a  portion  of  the  tendon  itself,  or  the  latter 

I  Ara.Tii:*iiTi'Xt-b.>.>knf  Disease*  iif  tlie  Eye,  1S99,  pp.  Jil-'CJ. 


MOTIOXS  Of  THE  EYEBALL  AXD  THEIR  DERASOEMESTS.     187 


may  be  shorti'ned  by  making  in  it  a  "tuck"  or  "knuckle."  Of 
tlu"  numcroaM  operations  for  simple  advancement,  the  writer  has  for 
many  years  been  satisfied  with  a  nioditieation  of  the  weil-known 
oiK'ration  of  Schweigger,  combinetl  with  the  Black  method  of  tying 
tiie  sutures.  It  is  usually  done  under  a  genera!  ana'sthetic.  A  full 
carved  needle  is  threaded  with  No.  3  iron-<lyed  silk,  bringing  the  en<la 
of  thread  together  and  tying  them  in  a  small  hard  knot,  or  both  ends 
of  the  thread  may  be  pa.s.sed  through  the  eye 
of  the  needle  at  the  same  time,  leaving  the 
end  of  the  suture  iii  the  form  of  a  loop,  in- 
stead of  a  knot.  The  neeilJe  is  now  |)a.'<.><e(l 
tiirough  the  conjunctiva,  iaking  a  good  bite 
into  the  .sclera  close  to  the  cornea,  as  indi- 
cated in  Fig.  9;i. 

After  the  thread  is  j)ul!e(l  about  half-way, 
the  needle  is  pa-ssed  through  b'tween  the 
threads  on  the  other  side  of  its  entrance 
into  the  sclera,  and  then  drawn  home,  thus 
affording  a  firm  point  of  fixation.  A  shnilar 
suture  is  fi.xed  in  the  same  manner  U])on  the 
<)])posite  side  of  the  cornea.  The  conjunc- 
tiva and  Tenon's  capsule  are  now  well  divided 
over  the  muscle,  the  latter  being  thoroughly 

exposed  and  well  cleaned  of  connective  tissue.  Two  strabismus  hooks 
are  passed  underneath  themu.>icle  (one  from  each  side  I,  or  an  advance- 
ment forceps  (Prince's  or  Clark's)  is  made  to  grasj)  the  nmscular  body, 
so  as  to  hoKl  it  steady  and  away  from  its  bed.  The  sutures  are 
now  passed  through  the   muscle  from   below  upward  as  far  back 


Advancement  of  a  inuM'ie.  Kx> 
poeure  of  tb«  mii'^ele.  (Uan^ki.l 
and  Rebeh  ) 


Flo.  92. 


Prince's  advancement  forcei«. 


as  is  believed  neces.s.arj',  and  pulled  about  half-way  home.  The 
muscle,  still  held  with  the  hook  or  forceps,  is  now  cut  off  just  in  front 
of  the  entrance  of  the  sutures.  The  piece  of  tendon  attached  to  the 
globe  is  grasped  and  cleanly  dis.sected  out. 

The  sutures  are  now  pulled  home,  and  both  grasped  between  thumb 
anil  finger,  while  the  glolx*  is  fixed  with  forceps  on  the  nasal  side  of 
tiie  cornea  and  turned  outward  (in  ojM-rating  on  the  external  rectus), 
wliile  the  nuisele  is  advanced  to  the  desired  position.  The  stitches 
are  now  tied  in  a  surgeon's  knot  over  the  muscle,  as  indicated  in 
Fig.  04.  The  original  ojiening  in  the  mucous  membrane  is  stitched 
together  by  fine  sutures.  Th(>re  may  be  some  reaction  following  this 
"[MTation, 'requiring  the  froijuent  .applic.-.tion  of  hot  fomentations,  but 
if  proper  precautions  have  been  taken  this  is  unusual. 


188 


THE  EYi: 


m 


( )no  of  \h-  !i...st  ftTcctivc  inn  liods  of  slwrlrninn  the  muscle,  by  takiiiR 
•I  "tiu-k"  ill  it-i  iciitloi..  is  comprised  in  an  ailvancfnicnt  o|HTation 
'.Icvis.-.!  iu  part  l.v  Frank  (".  To.l.l.  Sui)posinB  th.^  nitcrnal  rectus,  to 
Im.  opcratcl  on.  a"  Hap  of  i-onjunctiva  and  Tenons  eapMiie  is  dis8.Tte.l 

vip  and  turned   bark,  so   as   to  free.y 
expose  the  tendon.     (  KiRs.  (id  and  97.  > 
The  ui)iH>r  and    crossed    prong  of   the 
"tucker"  is  inserted  In-neath  tiie  ten- 
don and  the  arms  of   tlie  instrument 
sei)arated  l)y  tiie  screw-nut  to  produce 
the  desired  etTect.  as  shown  in  I'i;^  '.»o. 
Catgut  sutures  are   passed  above   and 
below,  tln-oUL.  the  I'ln-ee  layers  of  ten- 
don and  tied,  as  in  Fig.OS;  two  double- 
threaded  black-silk  sutures  are  i)a-^>ed 
(one  al)ove  and  one  below)  through  the 
looj)  in  the  tendon,  thence  through  the 
conjunctival  fiaps  and  epi.sderal  tiss\ie 
on  either  side  of  the  cornea  to     ose  the  wound,  and  act  as  guy-roiies 
while  the  healing  process  goes  on. 

Nystagmus.    This  svmptom  consists  of  mvoluntary  movements  ot 
the  glolK',  either  rotary,  from  side  to  side  (horizontal  nystagnms),  up 


Adraneement  of  a  muscle,    liilnxluclion 
orsutureii.    (IIANSKII.  nn.l  Rkber.) 


Flii.  M. 


First  step. 


Sft'on.l  stc('. 


Iiuroiliiction  of  siit\ire8  In  advancement  operaUons.    (Black. ) 

•ind  down  (vertical),  or  a  combination  of  these  excursions.  The  sec- 
ond is  [\:r  rwinnionest  variety,  and  it  is  often  found  in  those  Ix.rn  with 
defective  sight— e.  7.,  in  albinos,  in  coloboina  of  the  choroid,  and  in 
other  developmental  anomalies  of  the  visual  apparatus.  These  patients 


ffm 


M(>TIOXS  OF  THE  EYEBALL  ASD  TIIEIR  DERASdEMEXTS.     189 

arc  unconscious  of  tlio  oscillation  of  the  glol)o,  and  do  not  complain 
of  it  as  such.  That  this  jwculiar  condition  may  Ih'  hereditary  is  well 
.shown  by  many  nh.siTvers.  The  writer'  reported  a  family  of  twenty- 
three  children  and  grandchildren  descended  from  a  pronounced 
hlonde  male  ancestor,  with  ix'rfectly  healthy  eyes  and  nervous  system, 
and  a  decided  brunette  with  myopia  and  conpenilal  ii\  stafimus.  Two 
descendants  oidy  were  Sruncttes;  they  were  the  subjects  of  marked 
congenital  nystagmus,  while  the  other  twenty-one  had  healthy  eyes. 
From  these  and  other  considerations  it  sedans  justifiable  to  a.^sumc 
tliat  there  is  some  fault  of  the  co-orilinating  centres  in  most  of  the 


Flu.  95. 


Flo  96. 


Flo.  95 


Instrument  fur  placing  a  "  liicH."  in  miiwli'-shorteninK.    (ToDD.) 


Fio.  96.— Muscle-ihortening  with  t      Todd  "  tucker.'    Fjr>t  Muge 

congenital  cases.  While  visual  defects  are  fre(|Uciitly  present,  yet 
not  everyone  with  congenital  visual  anomalies  has  n.,stagmus,  and, 
ill  some  'instances,  the  eyes,  ajjart  from  the  irregular  globar  excur- 
sions, are  practically  normal. 

Acimred  nvstaginus  is  present  in  M  per  cent,  of  all  cases  of 
sclerosis  in  ;  'tches,  and  it  is  also  noticed  occasionally  ui  those  who 
work  in  abiion-al  or  strained  attitudes.  A  well-known  example  of 
the  actpiired  variety  is  "  miner's  nystagmus."  Here,  to  the  uniiatural 
positions  these  work,  rs  are  obliged  to  assume  for  hours  at  a  time,  is 
adiletl  insutiicicnt  light;  the  ocular  centres  of  co-ordination  are  not 

1  North  American  PracllUoner,  April.  1«92. 


n 

*  i 


I 


190 


Tilt:  Ai'A' 


,,rn,,.-rlv  stiim.hito.l.  ovviiiK  to  a  lack  ..f  ,l.-linit.;  r.-lu.al  inmpcs  aiul 
tl...  unvvont.a  >liain  on  tlu-  obli.,u.'  imis.-l.-s  in  |.arti.'ular  cihIs  ni 
irn'Kular  n.ov.-n.rnts  of  tlu-  >ilol«-.  W."  thus  l.av  to  .l.-al  with  a 
,,rof,-ssi..nal  inro-or.linatio.i  of  a  class  akin  to  wrifrs  cranip.  m 
m.livi.luil  ^<»  atlVctcd  In-inn  l."tli  conscious  of  an.l  annoy.'.l  l>y  tlio 
trouble  l-atcr  on,  his  nervous  system  a.lants  itself  to  the  situation, 
iust  is'in  tlu-  case  of  congenital  nystagmics.  The  treatment  ot  the 
congi'iiital  variety  is  to  iinjirove  the  vision,  if  possible,  and  to  correct 


no.  w. 


Km.  »n 


Third  auge 


If  this 


b 


Mii»cle<hortenlng  with  the  "  tucker.' 
staKe. 


muscular  errors. 

done,  improvement  often  follows. 
The    nystagmic    patient    usually 
holds  liis  head  in  a  peculiar  posi- 
tion while  fixing  for  both  distance 
and  near;    he  should  bo  allowed 
to  continue  this  practice   (unless 
it   Ix"  ilue  to  imbalance   of    his 
muscles),    a.s    he   often    succeeds 
thereby    in    steadying    the    iwcil- 
lating  eyeballs.    Patients  vitl   ac- 
8»eonii  (niired  ny.stagnius  should  abandon 
their   injurious    occui)ation.    and 
give  their  eves  prolonged  rest,  correcting-glasses  being  ordered   for 
distant  Hxation.     A  cure  generally  f<.llo -^  if  hygieiuc  measures  are 

"faercise  of  the  Weak  Eye  and  the  Use  of  the  Stereoscope  in 
Heterotropia.  Sf.il  less  than  formerly  is  the  ophthalmic  surgeon 
content  witi  mer^'lv  "straightening"  the  crossed  eyes  of  his  patients^ 
\s  we  li'ive  «een  loss  of  binocular  vision  is  involved  in  all  cases  of 
s.,uint  and  in  some  cla,ss<>s  of  heterophoria.  We  have  conse<iuently, 
not  .lone  our  full  dutv  until  we  have  ma.le  every  effort  to  rest  ore 
or  to  enable  the  patient  to  ac(iuire  the  capacity  for  seeing  with  l)oth 

eves  together.         •  .     ,    .     ,  ,  i.  • 

'  In  .luit.'  a  few  exami)les  of  strabismus  this  desirable  result  is  neces- 
sarilv  imi)ossible.  The  squinting  eye  may  be  congenita  !y  defective 
to  a'de-'ree  iiicai)able  of  vision  with  the  fellow  eye,  or  there  may  be 
•m  uncoiKiuerable  aversion  to  binocular  .''ight  upon  the  part  of  one 


../0770.V.S  II.    Tilt:  E\EI}M.I.  ASU  TllKlR  HKItASiiEMICXTS.     1«)1 


iir  Ixitli  eyes,  tin-  iiiituro  of  wliich  wi'  'in  not  kimw.  I'xcti  t  tlml  il 
|H((l):il)ly  |)i<'<li(':itrs  a  lack  of  dtvcloj     I'lit  in  soinf  one  or  ollin     f 
tin- ci'iitial   neurons  iniplicati'd   in  tlic  visual  art.      Again,  l)inocular 
cinjtlc  vision  may  l><'  unol)tainai)it'  on  account  of  iucurahif  lesions 
(corneal  hcbuhc'intra-ocular  disease)  of  the  strahisinic  rye,  \v'ierel)y 
siplit  is  jiennanently  lowered,  although  it  may  )><■  good  in  the  tixing  eye. 
Fortunately  it  happens  that  in  a  majority  of  instances  hinocular 
vision  is  to  a'jtreater  or  less  extent  possible  after  the  relief  of  strabis- 
mus.    Moreover,  the  eyes  that  acquiii    stew   -icojiic  or  single  vision 
are  usually  those  wliose  excursions  in  all  •       ctions  are  normal  and 
remain  normal.     The  ideal  result,  then,  f      i  the  surgeon's  stand- 
point differs  from  that  of  the  |)atient  in  th.    ,  while  the  lattci  is  alone 
interested  in  the  cosmetic  aj)pearance,  the  former  is  concernid  in  the 
<|Uestion  as  to  whether  the  hitherto  useless  eye  can  he  made  to  take 
part  in  the  function  of  sight.     The  old  device  of  covering  the  Letter 
» ve,  so  that  the     "ak   (or  s(|uinting)  organ  may  Ix-  CAerci.sed  and 
strengthened,   is   ■:  .pful   before  operation,  or  as  adjunct   to  other 
treatment,  if  car  '    '  out  regularly,  say,  for  half  an  hour  at  a  time, 
three  or  four  tmief.  daily.    With  a  little  patience,  children  of  tender 
years  can  Im'  induced  to'wear  a  light  bantlage  over  ♦!     am])lyopic  eye, 
and  use  it,  even  while  a'  play,  to  great  advantage.     As  it  is  highly 
desirable  to  begin  the  tr.  atment  of  infantile  strabismus  at  ns  early 
a  iKTiod  as  possible   this  plan  should  be  carried  out.  in  conjunction 
'with  the  periodic  use  of  atropine  and  tinted  glasses  as  soon  as  the 
child  begins  to  walk.    A  single  droj.  of  a  \  per  cent,  solution  of  atroj)ine 
instilled  into  each  eve  three  times  daily  for  the  Hrst  few  days  of  each 
month  certainlv  helps  to  relieve  ihe  early  s'.iasm  of    he  mterni  and 
cil  arv  muscles  and  to  check  a  convergent  S(|umt. 

In  quite  another  fashion  do  w'  endeavor  to  fo-      the  two  eyes  to 
functionate  as  far  as  possible  in  unison  after  ,       i-mployment  of 
means  (glas.ses,  atropine,  operation,  etc.^  to  corr        the  strabisnms 
iiroper      The   best   means   is   the   eniploynipi  :.   of  the   stereoscojie. 
Landoit    Worth,  and  others  liave  invenl.-u  v.nous  miproved  mstru- 
nients   and  while  these  are  '  '     .Ivantagf ,  .-iwially  m  private  prac- 
tice  none  is  absolutelv  nece>     r         Tlu   o..':nary  slereoscoj.e  is  pro- 
vi.led  with  a  card  on  which  a.e  oravvn  or  !.>rint-d  pictures-  two  such 
dissimilar  objects  as  a  s.iuare  and  a  circle  will  do  \.Ty  well-one  oppo- 
site each  ev«'hole.     The  patient  exercises  f(,r  a  few  seconds,  hrst  of  all, 
th<'  defective  eve  alone,  and  then,  uncovering  the  sound  eye,  looks  at 
both  obiwts  through  the  in.strument,  endeavoring  to  see  them  singly 
if  possible.     At  first  it  is  well,  as  Landoit  suggests,  to  we.aken  by 
ni.'ans  of  lenses  the  vision  of  the  better  eye,  and  so  further  encourage 
the  defective  organ.     Such  ex.-rcises  should  1k«  employed  immediately 
after  oi.eration,  and  ought  to  Ik-  continued  several  tinies^  daily  for 
w,..-ks  or  months.     Tnev  shoul.l  also  !«■  supplen.ent<>d  by  the  exercise 
of  Kin;;!e  vision  in  the  distance.     A  red  glass  is  placed  before  the 
better  eye  while  the  patic-nt  attempts  to  fuse  the  red  and  white 
images  of  a  candle  placed  6  tii.  away. 


i  1 


CHAPTER    V. 

DISEASES  OF  THE  OHBIT,  LACRYMAL  Al'PARATUS, 

AND  LIDS. 

Hv  u.  A.  ki:eve,  M.I). 

THE   ORBIT. 

Anatomy.  Tho  luiman  orbit  consists  of  two  pono-.shapod  cavities, 
■ilM.ut  .)iu'  and  thivc-iuartcrs  inclios  dcop.  which  sliftlitly  convorp- 
toward  or  another,  as  may  he  s.mmi  hy  the  accoin])anyniR  h-iurc. 
(Fig  09.)  Kacli  orbit  is  composed  of  a  number  of  bones— (.  <>.,  tne 
frontal,  the  superior  maxiUary,  tlie  malar,  the  palate,  the  lacrymal, 
the  sphenoid,  and  the  ethmoid. 

Hv  reaM)n  of  the  orpin  which  it  contains,  as  well  as  th(>  close  con- 
uection  which  it  has  bv  means  of  its  thin  walls  and  its  foramuia  with 
the  cranium,  the  ethmoidal,  the  si)lienoidal  and  frontal  sums-  ati(l 
the  antrum  of  Hifihmore,  the  orbit  may  well  be  regarded  as  .n,e  of 
the  nio.st  imixirtant  cavities  of  the  body. 

The  posterior  portion  or  ap(>\  of  the  orbit  contains  three  uuportant 
apertures-  the  optic  foramen,  for  the  tran.smission  of  the  optic  nerve 
■md  the  ophthalmic  arterv,  the  superior  orbital  fissure,  through  which 
l,.,^s  th(>  nerves  which  supplv  the  nuisdes  of  the  eye,  and  the  first 
branch  of  the  trigeminus,  and  the  inferior  orbital  fissure.  The  second 
briiich  of  tl-.e  trigeminus  passes  through  this  opening. 

The  supra-orbital  notch  is  found  at  the  upper  umer  angle  for  the 
tr  insmission  of  the  supra-orbital  artery  and  nerve,  while  a  canal  just 
l„'.|,,w  the  inferior  rim  of  the  orbit  contains  the  artery  and  nerve  ot 
tli(   same  name.  . 

The  orbit  is  relatively  large  in  chiKlren,  Merkel  being  authority 
for  the  statement  that  at  five  vears  of  age  the  ba.se  of  the  orbit  lack.s 
oulv  •'  mm  or  li  mm.  of  its  adult  height,  which  it  gains  usually  ni 
the"  next  two  vears.  Its  full  breadth  is  not  attained,  howev(>r, 
until  somewhat  later.  Th<'  jieriosteum  cov(>rs  the  walls  of  the 
orbit,  and  the  fissures  are  closed  in  by  membrane.  The  orbit  con- 
tains' the  evcball  and  its  attache.l  muscles,  the  ojuic  nerve,  the 
vessels  and' nerves,  and  the  lacrymal  gland.  In  addition  to  these 
structures  there  is  a  cushion  of  fat  which  fills  in  the  interstices  be- 
tween them,  and  a  dense  fa.scia  which  connects  all  the  i)arts  and  is 
expanded  along  the  wails  of  the  orbit,  upon  tiie  ocular  muscles,  and, 
finally.  up'>n  t!t<'  eveball  it.-^elf. 

For  tiie  protection  of  the  eye  against  injury,  the  orbit  is  b(«unded 
superiorly  by  the  eyebrows,  externally  uud  iaferiorly  by  a  strong  rim, 

IHL"  I 


DISEASES  OF  ORBIT,  LACRYMAL  APPARATUS,  ASIJ  Ln>S.     193 

and  intornallv  bv  the  no«>.    Tho  oyobroxN-R  vary  in  toxturo,  diroction 
•uul  size  in  difforont  individuals,  hut  as  a  r-ilo  they  are  coarser  and 
more  marked  in  men  than  in  women.  ,.  ,      ,  ,,    . 

Tie  fosure  whirl,  is  n>ade  by  the  opening  of  the  hds.  the  s,)-calle.l 
miDchral  fissure,  is  oval,  averapinp  fn.m  25  to  30  nun.  m  length 
imf  from  12  to  14  nun.  in  breadth.     If  the  eyeball  be  protruded. 

Fig.  m. 


UrmirJOT 


Antero-lateml  region  of  the  skull.    (Cbykr.) 


„„,,;„;,„l «.  Iho  fi!.«.n-  >vi,lc„.;  if  it  rcclo.,  ™.pM»ta«,  the 

exophthalmic  goitre.     (See  page  208.) 


194 


THE  EYE. 


Enophthalmos.  Rccfssion  of  the  eyohall  occurs  after  injuries  in 
wliich  cicatricial  contraction  of  the  orbital  tissues  has  followed,  ()r 
atropliv  (>nsue<l,  from  nerve  lesions,  anil  in  cases  of  Iracture  with 
, replacement  of  the  tloor  of  Xiv  „rl)it  (Lanji):  when  the  orbital  con- 
tents havi-  i)eeii  reduced  in  the  course  of  operations  or  m cholera 
(from  excessive  drainage),  and  in  marasinus:  also  in  i)aralysis  of  the 
svmi)ath<'tic  involving  MiillerV  li.l-muscle:  after  the  spontaneous 
siibsidi'iice  of  pulsating  exoiihthaliiios  (Brenner),  and  in  the  neurotic 
atiophv  of  the  face.  ,     ,       . 

Knophthalmos  also  occurs  in  a  class  of  cases  recently  worked  out 
bv  Tuerk  aii.l  bv  WoifT,  in  which  then^  an>  coiiRenital  shortness,  hxity. 
and  inaction  of"  the  external  rectus  of  one  or  other  side.  Iroiii  "par- 
alvsis"  (really  aplasia).  The  normal  tonic  contraction  ot  the  internal 
rectu*  draws'the  eve  slightlv  backward,  and  causes  narrowing  of  the 
oMliiebral  fissure,  owing  to  loss  bv  th<>  lids  of  the  u.-^ual  support  o 
the  globe.  In  atteinpte<l  adduction  the  retraction  is  more  marked 
•md  the  fissure  narrower,  and  the  glol)e  is  apt  to  be  turned  up  or 
down  Treacher  Collins  savs  the  tonic  contraction  of  the  orbital 
muscles  (which  are  congcnitallv  short)  is  not  comp(>nsate(l,  owing  to 
the  absence  or  insertion  too  far  back  of  the  check  ligaments;  henc. 
the  enophthalmos. 


Diseases  of  the  Orbit. 

Cellulitis.  This  may  be  of  a.  mild  type,  and  soon  abate,  but  much 
more  often  it  is  .severe  or  phlegmonous,  and  ends  in  suppuration 
(abscess).  The  earlv  symptoms  are  redness  and  swelling  of  the  lids 
and  chemosis  of  the  conjunctiva,  with  deep-seated  pain  and  sonie 
tenderness.  The  mobilitv  of  the  eye  may  be  imjiaired.  At  this 
point  resolution  may  begin  (first  group),  or  the  disease  may  be  arrested 
and  recovery  set  in;  but  in  the  usual  course  the  mfiammation  goes 
on  steadilv  and  rapidiv,  the  temperature  rises,  and  the  i)ain  becomes 
intense.  As  earlv  as  "^the  third  or  fourth  day  the  greatly  swollen  lids 
nciv  be  distended  or  even  imshed  apart  by  the  highly  engorged  and 
eheniotic  eveball.  which  is  now  <iuite  prominent  and  immobile. 
The  lids  become  brav.ny,  and  soon  there  is  indication  of  pointing, 
and  spontaneous  evacuation  of  pus  may  occur.  The  vision  may 
remain  good,  or  it  may  become  defective,  owing  to  optic  neuritis, 
etc.  The  degree  of  stretching  of  the  o])tic  nerve  from  jn-optosis  (for- 
ward disi>lacement),  compatible  with  normal  vision,  is  often  a  matter 
of  surjirise. 

Etiology,  rellulitis  may  be  caused  by  exposure,  cold,  etc.:  trauma, 
blows,  penetrating  wounds,  especially  with  se])tic  invasion,  lodge- 
ment "of  foreign  bodies:  lacrymal  cystitis,  erysipelas,  anthrax,  etc.: 
sejitic  emboli  <>f  the  orbital  veins,  as  in  pya>mia.  metria.  etc. :  periostitis 
and  osteitis  of  one  or  other  wall,  as  in  sinusitis  of  the  ethmoid,  frontal, 
i.r  antrum,  and  suppurative  i)eriodoiititis:  metastasis,  in  which  the 


DIi>i:AS£S  OF  ORBIT,  LACBYMAL  APPABATUS,  AND  LIDS. 


1J>0 


nncuiiiococcus  is  ho  active  agent;  also  septic  phlebitis  and  thrombus 
ill  thrombosis  of  ti..  f-avernous  sinus.  There  are  at  times  points 
which  aid  in  the  diagnosis,  e.  g.,  if  in  a  case  of  purulent  rhinitis  (m- 
tiuenza,  la  f^PPf")'  ^^'^h  ensuing  a-dema,  mainly  of  the  iimer  end  of 
th(  lid.C'hemosisand  impaired  adduction,  acute  cellulitis  should  de- 
velop it  might  fairly  be  ascribed  t"  ethmoiditis,  which  would  cause 
■in  exudation  on  the'inner  orbital  wall  that  would  cripj-le  the  internal 
rectus  So  if  the  lower  lid  became  first  affected,  the  eye  being  pushed 
up  and  rotation  down  restricted,  disease  of  the  antrum  would  be 
-suspected.  If  the  cellulitis  is  synunetrical  (double),  or  that  of  the 
second  e-.  follows  after  a  short  interval,  a  diagnosis  of  thrombosis  of 
the  cavernous  sinuses,  likelv  septic,  would  be  warranted. 

Treatment.    If  the  case  is Wn  early,  the  ice-bag  or  iced  compresses 
■AunM  be  ordered,  with  local  depletion  by  leeches  or  wet-cups  at 
temple-  if  the  leeches  are  applied  at  the  inner  canthus.  the  bleeding 
is  more  effective.    The  patient  should  b«'  put  to  bed:    small  doses 
of  calomel  with  anodynes  and  salines  may  be  given,  and  any  faulty 
condition  of  the  nasal  passages  attended  to.    If  relief  is  not  had,  the 
hot  fomentations  should  be  substituted.    And  if  there  is  reason  to 
su.-.ect  the  formation  of  pus,  or  the  eye  itself  is  suffering,  deep  inci- 
-.ions  should  be  made,  preferably  through  the  conjunctiva,  but  if 
the  lid  cannot  be  pressed  back,  then  directly  through  the  lid.      Creat 
care  mu«t  be  taken  to  avoid  the  globe,  the  point  of  the  long  narrow 
scalpel  or  linear  cataract  knife  being  pushed  .'.lowly  m  and  tle<>ply 
along  one  or  other  bory  wall  of  the  orbit.    The  adult  orbit  is  one  and 
tiiree-duarters  inches  in  depth,  and,  as  pus  sometmies  forms  near  the 
apex,  the  knife  should  go  deeply  if  needful.     If  pus  does  not  escape, 
a  second  or  even  third  exploratory  puncture  should  be  made  at  other 
points.    The  wounds  should  be  kept  open  by  tents,  and  if  pus  pre- 
sents svringing  should  be  practised  daily  with  1:  3()00  solution  of 
,„.rch'loride  orl:  40  carbolic  acid,  etc.     Where  empyema  of  the  eth- 
inoi.l  is  found,  it  is  desirable,  in  some  cases  at  least,  to  o|x>n  a  passage 
l,v  means  of  a  strong  probe  or  trocar  into  the  nasal   fossa  through 
the  ethmoid.  .Irawing  the  drainage-tube  through  by  nieans  of  a  thread 
at tache<l  to  the  eve  of  a  probe.     In  this  way  more  effective  irrigation 
of  the  parts  can  be  made.    Necrosed  or  carious  bone  will  require 
(Miretting,  and  any  disease  of  the  antrum,  frontal  sinus,  lacrj-mal  sac, 
etc..  should  be  treated.  „, 

Periostitis  and  Osteitis.  These  maybe  acute  or  chronic.  The 
acute  form  mav  be  caused  by  extension  of  inflammation  from  adja- 
rent  i.arts,  mo^t  often  the  ethmoidal  or  frontal  sinuses,  the  signs  indi- 
cating the  probable  point  of  origin :  also  by  blows,  foreign  bodies,  etc. 
the  iH.int  of  impact  determining  the  site,  generally  m  the  region  of 
th..  orbital  bonier.  Slight  injuries  may  be  effective  in  young  scrofu- 
lous subjects,  in  whom  osteoperiostitis  may  also  appear  to  be  k  lo- 
pathie.  'Svphilis  may  set  up  an  acute  localized  periostitis,  ami  cellu- 

•  ',  ;,      inTitr.  rii't-itistitis   sud  osteitis  mav  60(1  in 

mis  mav  also  cause  it.     Acute  pdioMiii:!   .ttm       .  , 

resolution,  but  more  often    suppuration  (abscess)  develops,  or  they 


196 


THE  EYE. 


become  chronic.    Thronic    periostitis  and  osteitis  are,  as  a  rule,  due 
to  syphilis  (tcrtiarv).     The  orbital  rim  is  t'  ?  most  i-ommon  seat  of 
the  at  Hrst  ill-dehned  doughy  tumors  (nodes)  attached  to  the  bone, 
wliH'h  are  attended    by  characteristic  nocturnal    i)ain  or  increase  of 
pain.     The  infiltration  and  pain  soon  yield  to  large  doses  of  potassium 
iodide.    Left  alone,  ulceration  and  caries  may  set  in,  causing  sinuses  in 
the  fascia  and  lids,  with  final  deformity  (ectropion,  entropion,  etc.). 
Nodes  may  also  undergo  eburnation,  either  from  chronic  periostitis 
(periostosis)  or  condensing  osteitis  with  hyijertrophy  (exostosis),     k 
deei)-seated  periostitis  now  and  then  occurs,  mostly  syphilitic  and 
tertiary,  which  causes  paralysis  of  the  orbital  muscles  by  involving 
th(>  thiVd,  fourth,  or  sixth  nerve,  and  it  may  also  cause  exophth-dmos, 
partly  hidden  by  the  ptosis.     When  at  the  apex  the  optic  nerve  may 
also  be  involved,  the  i)ressure  or  neuritis  causing  amblyopia.     Peri- 
ostosis mav  ensue,  and  in  this  event,  or  if  treatment  be  too  late  or 
inetTective," there  will  likely  be  permanent  blindness  from  seconilary 
atroi)hy  of  the  optic  nerve,  with  ptosis  and  other  i)aralysis.     \  ery 
rarely  i)eriostitis  at  the  apex  with  some  cellulitis  and   pure  proptosis 
are  due  to  empyema,  etc.,  of  the  sphenoidal  sinus.     Secondary  am- 
blyopia and  contracted  field,  or  optic  neuritis,  atrophy,  and  blindness 
are  ai)t  to  occur,  and  may  be  double.     Pain  in  frontal,  tempt)ral,  and 
occipital  regions,  variable  vision,  and  the  results  of  rhinoscopy  and 
ophthalmoscoiiv,  may  point  to  the  diagnosis.     In  i)eriostitis  ])ressure 
on  some  part    .  the'  orbital  rim  causes  nmch  pain,  and  the  (cdema 
of   the   lids   develops   less   regulariy  than    in 
cellulitis  proper.     In  the  former,  signs  of  the 
disea.se  are  much  more  a])t  to  be  localized, 
e.  g.,  one  lid  or  even  part  of  a   lid  may  be 
swollen,  etc.,  and  the  bone  oidy  tender  beneath 
it.     (Fig.   100.)     In  cellulitis  ])ressure  (m  the 
gl(>be   it.'ielf   is  apt    to  cause  deep   ])ain,   and 
pal])ati(m  just  within  the  bony  rim  shows  that 
the  parts  are  firm,  tense,   and  tender.     Wry 
rarely  acute  rf(7f((.ve  periostitis  occurs,  and  cell- 
ulitis ([uickly  ensues.     Tlie  systemic  disturb- 
ance is   greater   than  in  acute  cellulitis,  and 
the  condition  is  much  nxore  grave.     As  suppuration  is  apt  to  f)ccur 
rapidly,  with  added  risk  of  necrosis  and  burrowing  siiuises  if  a))or- 
tive  treatment  fail,  eariy  incision  to  the  bone  is  indic:ited,  and  several 
will  be  needed  in  the  diffuse  form. 

Periostitis  of  one  or  otliei  wall  of  the  ori)it  which  stops  short  of 
exciting  acute  diffuse  cellulitis  is  not  uncommon.  In  chi^onic.  quiet 
cthmoiditis  with  i)urulent  discharge  from  the  nares,  osteitis  of  the  os 
planum,  and  secondarv  periostitis  by  extension  im  the  orbital  side, 
the  cellulitis  and  exudation  may  be  limited,  the  crdeina  being  mainly 
in  the  na.-al  half  of  the  ui.per  iitl.  with  impaiml  ndductinti  ami  prob- 
ably slight  displacement  of  the  eyeball  outward,  with  diplopia. 
In  "the  same  way  periostitis  of  the  upper  orbital  border  may  follow 


no.  100. 


PeriMtitis  of  orbital  marsfin. 


DISEASES  OF  ORBIT,  LACBYilAL  APPARATVS,  ASD  LIDS.    197 

osteitis  of  tlic  floor  f.f  the  frontal  sinus  in  c'rronic  or  acute  sinusitis 
with  soco'ularv  (I'dcMna  of  only  the  upiK-r  lid,  mainly  at  the  inner  ha  f. 
Under  these  conditions  pressure  on  the  ho-iy  rim  is  paniful,  and  the 
eve  mav  he  disi^laced  slightly  ilown  and  out.  If  the  antruni  is  the 
m'"it  of  the  i)riinarv  disease,  the  lower  margin  of  the  orbit  wil  be  very 
tender  and  (cdeina  mostly  of  the  lower  lid  will  develop,  movement  of 
the  eye  downward  bci  ig  restricted,  or  the  globe  may  be  tilted  up- 

^"Twatment.     In  aduHs  local    -lepletion     by  leeches  or  wet-cups, 
the  ice-hag   the  Lciter  coil,  or  compresses  wet  with  the  lead-ami- 
spirit  lotion,  rest  in  k'd;  in  rheumatic  cases  sodium  or  strontium 
s'llievlate  in  frequent  tloses  witii  or  followed  by  potassium  or  sodiu- • 
iodiiie,  and  in  these  subjects  dry  hetit  by  Japanese  hot-box  or  h.  ■, 
fomentations  mav  be  more   comforting   than   cold;    in    secomlary 
c-ises  a  short  active  course  of  mercury  by  inunction  or  internally, 
with  potass,  iodid.  in  a>eending  doses,  and  in  those  p1  the  t.     ary 
sfiL'c  pot    or  s(k1.  iodid.  in  doses  of  fifteen  grains,  thirty  grains,  to 
siMv  grains  every  four  hours.     If  signs  of  pus  show,  early  mcision 
t.;  the  bone  is  indicated,   followed  by  a  course  of  gentle  syringmg 
with  antiseptics,  e.  g.,  carb..lic  acid  1  :  100  or  1  :  40,  hydravg.  p<«r^ 
chlorid   1  :  .3000,  etc.    Svringing  should  be  kept  up  as  ong  as  there 
:  anv  purulent  discharge,  an.l  a  tent  or  lube  used  until  it  is  evu  ent 
tlie  d'isease  is  spent.     In  so-called  scrofulous  cases  syr.  fern  lodid. 
,"l  svr.   c-dciJ  lacto-phosph.,  syr.  phosph.  (Parrish),  ol.  n.orrhua« 
th  the  best   hygiene,  are  indicated.     In  case  of  osteoperiostitis 
ere    here  has  r,een  spontaneous  opening  the  probe  should  be  used 
Jul  y  so  as  not  to'di.sturb  unduly  nature's  barriers  and  cause 
further  "complication.    All  rough  bone  is  not  necessarily  necn/ic,  and 
i       should'be  given  for  necrosed  tissue  to  7-"^^ -«' '  ^^^f 
surface  to  heal  over  before  one  actively  mterferes.     Then,  if  nee<l  ul, 
,he  sinus  shoul.l  be  enlarged  by  sponge  tent  or  mcis.on,  and  ihe 
iiirctti"   miiiire  etc    u^d  xecumlcm  nrlem. 

Teioii  8     Th     is,  as  a  rule,  a  mild  type  of  inflammation  ..f  the 
.ap'dani'rtion  of  ti.e  orbital  fascia     7''-y"M>torns  are  ,Wsis 
:n  1  exophthalmos,  which    may  be   slight:  P^'/'';'  /'  '^^f,    ^  /  J 
pressure    with  impaire.l  nmbility.     (Ed.^m.  of  the  l^'/     ^       f     .  ,"^ 
'  lifiht  cases,  an.l  is  not  a  marke.l  feature  of  any.     Th.    is  •>«  P'  "'t 
i.rdiagnosi;  between  tenonitis  and  .-'^lU'lit. M'roiH^r-m  the  a    e    the 
u'dema  of  the  li.ls  is  marke.l.     Tiie  chemosis  of  tenonitis    s  also  ,  s- 
,i  c     and  at  times  .leci.led.  and  is  always  out  o^  .P-P-  j''"  ^^  ^ 
„.d,.ma.     The  reverse  is  the  case  m  cellulitis.     It  is  'I  '^Jylj  J 
tisin   -md   srout    mild   sepsis,  ami  erysipelas,    an.l    ah  ajs    f.)ll'.ws 
;ano,i;;halmSk  which  may  also  excite  cellulitis;    it   1.  sometimes 
I,,us,:.|  l.v  injury  an.l,  now  and  then   follows  t™"t""'>-  .     , 

Treatment.     In  the  tenonitis  o:  rheumatic  ..r  g..uty  ""K'"  ."  f^'^^ 
.u,l  "ee,ly  relief  f.-Hows  the  prompt  ..n.l  full  -»"»''  •-j'f;";;';  ,', 
str..n{:uni)  salicylate  with  or  witlumt  colchicum;  P"^'  ^f '"  "  ,^™ 
io.ri.le,  aiul  lithia  being  given  at  the  same  time  or  later.     Pilocarpine 


-^ 


I'.IH 


THE  KYE. 


or  jal)oraii<li  in  doso  suHicioiit  to  cause  free  sweating,  daily  for  a 
few  times,  may  suiJice  alone,  and  it  may  be  used  as  an  adjuvant  to 
hasten  recovery.  Topically,  tiie  lead-and-spirit  lotion  may  l)e  useful, 
and.  where  dry  heat  is  ])n'ferred,  the  .Japanese  "hot-hox.  " 

Injuries.  Foreign  Bodies,  etc.  I'oreign  bodies  most  often  enter 
between  the  fjlobe  and  the  roof  or  the  inner  wall.  A  larjre  foreign 
body  may  enter  and  be  impacted  and  the  eye  escape.  Hence  an  oft- 
hand  ojunion  shouM  not  be  given,  especially  in  view  of  the  tolerance 
of  the  socket  for  intruding  non-s(>|)tic  Ixxlies.  Many  notable  examj^les 
of  the  latter  could  be  cited,  curious,  interestuig,  and  instructive. 
On  the  other  h:!  1,  the  possible  risk  to  life  from  secondary  processes 
hi  seeming  slight  uijuries  should  be  kei)t  in  mind,  and  therefore,  as  a 
rule,  a  guarded  prognosis  be  given,  especially  in  view  of  a  jxissible 
medico-legal  bearing.  The  jrrimani  effects  may  include  injury  or 
los,s  of  the  eye,  or  lesion  of  the  optic  nerve,  with  sudden  blindness, 
or  true  aneurism,  or  aneurismal  varix,  or  free  liemorrhage  with  infil- 
tration of  the  tissues,  proptosis,  etc.  The  orbital  wall  may  l)e  pcnv- 
trated  or  fractured.  Following  forcible  entry  of  a  jKiinted  stick, 
foil,  etc.,  especially  from  below,  perforation  of  the  roof  with  lesion 
of  the  meninges  or  brain  is  ar-t  to  occur.  Bullets  may  enter  through 
the  temple  and  cut  the  optic  nerve,  or  plough  their  way  through  globe 
or  lids  and  on  into  the  anterior  ;»i  middle  fossa.  Severe  blows  may 
fracture  one  or  other  wall  of  the  orbit  or  of  the  optic  canal,  cause 
hemorrhage  into  the  .sheath  or  direct  lesion  of  optic  nerve  and  blind- 
ness, without  external  sign,  or  bleetling  into  -he  cellular  tissues,  with 
extr'ivasation  into  the  lids,  when  fracture  i-^  almost  certain;  or  may 
open  rommunication  with  one  or  other  sinus,  causing  ei.iphyseina, 
with  much  swelling  and  crackling  crei)itus.  Some  large  foreign 
bodies  lodge  in  part  in  adjacent  cavities,  as  the  sphenomaxillary 
tis.sure,  nasal  fossa,  etc. 

The  nvcondary  results  of  injuri(\s  are  orbital  cellulitis  (generally 
septic),  with  possible  optic  neuritis  and  airophy,  antl  blindness; 
paralysis  of  one  or  more  ocular  nmscles,  periostitis,  a'ld  osteitis, 
with  consecutive  meningitis,  Ijrain  abscess,  and  death;  also  throm- 
bosis (  ■  the  cavernous  sinus,  single  or  symmetrical,  from  the  septic 
orbital  ph'..  bitis  of  cellulitis:  and  enophthalmos.  It  should  be  borne 
in  mind  that  i)enetrating  wounds  with  lesion  of  the  roof  are  treach- 
erous; a  ([uiet  interval  of  several  days  or  even  weeks  with  fair  promise 
mav  end  abruptly  in  grave  acute  symptoms  with  speedy  death. 

One  may  get  .some  clue  to  the  lesion  from  tlie  nature  of  the  accident 
and  the  svmptonis,  and  by  the  careful  use  of  the  probe  and  finger. 
C.reat  pains  should  be  taken  and  will  be  rewarded,  while  care  is  had 
not  to  add  to  the  trauma.  Where  an  interval  has  elapsed,  a  sjiongy 
'•icatrix,  a  wound  which  will  not  (luite  heal,  or  one  which  reopens, 
is  significant.     At  times  several  foreign  bodies  may  be  lodged.     Some 


>  iifreotntoiies:  knifi'-bliulo,  3S  mm.  I.iiig  by  «  mm..  In  lower  pert  of  orbit  thirty-lwo  >■»".  ""•' 
normal  vision  and  perfect  movement  of  tlie  globe,    (r.  Holmes.) 


nrsic.isKs  OF  orbit,  l.'crymai.  apparatus,  am)  lids. 


I'M 


,.as,..  arc  not  (.bscurr,  e. ,,.,  tni  iiuiuu-fii  splinter  m  thj-  ou  cr  wall  may 
■.ripi.l.-  the  oxtornal  n-otus,  causing  ,,ain  in  attcn.i)t(Ml  al«luct..,n,  with 
Zlvv^rouX  s.iuintana  dipl.-pia.  A  skiagrai.li  aftor  t  ,.■  improv.-.l 
,u,.ti....ls  of  Swwt.  ]):-A-ia.on,  an<l  others  is,  of  cours.-,  -lecsiv.-  as  to 
the  site  of  metallic  missiles  or  other  foreign  bodies  opa-iue  t-  tn< 

'"Twatment.     Small  bodies  unless  easily  got  at  are  best  left  in  situ 
if  not  causing  trouble.     Large  bodi.>s  should  Ih-  removed  promptlj, 

oting  on  a  tVial  attempt  if  the  glolH-  is  dragged  upon      Some   reemg 

"  reful  dissection  mav  1k>  .u.-essary,  th..  wound  being  enlarge.l, 

and  i    c  so  of  in.racted-arrow-shafts  or  a  large  splinter  stn.ng  for- 

;  ' ,;     e  roMuired  in  lieu  of  th.  sequestrum  or  crocodile  if  .rn  wh    1 

1.  allv  suffices.     Iced  compresses,  c.ld  lead-an.l-sp.rit  lotion    le^ 

,  S     salines,  etc.,  will  t.'nd  to  ward  of=f  undue  reaction      If  pan 
!„u  Iswe  ing  persist  or  liglit  up,  with  pyrexia,  in  s^.te  of  these  am 

,;;;i  de  Iletlns,  and  pus  seems  fornuiig.  hot  fomentations  should 
1,P  u-<ed  and  incision  made  as  in  cellulitis  and  periostitis. 

P^satiut  Exophthalmos.   This  is  a  condition  larg.-ly  due  to  rau ma, 

i,.^S^^L  and  pulsation  of  the  'eyeball  a^dou^ul^c^- 

.,n<l  audible  tinnitus  are  leading  symptoms.    The  <>'  ^'^  '""  .\';^..'l,^ 

"t      hi  etiology  is  not  now  held,  for  there  can  be  no  doubt  that  u  m 

ost  otm  cL  to  intracranial  and  not  orbital  lesions,    he  "hang^s 

the    rbital  contents  Ix-uig  secondary  and  ^y"'Pt«?-'^'r;.     "  ^^^^/^ 

Vvv  cases  in  which  the  mischief  has  been  prove,   to  be  orbita   th^e 

haveti^n  found  true  aneurism  of  the  ophthalmic  artery  or  of  some 

,,f  its  branches,  traumatic  diffuse  or  cir- 

emnscribed  aneurism,   and   arteriov<-n«)Us 

aneurism,   aneur=sm  by  anastomosis  and 

aiigomata,  or  telangiectatic  tumor.     Ot 

intracranial  lesions,  the  most  common  is 

traumatic  aneurismal  varix  in  the  cavern- 

,ms  sinus,  the  carotid  artery  pumpmg  into 

ihe  sinus  through  a  breach  m  its  wall,  muI 

s„  into  the  ophthalmic  vein,  etc. ;  aneunsm 

,,f  the  internal  carotid,  aneunsm  of  the 

ophthalmic  arterv  at  its  point  of  origin 

s;:';.:*i  Xs  s.:vr :  a^=.^r;n.p, u. 

iiresent  in  many  cases.  _  „,„,i..p,i    with  inability  to 

Obifctivk.     Proptosis,  sometimes  very  marked,  ^^ '^"^  "V^^^^^^^^^^^^ 
..1.,  "he  eve,  a.ul  at  times  displacen.ont  -^-:f;;\,f /^^^ ^T-ll 
with  impaife.1  motility:  convergent  -^^"^^''^^ff^^^    fbr""  fore- 
abduction;  eyelids  dusky  and  much  sw.:-  n,  and  veins 


Vio.  101. 


J 


^ 


1 


2(K) 


Ti/A'  £rf:. 


hciiiland  temple  notably  (listende.!  and  <iuite  sinu< 


lus;  a  tense  Imt 


sil)le  vascular  tumor  at  inner  en( 


I  of  l)row— iliiateil  ophtlialmic 


ooinnressinie  viiMuiiw  lu......  ill • -  . 

vein-giving  a  strong  impuls.- to  finger-tii);  vessels  ot  ey.-hal  niuci 
engorgea  an.l  eonjunetiva  eluMnotic;  caruncle  large  and  t^eshy  an, 
nrotru.rmg.  (Kig.  101.)  Palpation  of  lids  an.l  globe  yields  a  thnll 
luul  distim-t  pulsati.m,  the  latter  visible.  There  is  a  loud  bruit  with 
ear  to  sid,.  of  head  ..r  at  any  point  of  it,  loudest  '.vith  stethoscope 
at  inner  end  of  brow,  with  instant  almost  startling  quiet  on  com- 
pression of  common  carotid.  The  latter  stops  all  thnll  and  pulsati.m, 
lheevci)all  readily  yields  to  pressure,  and  the  finger  may  1m>  dipped 
deei>lv  int.)  th.-  Hacci.l  ophthalmic  vein.  The  sight  and  hel.l  ..f  visi..n 
mav  be  normal  or  but  little  atlVcte.l.  The  fun.lus  sh.)ws  hyperainia  ot 
th."" optic  .liskand  pulsation  of  the  r.'tinal  veins,  which  an;  apt  t..  be 
greatly  dilated  an.l  t.)rtuous.  There  are  at  times  papillitis  an.l  reti- 
nitis, etc.  .  ,.        ,  .  . 

Etiology        Pulsating  exophthahmxs    may  be  idiopathic  or  trau- 
matic    The  former  occurs  mainly  in  females,  the  latt.>r  most  otten 
among  men :  while  in  some  of  the  traumatic  cases  the  symptoms  api«"ar 
i.uicklv,  in  others  they  .levelop  slowly.     In  the  idiopathic  varu-ty 
th.'V  are  apt  t.)  be  su.l.len  in  onst^t-pam  an.l  a  great  "crack     or 
"snap"  at  the  start,  an.l  in  a  few  hours  gmit  swelling  of  lids,  .clema 
of  conjunctiva,  proptosis,  an.l  pulsation,  with  most  disturbing  tinnitus. 
When  due  to  trauma,  an  early  if  not  the  first  special  symptom  ii.  s.)me 
cases  is  a  high  n.ite  as  if  there  were  only  a  small  hole  in  the  vessel 
wall     The  loud,  |)ulsating,  an.l  roaring  tinnitus  may  not  ensue  tor 
some  days  or  weeks,  and  the  same  interval  may  mark  the  other  mam 
svmpt.ims.     Aneurismal   varix   in  the   ii(>ck   may   cause   jnilsating 
exophthalm.)S  bv  damming  the  venous  outflow  from   the  sinuses. 
(Gifford.)     The  .liagn.isis  sh.mld  be  much  ai.leil  in  the  i.liopatluc  cases 
bv  the  rapi.litv  anil  fulminating  nature  of  the  sym])toms.     The  fact 
of  trauma,  m'"'"  or  less  severe,  and  of  the  tense  pulsating  sac  at  the 
upper  inner  iwrt  of  the  orbit,  at  once  made  flaccid  by  stoi)|)iiig  the 
caroti.l  flow,  shoul.l  .listinguish  from  orbital  growihs.  esi)ecially  vascu- 
lar malignant  forms,  which  also  cause  i)roi)tosis  an.l  pulsation.     Then, 
paresis  of  the  w/cr/i'//  rectus,  with  pulsating  tumor  .)n  the  i)i«(Tsiile 
of  the  eyeball,  is  significant.  .Some  points  in  the  patholixm  have  already 
been  cite.  1.     There  are  some  an.mialies;  the  absence  of  aneurism  ..r 
other  vascular  lesion  has  been  shown  in  a  series  of  cases  by  autoi)sy. 
An.l  in  vari.ms  instances  of  true  aneurism  of  the  internal  caroti.l  in 
the  cavernous  sinus,  as  proved  by  ])ost-m()rtem,  pulsating  exojrhthal- 
mos  hail  n.)t  occurre.l.     R.'lief  of  pressure  on   th.'  .)phthalmic  vein 
thr.)Ugh  the  setting  up  of  collateral  circulation  might  ex])lain  this. 

Treatment  and  Prognosis.  In  view  of  the  fact  that  th<>re  has  been 
spontaneous  recoverv  in  i)r.)bal)ly  7  or  8  jht  cent.,  some  surgeons 
f.iUow  an  .■xp.Ttaiit  course,  giving  pot.i-ss.  io.lid..  and  enjoining 
quiet  etc.  (:onipressi.)n  of  th.-  common  carotid  has  cured  in  a 
still  Larger  number,  and  rightly  is  held  w.)rthy  of  trial.  It  is  resorted 
to  by  snme  merelv  as  a  safeguard  before  operating.     If  kept  up  for 


nrSE.lSES  OF  orbit,  LACBYMAL  APPABAl'LH,  A.SD  LIDS.    201 

:i  short  time  ovorv  day  for  weeks  or  iiiontlis  in  idiopatliie  caws,  it  may 
siieeeed:  in  trauniatie  eases  it  should  Ih>  applied  eoiitinuously  for 
hours  dailv.  (Sattler,  iu  Noyes.)  In  a  ease  of  the  writer's,  of  suide 
pulsating  exophthalmos  due  to  trauma,  in  whieti  ligation  of  both  com- 
mon carotids  proved  ineffeetivi-,  it  was  prefern'd  to  test  first  the 
etTeet  of  i)r('ssure  in  conjunction  with  a  cours(>  of  potass,  iodid., 
iM'cause  there  were  no  urgent  symptoms  present:  the;  sight  was  good, 
there  was  no  pain,  the  i)rocess  was  seemingly  at  a  stand-still,  and 
eompression  had  availed  in  variou:}  cases ;  while,  on  the  other  hand, 
ligation  iiad  sometimes  failed,  and  was  itself  not  free  from  risk. 
Ligation  of  the  conunon  carotid  is  the  most  reliable  treatment,  being 
etfective  in  al>out  (M)  per  cent,  of  the  cas<-s  operated  on.  Death  has 
followed  iu  about  10  iM>r  cent,  of  the  remainder. 

Ligation  of  the  second  conunon  carotid  has  now  and  then  l)een 
curative  in  failure  of  ligation  on  the  affected  side.  Ligation  of  the 
external  carotid  on  the  affected  side  after  failure  of  that  of  the  com- 
mon carotid  has  sometimes  been  successful,  and  in  the  writer's  opinion 
it  is  a  step  that  should  be  taken  in  preference  to  ligation  of  the 
second  common  carotid.  There  seems  ground  for  the  view  that 
treatment  bv  prolonged  compression  militates  against  the  success  of 
lisration  As  a  rule,  life  is  not  jeopardized,  although  rendered 
miserable  in  cases  which  have  been  left  alone.  The  attempt  t(.  plug 
tiie  oi,hthalmic  vein  bv  a  firm,  deeply  placed  clot  by  means  ol  gal- 
vmoinmeture  the  positive  pole  (needle)  being  passed  farm,  is  worthy 
of  trial  and  it  should  prove  useful,  if  not  ;)er  se,  at  least  with  com- 
pression, medication  by  potassium  iodide  and  ferric  tannate,  or 
when-  ligation  has  given  only  Jiartial  relief.  ^      ,      .      ^  .    . 

l)r  Argyll  Robertson  reports^  two  cases  of  pulsating  tumor  of  the 
orbit  with" bruit,  in  which  electrolysis  was  used. 

Thrombosis  of  the  cavernous  sinus  causes  venous  stasis  in  the 
.„bit.  with  g.'i>eral  infiltration  and  .edema  of  lids  If  due  to  sepsiss 
a^  is  th.-  rule,  phlebitis  and  thrombi  with  cellulitis  to  low,  with 
marked  .edema  of  li-ls,  (>x..plith:ilinos,  an.l  immobility  of  gl..lK>.  He- 
Inn-  tl,.-  .-veball  Ix^eom.-s  tix.^.l.  paralysis  of  the  thir.l  ai.  sixth  nerves 
,nav  be  ma.le  out.  The  pupil  is  g.-nerally  .li  ate.l.  There  may  lie 
irrrat  tortuosity  or  thrombosis  of  the  intra-ocular  veins,  with  mipaired 

-iijlit  or  blindness.  .        .  .    . 

Etiology.  Thn.mbosis  of  the  cavernous  sinus  is  generally  se,)tic  in 
ovWm  and  -hie  t..  purulent  ..r  carious  foci,  likely  infective,  in  some 
part  of  the  h.-ad  or  neck:  nu.st  often  a  se.piel  ..f  inf<>etive  mHammation 
l,i  the  lat.Tal  sinus,  with  septic  thrombosis  fn.m  sui-purative  otitis, 
with  or  without  caries  of  the  petrous,  l-rysipelas  may  set  up  throm- 
bosis thn.ugh  the  medium  of  orbital  phlebitis  or  cellulitis;  also  septic 
to,.;  mav  cause  it  in  the  nasal  f.issa,  lacrymal  sac,  ..r  cheek,  as  m 
u.ihrax  or  malignant  pustule.    Thrombosis  of  the  second  cavernous 

1  Transactions  of  Ophthalmologtcal  Society,  IS9!1.  ,  v-,„.»inm  »ni  tt 

'  TranMctions  of  the  OphthalmoU.glcal  S<K-ie.y  of  the  fD.ted  K.ng.iom,  vol.  ix. 


I  ' 


ao2 


rut:  t:Yh:. 


siniH  occurs  l,v  cvtonsion  froiii  thn  first  throuKh  the  circular  smus,  or 
.lircctlv,  as  in  '•■rvsiiH-las.    This  continpMicy  ad.ls  a  l<-atuiv  ol  jtravit y 
to  fncial  crvsiiM-las  wliich  siioul.l  Ix'  borne  in  iniiul.     lii  throinLosis 
tlicrc  woul.i  1h'  the  Rravc  Roncral  con.lition,  weak,  .lUick  puiso,  tcm- 
,M>raturc  sl.ouiiiK    stcci)-iK-aki>.l    chart,    with    prol)ahl.-    rigors   and 
hchctu.lc,  tlic  liistorv,  likely,  of  chronic  otorrh.eu  or  recurrent  ot.tm 
witli  .ideina  and  teiulerness  over  and  behiiul  the  p(,stenor  edjje  ol 
the  mastoid,  an.l  double  o|)tic  neuritis.     To  make  a  correct  diapnosw 
is  to  cive  a  ba.l  i.roRnosis  a.ul  to  avoid  tlu-  error  ol   treating    he 
,..,ndition  as  cellulitis  i>er  se,  for  s..ptic  cases  an',  as  a  mle,  sinvdily 
fatal ,  and  when  double,  death  is  the  m. .re  certaui.     In  the  early  stage 
antitoxin  treatment,  or  the  use  of  Credo's  omtment,  coUargolum,  etc., 

mav  ijrove  of  value.  _  .  ■     i  *• 

Tumors.  The  anatomv  of  the  orbit,  its  constituents  and  n;lations, 
ren.ler  it  prone  to  lHT..nu- the  seat  of  neoplasms  and  to  be  mva.  ed 
hv  growths  of  adjacent  parts.  Any  change  in  tli.-  bulk  o  its  contents 
„r  its  capacitv  is  apt  to  alter  the  position  of  the  eyeball,  which  is  a 
sort  Of  movable  plug  in  the  8t>ptum  orbitie.     Hence  prominence  or 


Fig.  Wi. 


F.0  102.-?«reon,a  of  orbU.    Twenty K,ne  tncte,  in  circnmferenco^  Wel.-h..  thr^-e  ponn.l.. 
Fio.  lu:!.-.v  .ry  i.x.».io»ls  of  F.  Sinus  an.l  orbit  witti  murkf.1  exophthaln..*. 

protrusi.m  of  Mie  globe,  cxophthohm.,  is  the  most  common  sign  and 
l-,.suli  of  orbital  hvperplasia  an.l  tmnor,  and  it  .,ften  .lepends  u.o 
the  same  changes  in  adjacent  caviti<-s,  with  disteition,  etc      \\\nn 
the  glob.-  is  push.-d  straight  forward  or  in  the  line  ot  axis,  the  tern, 
,,ro^osi.  is  used;  displacement  is  generally  lateral  ..s  ^vH  ^^  '  ^^   '1^ 
\  .  isnlaced  eve  mav  fiuictionate  normally  ami  give  no  t n.uble.  but 
;.rip,.lin.r  of  <me  or  other  of  tlu-  orbital  muscles,  directly  by  pressure 
or  invasion  ..f  its  fibres,  or  through  the  motor  nerve,  at  once  causes 
disabilitv.     The  ease  with  which  paresis  is  m.luced  renders  ,t  a  coii- 
,non  result  of  orbital  lesion  fas  well  as  intracraman      In  add  Hon 
to  exophthalmos  and  defective  motility,  <v<lema  of  the  lids  ami  at 
times  great  stretching  are  incidents  of  orbital  groxMi      lam,  wluci 
is  o'Jen  wanting,  may  be  most  s.>vere  and  annoying  if  there  ,s  much 
tension  of  the  parts.  . 

Tumors  of  the  orbit   may.  as  e'sewhere,  be  benign,  recurient.  or 
malignant.    To  the  benign  class  belong  fibromata,  osteomata.  e>bts. 


DlsKASJiS  OF  ORUIT,  LACIIYMM.  M'r.m.Vri.s.  AMi  LUX.     •2(t3 


Fill.   ICH. 


Sarcimie  of  orbit.     Encf|.haioltl  f  nicreiiin 
LlviiiK  tblrtetii  jcars  antrwanl.    No  ncur- 

rtiice. 


vaspular  tumors  (anRioumta,  oto,  ami   lymphoinata  or  lyiiipliailc- 
luiinata.    Malignant  growths,  j;li(iiimta,  farciiHiiiiata.  sarcomata,  tic.. 
arc,  of  course,  apt  to  recur,  tlu-  rouii<l-eell  xareoma  of  eliildreii  praet-- 
cally  certain;  but  nrurrcnce  dues  not  stamp  nialinuancy,  for  \ascular 
ami"  cystic  neopla.sms  are  prone  to  prow  apain  unless  ermlii-ated.     .\ 
fatal  result    is  hroujrlil   aliout   liy  extension  to  the  brain  along  ' 
optic  nerve,  or  tliroupli  the  splic- 
noidal  fissure,  or  through  tlie  walls, 
e.  (J.,  roof  by  caries  or  l)y  metas- 
tasis.   It  is  often  delayed,  and  may 
l>e  averted  in  orbital  tumor  from 
the  preat  tendency  in   such   cases 
to  prowtli  outward,  i.  c,  forward. 
(Kips.    102,   103,   and    104.)     The 
division    may  1)0  arbitrary,  but  is 
useful,  of  orbital  tumors  into  those 
arisinp  within  the  socket  and  start- 
ing from    the   cellular  tissue— the 
main     seat,    the     walls,    lacr>-mal 
pland,  optic  nerve  or  vessels— and 
those  invaiUnp  the  orbit  from  ad- 
jacent i)art.s  or  cavities,  as  is  often 
the  case  in  osteomata  anil  sarco- 
mata.    In  the  latter  in  younp  sub- 

j,.cts  with.mt  i.ain  or  pyrexia,  there  may  Im>  no  sign  un.  ev.phtha- 
,s  shows,  and  then  there  is  rapid  growth.  One  should  --^'^^^^  ---]] 
such  points  as  the  condition  of  the  pat.ent  the  s,7.e  and  tlu-  rat  f 
prow  h,  site  or  origin  and  attachn.ents  ot  tlu-  ....oplasn.s,  whether 
fixed  or  movable,  hard  or  soft,  smooth  or  m.dular,  <-'i;>-<-''  ; 
",.nder  or  pulsating:  the  kiml  and  degree  of  displacement  of  th,> 
g  e  anVof  anv  paresis,  the  acuity  of  vision,  state  of  the  f.tndus 
oculi  and  of  the  idnexa  an.l  accessory  sn.ases.  As  growths  Nar> 
:.'  nudtln  nature,  and  if  .n:dignant  should  ^^rfy^^^^^^^ 
at  all    it   is  advisable  to  employ  every  diagnostic  au        1">1'"  ' 

,di,e  careful  use  of  the  finger  can  tell  one  much.        "^  'J  ;   '^ 
i.  pn-ssed  along  and  just  within  the  orbital  run    ••*»;7'       ''•    "^ 
Letlveen  it  and  the  globe,  testing  the  floor  of    >»;i7'; ;;'";,;  J 
region  of  the  ethmoid  back  on  the  ir.ner  wall,  of  t"">  ";     P'^'   ' 
owl  of  the  antmr-.     Cvsts  mav  feel  hrm  when  well  packed    sett, 
:     .d-c^U  s^:^a  if  encapsulated.,  ttuiy  stretch  the   Kig  so    igh  ly 
ts  to  sp,.m  quite  hard,  ami  a  subperiosteal  mass  of  the  same,  or  .  n(  n 
.      u  :  may  simulate'  hyperostosis.     Hence  the  .>eed  "    -P  ;;  f  ^  ^ 
i„,  sion  to  determine  the  true  state  of  thmp.,  espma         h.  ,    co 
deep  for  palpation.     Under  asepsis  it  is   ree  from  ^^P.'^  "'.J  r|r'fX 
it  slould'alw'ays  be  made  in  cases  of  .l"ubt  ,   A--.  .    is  c^  fully 
made  through  the  skin  m  line  with  ^^'^^''^  J'f"'^'^  T'^,:,,^    '    ;„„ 
within  the  Jrbital  margin,  or  between  the  ''£ -^l'^      '^f^fb^  S 
deeper  and  slowly,  and  if  beyond  one's  ken  the  mirror  ma>  be  aeci, 


i 


I 


n 


ii 


20^1 


THE  EYt:. 


i,lso  tl.o  r.ttlr   liiw-r  a...l  prolK^.     Kxplorutory  ,ninrtur..  at   tiiuos 


(jivt's  11  U!*t 


till  liini,  aiul  till'  iiiicriiscopc   iiiay  Im"  \uv< 


ili'tl  to  fix  till 


tliajjiii 


iis.     Knuilfiii's  ujttcf "plastic  rt'sci 


tioii  of  till'  outer  wall  of  the 


.rbit  has  1 ii  ur>£<". 


1  ami  UK*'. I  for  (lia>!iiostii'   purposes 


It  I 


las 


pn 
\vi 


)V(M 

th  tl 


1    useful    ill   exposing   ami    reiiinviiin 


leep-seateil    neoplasms 


le  leas 


t  risk  to  the  (ilohe,  optic  IK 


rve   etc.     lives  iiiav  ie(|Uire 
(I  1) 


,.,  1„.  s.erilice.1  l.v  n,HTatiiiK  from  the  Iroiit  which  couM  U-  sav.-.l  l.y 

1,..  Kr..nl.Mii  metlio.1.     This  Kraiite.l,  K"«»<1  ^..rk  can  U'  <lone  a.i.l 

1.  ^owths  remove,!  I.y  u.eisions  through  the  li.ls.     It  ,s  important 

uXL  the  state  of  the  n:usal  imssa^es  l,y  ant.-r.or  a.ul  posterior 

i  ...  '  ■  -.aiulof  themaxillary  sinus-  at  l.-ast  by  exclusion-I.e  ore 
Ki\inK  ■  ..  prognosis  .)r  resortiuR  to  o,K.rat.ons.  Iraus.i  uimnatu. . 
mVv  Ik  o  Iryirv.  for  if  the  antrum  or  fn.ntal  smus  f^il  to  light  up 
there  is  iikelv  a  growth  or  other  iiusrbid  condition. 
"'  .  U"  ,„„  may  '.gin  in  the  li.ls  an-l  dip  into  the  orbit  a.id  .  .nay 
.tart  in  the  orbit  and  invad.-  the  li.ls,  mv.>lyi..g  also  the  lacry. nal 
g  !  id  aiul  re.,uiring  sacritic-  of  the  latt.T  m  the  extirpation  (de 
Schweinitz).  The  ran-  e,u-n,,snM  rarenu,us  variety  of  ='"{^';'""' ^ 
iMtes  tumor  of  the  ..ptic  nerve,  but  vision  is  unaffected.  It  is  remoM.l 
I'.v  careful,  lissection.    The  Kroiilein  method  is  pr.-ferable 

■  ineurism  hu  AwiMomosk.  Subcufcuieous  na-vus  is  a  species  ol 
•mltioma  in  whi<-h  congeries  of  .lilate.l  arteries  fnmi  a  mass  that  yie  ds 
,,ulsati..n  an.l  a  t..ugh  au.l  .loughy  fei'l  on  pal|)ation,  a.u.l  gives  a 
bluish  tinge  to  the  swollen  lid.  i.  -i    .    i 

To  a  varietv  of  angioma,  vnric.-  vein,  in  th..  ..rl.it.  is  attributed 
th.-  rare  inlrrmillrni  exophthahnr..,  in  which  protrusK.n  ..f  tli(.  eyeball 
,„.c..fs  wh.-ii  th.'  h.-a.l  is  depen.leiit,  an.l  n'cession  m  the  erect  <.r 

reciiiiibeiit   p..sition.  •  it   ;-        mtro- 

l  umnhiiiKiiomn  is  allie.l  to  caverm.us  angioma.      It  is       retro 
ocular  encapsule.l  growth,  an.l  is  similarly  treato.l  by  extirpatmn. 

rare  >m,lo>nn  ...•.■u.-s  n..w  an.l  th.-n  as  a  ...ft  ..r  .l..ughy  ..ncai.sule.l 
tum..r.  ca.ising  ex..phthMlm..s,  etc..  an.l  sh..uld  Ik-  .lissecf.l  ..ut. 

h,mphm,„  ..r  hr,pl>'"f<-'^'>">''  '^  ^''  ..eeasi..na    iim..c..nt  lu-oi.la.s.n 
simulating  .•lini-'ailv  an.l  l.ist..l..gi.-ally  small-c.;ll  sarc..ma.  iH't.y.H'  " 
i  ,g  t..  a  bill  .-.urs..  of  ai-s.Miic.     This  reme.ly  sl,..ul.l  have  a  hu    tri  .1 
in  ail  .l..ul.tlul  cases  as  should  p..tassium  i.,.h.le  wlu-nevr  there  .>  tl  e 
lea.st  susi.icion  ..f  specific  ..rigiii.  ♦!       n 

Li,.  J,  or   ......apsde.l    fatt:.   tumor    s  ..very  slow  gn.v.th.     . 

<mall.  it  mav  b.-  tVlt  as  a  soft,  elastic,  nu.vabl..  tum..r:  •>  '^''^Y,'' 
eve  an.l  li.ls  will  be  m..re  ..r  less  pn.minent.  an.l  the  atter  yu'H  a 
flVshy  f.«l.  Ii  is  very  rare,  an.l  excision  is  the  only  treatia.-nt. 
Fibn.-an.nolii.oniM  is  ii.it  unusual  f\V.  A.  H..l.len). 

rhnn.ln.ma  or  n,rl,ondnm,>.  .a  j.ur.'ly  cartilaguu.us  tumor,  is  ex- 
cee-linglv  raiv.  It  mav  spring  fn.m  the  sphenoi.l,  an.  ,  gn.wmg  ver> 
slnv'ly  cau^r-  at  !.i,gth  gro.Mt  exonlitholmo.s.  N.)W  an.l  then  ehondr..- 
saroma  an.l  ch<.ii.lrotibroma  oecur.  i    .    „  ,„i„ 

T>nmr  of  thr  Optic  Xrnr.  Th.-  f.-atures  are  sl.,w  an.l,  as  a  rue, 
painless  growth  in  a  healthy  subject,  gradually  increasing  proptosis, 


'im'mm 


DISEASES  OF  ORBIT,  LACRYilAL  APl'.iliATUS,  AXD  LII>S.    205 

.,tly  ill  thi'  line  of  tin-  axis  of  tin-  orl)it.'  Imt  willi  i  lohility  of  the 

Imll  prolial.ly  H"<«l.  "I't""  "•'uriti'^.  or  "atrophy,  "  aii<l  visu,    curly 

I  or  lost.-     Ill  some  cases  iiiarkcil  liy|MTimtropia  develops 


inos 
iiiipam 


from  flatt«'iiiiiK  of  thi-  y^My^'  l>y  retro-ocular  i.ressure.     I'alpatioii 

may  not  make  out  the  tumor  if  small.     Removal  is  indicated.     The 

iplasm  is  encapsulated  and  non-recurrent,  and  therefore  the  projj- 


neo, , - 

..         Leiy  a  much  higher  i>erceiitape  succiiml) 

to  "iiiiracranial  extensi..n— possibly  after  a  loiij;  interval- than  is 
«ia«|M-cted.  Filiromatosis  e.xpri  .sses  the  patholojiical  character  ot  these 
growths,  which  histologically  are  es.sentially  mesobla.stic  in  nature 
iHvers).     (See  page  4r»4.) 

Oi'KK.vrioN.  Kxtiri)atioii  may  Ix-  done  by  careful  deej)  dissection 
till  the  inner  or  outer  side  of  the  glob'  with  the  hnger-tip  as  a  guide 
(11  Knapp's  method),  tlie  closed  sci.ssors"  jwiints  being  used  to  s<'p- 
arati"  parts  and  to  i.solat«'  the  gnn.th.  Hie  externa!  n-ctus  and 
outer  caiithus  mav  with  advantage  Ik-  cut  to  gain  access  (Lagrange), 
to  be  reunit«'d  after  removal.  The  optic  nerve  is  cut  clos«-  to  the 
•iiH'X  traction  is  made  the  neoplasm  detached  from  the  gloh<-  if  m 
contact,  the  ner^e  then  divithd  next  the  ey«'ball,  and  the  gro\yth 
brought  away,  tninie  prefer  to  section  tlie  ner\-e  in  the  r<-vers<-  order. 
The  eve  sometimes  is  saved,  and  remains  cosmetically  g(K.d,  but  •■  lort' 
often  "it  is  either  sacrihced  or  finally  shrinks.  Th.'  Kronlein  method 
■  ives  fncr  access  to  the  orbital  contents  than  the  above  method, 
ioiig  in  vogue,  and  with  less  risk  of  excessive  hemorrhage  anil  of  loss 

"'  Kuonlkin's   Method.     A  slightly  curved  incision  is  made  al..ng 
the  outer  bonv  marg.n  of  the  orbit,  dividing  the  periosteum.    I  he  peri- 
..steum  Hniiig  the  iLrsi.lc.f  the  lateral  wall  of  the  orbit  -retracted 
t.g,.ther  with  the  soft  orbital  content.s.  and  the  '"t''"<'r  «;rl.itaUsMir( 
localized.     From  th.-  anteri..r  en.    oi  this  hssu.v  the  «'"">.;;'"; 
the  orbit  is  cut  through  with  a  chisel  along  two     ^<''-f-'";.P    "  ^^     :^'^ 
one  pa-siiig  up  and  out  to  the  exiernal  nngular  process  ot  the    ront.i 
I,!  ,ne   urJx\.l  -v  in  th.-  suture  lH.tw..n  the  great  wing  of  the  s,.l,..noid 
Mnd  ille  malar  bone,  and  the  other  in  a  horizontal  plane  V^^^ 
;,nd  forward.  api.earing  on  the  .-xfrna    surfa.-e  of  the      a  ar  Ih 
i„  ,  |i,„.  direc.tlv  alx.ve  the  inserta.n  ..f  the  zygomatic  "rch      Ihis 
we.lge-sluM>."d  piec.-  of  bo.      with  its  muscular  and  '^^^^f^^^: 
nuiits    is  stronglv  forced  backwanl.  giving  fn-e  access  to  the  orbi 
T,p;.riosteunil- incised  inahorizontal  .lirection  (.Mno  d  H.  KnapP  • 
.Nftel-  removal  the  bone  and  overlying  soit  parts  are  ^'Pla  - U    I      - 
!,,tt..r  earefullv  .suture.l.    The  electric  circular  saw  makes  .lUickir  and 
hett.^r  section  of  the  b.me  than  the  chisel. 

Oleoma.  The  ivorj-  exostosis,  osteoma  ehurnea,  which  is  the  one 
most  often  met  wi(h  in  the  orbit,  is  of  very  slow  and  pamles.  growth 
a.ul  as  a  rule  gives  n<.  sign  u:.  exophthalmos  'M>P«;ars.  It  is  at 
lime,  well  borne  until  there  is  decided  malposition  of  the  glof^e,  and 


>  About  60  per  cent 


70  per  cent.  (Byers). 


H    -:  ? 


!H 


It! 


206 


r/Zi?  EYE. 


so  llisKllou 


IS  is  its  growth  tii;it  lliis  is  tlic  case  f'\ 


,-on  whon  it  has  startod 


II  tlic  fniiital  (or  t 


it.     When  it  involves  or  invai 
other  syiiii)toiiis 


thiiioi(lal)  sinus  and  pushed  the  orbital  wall  before 
les  the  cranial  cavity,  cephalalgia  and 


[ire  apt  to  sot  in,  and  optic  neuritis  may  occur. 


I'alpatioii 


;ho\vs  a  hard,  li.xed,  nodular  tuiiio 


ir  on  the  orbital  roof 


or  inner  \va 


a  rule,  am 


1  a  smooth,  hard,  licmisi)herical  swellinjr 


t  is  in  the  sinus.     Hut  exjiloration,  as  stated,  is  necessary 


if  the  -ea 

to  a  correct  diafjnosis. 


riie  etiology  is  indefinite;   rheumatism.  g( 


)Ut, 


ihili 


etc.,  are  of  uncertain  wei 


ht.     Trauma  has  a  jjlace.     In 


three  fronto-oi 


bital 


ca.ses  o 


if  the  writer's— two  osteomti  ebunica- 


traunia  in  earlv  life  was  almost  suiel\-  a  tactor. 

Treatment.     This  is  extirpation,  which  is  a  safe  procedure,  and  the 
eve    as  a  rule    c-.n  be  .saved.     The  same  may  be  said  of  sinus-ori)it 
ri<es  if  the  proper  method  is  followe.l      The  attempt  to  remove  only 
the  orbital  part  bv  attacking  the  body  of  the  tumor  is  unsafe,  and 
is  not  now  made.   "  It  has  been  replac(>d  by  the  method  of  "  subi^erios- 
teal  enucleation  ■'  of  H.  Knai)p,  after  Maisoiineuve.      Flie  first  step 
in  the  operation  i)roi)er,  after  reaching  the  site  by  incision  througli 
the  li.l    septum  orbita',  etc.,  is  to  divid(>  the  periosteum  over  the 
tumor  and  peel  it  off  to  the  basal  wall;   the  latter  is  then  carefully 
chiselled  through  close  to  the  tumor,  and  the  latter  is  gra.sped  and 
rotated,  ami  then  lifted  or  shelled  (mt.     If  the  tumor  be  of  the  smus- 
orbit  kind-e.  r/..  growing  from  the  frontal-the  wall  or  walls  will 
re.iuire  chiselling  in  order  to  release  the  growth  from  its  bed.     Alter 
removal  an.l  careful  cleansing,  etc.,  the  periosteum  is  reunited  by 
de.-p  sutures,  and  then  the  wound  closed.     Packing  or  a  . !  rainage-tul)e 
may  be  used  temporarily,  ami  after-treatment  is  according  to  general 
i)riiiciples.  .  . 

Kmcuhahrcle  is  a  congenital,  fluctuating,  nearly  always  pulsating 
and  compressible  tumor,  found  at  the  inner-ui>per  part  of  the  front 
of  the  orbit,  ami  at  times  is  of  large  size.  It  is  a  hernia  of  the  bram 
and  membranes  through  a  hiatus,  which  may  at  times  be  felt  at  the 
site  of  junction  of  the  frontal,  lacrymal,  and  superior  maxillary  l)ones, 
and  is  often  double.  It  is  extremely  rare,  and  is  inoperable.  Its 
diagnosis  is  onlv  imi)nrtant  if  the  subject  lives— the  exception. 

Siircimia  is  the  most  common  growth  in  the  orbit,  and  occurs  more 
often  in  children  than  in  adults.  It  may  originate  in  any  intra-orbital 
tissue  or  invade  the  socket  from  adjacent  p.arts,  sinuses,  etc.  Sar- 
coma of  the  choroi.l,  like  its  congem-r,  glioma  of  the  retina,  may 
beeome  extra-ocular  and  then  virtually  orbital.  In  som<«  cases  the 
growth  forms  a  large  mass,  which  is  covered  but  partially  by  the 
I'reatlv  stretched  lids— so-called  eiicephalui.l  or  fungus  lia'inatodes. 
Kven'.it  this  stage  radical  relief  may  follow  exenteration,  and  this 
is  the  more  likelv  if  the  tumor,  though  large,  be  movable  and  the 
periorbita  unaffected.  Prolonged  immunity  from  pain  and  recnides- 
eeiice  at  least,  mav  be  ha<l  in  seemingly  desp.'rate  ca.sos;  but  this 
applies  almost  who'llv  to  adults  and  to  mixed  forms-c.  f/.  adeno- 
sarcoma  aiul  fibrosarcoma.    The  latter,  which  are  encapsulated  or 


VIHEAHLil  OF  ORBIT,  LACBYMAL  APPARATUS,  ASD  LIDS.    207 


oircumscrihcd  iuul  of  very  slow  growth,  yidil  pood  results  t(j  thor- 
ough cxiMsioii.  (This  holds  also  in  rogard  to  carcinonia.  which  has 
occurred  onlv  in  tlie  laerynial  gland  and  on  the  optic  nerve.) 
The  consensiis  of  opniion  is  against  operation  in  orbital  sarcoma  of 
ciiildren,  in  whom,  as  a  rule,  it  is  of  the  small,  rouml-cell,  most 
malignant  tvpo,  and  decidedly  if  growing  from  a  sinus.  It  is  lieKl 
It,  he  inoperable  in  the  sense  that  recurrence  is  almost  certain,  and 
death  is  ha>^t<'iied  rather  than  retarded.  The  relief  ()f  i)ain  or  other 
Miecial  indication  or  condition  may  warrant  opeiati(m. 

KxKNTKH.vTKJN  (ou  Kvisckkation)  o¥  thk  ( )iiHiT.    Complete  exen- 
teration means  the  removal  of  all  tli-  contents  of  the  socket,  includ- 
ing the  perio.-^teum  to  the  apex,  and  also  at  times  ablation  ol  one  lid 
,,r   both    liils  when   involved   primarily  or  in   course.    The   outer 
caiithus  is  divided   bv  a  cut   to  the   bone,  the   lower  lid   is  drawn 
.lowii,  and  an  incision  is  made  in  the  retrotarsal  fold  to  the  bony 
luargin  from  the  outer  to  the  inner  canthus,  and  then  similarly  to 
the  upix'r  orbital  rim,  i)assiiig  l>ehind  the  lacrymal  sac  if  it  is  iiealthy. 
The  closed  scissors  (strong  and  curved)  are  then  iws.'^ed  deeply 
along  one  or  other  bony  wall  and  made  to  sweej),  if  feasible,  aroun.l 
the  ma-^s      Traction  is  made,  and  the  tissues  cut  as  close  to  the  apex 
;,-l)ossibie:  bleeding  is  stop])ed  by  pressure:  the  periosteum  is  treed 
rn,m  anv  remnants  bv  the  scissors  and  sharp  curette,  and  the  stump 
trimmed  ;'iid  treated  with  10  per  cent,  solution  of  zinc  chloride.     Ihe 
outer  canthus  mav  1k>  restored  l)v  .'futures,     \\hvu  oozing  has  ceasec 
the  cavity  is  cleansed  and  packed  with  medicateil  gauze  anointed 
with  steriiize<l  vaseline;  a  compn>ss  is  aj.plied  over  the  lids  and  s<>cure( 
bv  a  bandage.     The  outer  dressings  should  be  replaced  on  the  second 
<lav  but  the  ixu'king  niav  be  left  four  to  six  days.     If  the  growth  is 
adherent  or  the  periosteum  involved,  the  latter  is  detached  at  the 
margin  of  the  orbit  all  around  and  from  the  walls,  so  as  to  be  removed 
entire  as  far  as  mav  be  when  the  tissues  at  the  ai«'x  are  severed 
\nv  di-^eased  periorbita  or  patches  of  bone  found  are  curetted  and 
treated,  as  well  as  the  stump,  with  10  per  cent,  solution  of  zinc  chlo- 
ride, or  th.'  chloride  of  zinc  i)ast<-  applied  on  lint.     If  the  floor  of  the 
orbit  is  carious,  it  is  advisable  to  explon^  the  antrum,  and  thorough 
removal  of  the  contents  of  the  latter  is   necessary  if  it  has  been  in- 
\aded      It  is  wi.^er  to  sacrifice  the  li.ls  in  i)art  or  wholly  than  to  l(;aye 
anv  suspicious  tissue  which  mav  be  the  nidus  of  new-growth.     Ihe 
l.icVvmal  tfland  is  alwavs  removed:  and  if  the  sac  is  nnphcated,  it 
-hould,  of  cour.-^-,  be  cu\  awav  and  the  nasal  duct  carefully  curetted. 
If  die  lids  are  to  be  sacrificed,  the  first  step  is  to  cut  through  the  skin 
•  .  tile  bonv  rim.  and  follow  this  around.     Recn-ery  is  much  (luicker 
ind  after-tivatm.'nt  simpler  if  the  denude.l  walls  of  the  orbit  are  at 
,nce  lined  with  Thiersch  skin-flaps  carefully  adapte.l  and  su].ported 
!.v  iK.ckiiK'  (Mickulicz  and   H.  Friedenwald).     The  Thiersch  grafts 
niav  also  b,.  ai)plied  later  with  advantage  to  the  ((.repare.)  granu- 
latmsr  surfaces  ( liusachi).    Tlu-  .•xlieme  retraction  of  the  luls  is  thus 
ixerfd  and  a  special  form  of  artificial  eye  may  be  worn. 


li 


208 


i! 


THE  EYE. 

blood,  scbii 


•icrouR.  1)100(1,  sebaceous,  dernioul,  hydatids, 
echhiu7.'.eeiraml  fvsticerci.     Tliey  occur  mainly  in  the  front  of  the 
orl.it  are  mostly  c.msenital  and  ..f  slow  prowth.an.l  are  pan.less  unless 
very  'large      They  may  be  firm  on  palpation,  but  on  exposure  elastic, 
f  not  Huctuatini.     Hydati.ls  are  yery  rare  in  Anu-ru-a:  .J.rmo.ds 
are  not  unconnno.i.    Th<>  latter  may  lie  dormant  durmg  adul  K-ence, 
sLyins  as  a  circumscribed  swelling  at  sonu'  pomt  just  ^v.tlun  the 
.     ital  rin..  and  th.-n  at  puberty  begin  to  grow.     Their  contents  may 
be  yaried,  as  thev  an-  ,1.>  where.    It  is  well  to  beam,  nund  that  c>.  ^ 
are  often  found  "to  dip  deeply  h.to  tlu-  socket  and  to  n.terp(n.etra  e 
,.,rts  f.  a  degree  not  siisp.>cte.l  before  they  are  explored.    .\n.l  a>  the> 
„ay  be  unit.^l  to  th.-  she  -hs  of  the  muscles  or  of  the  opt.c  nerye  or 
glube  itself,  their  remoyal  may  requin-  careful  an.  1  deep  dis.section, 
wit    risk  to  healthy  parts.     Hence  some  pn-fer  ohhteraom  by  mcision, 
'v  sceration,  in  hydaf-d.s  as  w<>ll  as  dermoids,  etc.,  an,l  light  cauteriza- 
tion of  the  sac-liuin;;  l.y  means  of  arfj.-nt.  n.t.  crystals,  or  so  .  t.nct. 
dine    etc..  applyi.rg  cold  to  less.-n   un.lue   reaction,  and    keeping 
"um.th  open  until  the  walls   become   fused  ( BulU-r.  Mathew.soi, 
8t  ui.lish.  et  -.1.     Antiseptic    inj.'ctions   are  us.-d  to    the   same   end 
(Swaiizy^.     Others  ,lo   an.l   adyise  extirpation  (Berlin,  Nettleship, 

^^Eiophthataiic  Goitre  (Parry's  Disease,  Graves'  Disease,  Base- 
dow's Disease).  This  dis.>ase,  as  the  name  suggests,  is  marked  l.y 
j;it  "  and  enlarg..meiit  of  the  thyroid  gland,  which,  with  tachy- 
rar  1  a  and  tremor,  form  the  so-calle.l  canhna  symptoms  Ihe 
wei<rht  of  eyidence  points  to  the  f.xic  action  oi  abnormal  thyroid 
s.-cn-tion  as  the  cause  of  this  strange  symptom-comi.lex,  with  a  basis 

"'BrAoX^'^i^ullySO  per  cent.  ..f  the  cases  are  females,  and  about 
T?  1)  '  'ent.  occur  in  the  third  decade;  it  is  rare  early  and  late  m 
lif,.  The  acute  form  follows  fright  or  other  strong  emotion,  which 
gives  color  t..  th.-  claim  that  it  is  primarily  a  pure  neurosis.  Ihe 
usual  chronic  type  is  offn  pn-ceded  by  a  i.er.od  of  care,  anxiety,  o, 
other  nery.ms  "strain.  Heredity  plays  a  part  in  ....  far  at  east  as 
„,.ur<.sis  is  an  ..ti..l..gical  fa.'t.-r.  Central  l.'sions  (m  he  me.lulla. 
etc  )  inyohing  the  sym|.atlietic,  which  hay.'  b.rn  r.'giir.le.l  as  causa- 
tiv..  an-  h.'l.l  by  I'ntnam  an.l  others  t<.  be  nx.st  hk.^  y  sec.mdar> 
Th.>'.-seiic..  of  the  dis(>as.>  is  s.mie  fault  in  th.-  thyroid  (hyp.'rthyrea) 
whi.'h  pn's..nts  a  sort  ..f  comp."nsat..ry  hypertropln  with  perverted 
secretion  ((ireeiifi.'ld,  Moebius,  H.irsley,  etc.). 

Symptoms.  On.'  or  other  featur."  of  the  clinical  picture  may  w 
lacking,  an.l  the  ev..lution  of  th.^  symptoms  is  lu.t  constant.  Ihe 
';,l.ot  %  generally  gra.lual  an.l  the  disea.se  chrome.  Th.-  signs  ot 
,|,.,.id,Ml  fun.'ti..nal  .listurbance  of  the  nervous  system  are,  as  a  rule, 

clearly  in  eyidence.  .         .  ,       ,  ^    <■*„„ 

TachumnlHi.    Car.liac  palpitation  ami  rapid  pulse  an^  most  often 

t,,;  initial  symptoms.    The  pulse  runs  from  1(X)  t..  140  or  more^ 

There  are  marked  throbbing  of  the  carotids  and  a  yascular  murmur 


DisKASKs  OF  onnir,  lachymal  AvrAnArrs,  axd  lids. 


209 


ov(>r  the  thvn.i.l.  KnUirRonu-iit  ..f  tli(>  thyroi.l  is  fjoiuTally  patent 
when  till'  ..tluT  principal  symptoms  arc  present.  There  is  visible 
Dulsation,  and  a  thrill  may  be  felt. 

Kj-oMoIwo..  The  pn.ptosis,  which  .3  almost  always  .louble 
•unl  but  rarc-lv  absent,  varies  acc.nling  to  the  .lepree  ot  va.sculai 
tur.'.-cenc.-  of  the  orbit  from  sllRht  .IcRrees  to  marke.l  protrusion. 
So^iireat  is  the  latter  at  times  that  the  cornea  n'mains  c.mstantly 
,„ore  <.r  less  expose.l.  It  is  then  apt  to  ulcerate,  with  loss  of  the  eye 
•It  the  time,  or  later  by  secondary  glaucoma  or  septic  invasion  an.l 
'innoi.hthalmitis.  Hyix-rplasia  of  the  connective  tissu.'  and  increase 
,f  the  orbital  fat  delay  recession  of  the  eye  m  favorable  ca.s<.s. 

There  are   other  ocular  symptoms  of   mten-st:    '«\ ..{>''.'-.'/"'/'''' '^ 

.inn  ■  retraction  of  the  upper  lid  from  tonic  spasm  of  Mullers  fibres. 

T  is'..aus..s  the  notably  starhifj  look  of  such  cases  by  exposing  a 

.irin  of  -rlera  above  the  cornea.     It  occurs  without  jm.ptosis,  and 

Ml  Is  to  the  effect  of  the  latter  when  present.     (7,)  Slelhrag.  sujn  :  m- 

;>„ueiit  and  imperfect  winking  (a  a.ul  I,  may  be  due  t..  loss  r^  sen- 

ti  1     f  the  cornea  and  conjunctiva  and  <.f  the  reflexes  (('.  Wood). 

"     Vo    araclc-ssi,,n:  loss  of  the  consensual  descent  of  the  upper 

a  i  ,   I  .wnwird  movements  of  the  eye.     The  upper  lid  lags  behind 

le  sclera  mav  be  exposcl.     In  not  a  few  cases  tins  is  absen 

iJIsutSiency  of  convergence  fn.m  .Usability  of  the  mternal  recti  is 

(il'tcii  oresent  (Moel)ius).  ,      ,.  i   /,  >  u    i    _\ 

^    ,    aneous  pulsation  of  the  retinal  arteries  on  the  disk  (( ).  Becker) 
.,1  o'    ,   uJs    bu    is  not  constant.     The  n'tinal  arteries  may  be  rela- 
;  V  1    la  ^>;  but  the  fundus  is  practically  normal,  and  visum  is  uiiaT- 
H  ,  ;i      l)rvn.-ss  of  the  eves  is  a  not  uncommon  source  of  discomfort 
T    :  .v'i^Jance  of  the  bi.dy  to  the  electric  current  is  grea  ly  re.luced 
(NNolfenden).     Profuse  sweating,  pulsatory  t.nn.tus   hea.hjche,  ana - 
,ni.,    .m<l  mental  dei.ression  are  common  symi.toms.     A(ut.    cases 
.     - 1.  t  ,.  acme  in  -i  few  davs  or  weeks  .in.l  recover  as  .luickly, 
;;r  n  1      h      As  a  nile.  months  may  pa  -  ..efore  the  pal,.itat.on 

,  I     u    k        i  are  followed  by  exophthalmos  or  Dalrymple  s  sig^i 
;.;;  .  S  frlm.  six  months  to  one,  two,  or  more  years  before  roco^ery 
oiKiiiw   or  the  disease  mav  i)ersist.  .      i     i 

"'i^^::ni:;     Rest,    mentil   and   physical,   -   ""J-;;-* ;  J';;  j;; 
,l„.n,,v  '.nd   massage  are  of  serA-ice:    iron  an.l  .ligitaos  an    olt.  n 
:  ;     n  alia-mic  ca's.  an.l  the  tiiu^ture  of  ^tn-phanthiis  i.  a  car.    .c 
„„•,,,    ,,.lUul..ima.  i...line,  co.l-liver  ...1,  an.l  ';'"''''; 'r  *f  *   i;'^^^^^^^^^^^^^ 
l„.l,,tul.    ()sl..r,  wh..  a.lmitsthe  m.c.-rtainty  ''V'"'''''''     „  '     're  ",, 
n  1  .lecries  v..  atrum  viri.le  an.l  a.-..nite.  says,  "no  ""'''^.'^  '      .    ' 
'  1  '■..  sful  as  protracte.1  n>st  in  be.l  with  an  u-e-bag  'M'l'l""l    '        '" 
u..usiv  bv  .laiover  the  heart,  or,  what  is  sonietunes  •';<;"  .''^--f;; 
„v..rthe'  l.,wVr  part   of  the  neck  ami  '"'"';''^"''"V    ™. '■ 
known  tl...  puis,,  t..  be  nxluce.!  in  this  way  fn.m  l"**  J''  ■«^- 

T!,..  svstematic  use  ..f  the  galvanic  current  has;  been  ff^^"^' 
servi..o  in  manv  cases:   a  current  of  from  .K5  to  L.>  "'; '^  Ij^;  {  ^ 
from  .,1...  t..  ihree  minutes  on  alternate  .lays,  the  cath.^.le  at  the 

14 


210 


Tin-:  EYE. 


aiifilc  of  the  lower  jaw,  first  one.  then  tlio  other,  with  the  anode  at 
tile  l)aci<  of  the  neel<.  Persistent  farailization  or  jtalvanizatioii  of 
tile  thyroid  f;laiid  with  stronf;  eurrents  is  eertainly  userul,  whatever 
its  mode  of  aetioii  iJ.  J.  I'utiiaiu).  Thyroideetoiny  has  been  of 
undouhted  value  despite  the  larjte  mortality  hitherto  attendinjj  it. 
Of  svnipatheetoinv  there  have  been  favorable  reports  and  unfavor- 
abl<>.' 

Local  Tukatmknt.  When  the  cornea  is  partially  exposed,  the 
sini])li>st  expedient  is  the  wearing  of  a  light  proteetive  compress,  at 
least  at  night.  When  the  whole  cornea  is  uncovered,  tarsorrhaphy 
should  1k>  done:  and  this  failing,  the  lid  margins  should  be  made  raw 
at  corresponding  ])oiiits.  and  be  united  broadly  in  the  centre  or  at 
several  points,  sutures  being  inserted  sufficiently  far  from  the  free 
edge  to  hold  firmly.  This  is  esjiecially  n^iuired  in  |)rogressive  exojih- 
thalmos,  and  may  save  the  eyes  from  destructive  ulceration,  or 
arrest  the  latter  so  as  to  prevent  utter  loss  of  sight.  In  a  few  in- 
.stanees  removal  of  the  eye  has  been  necessary  to  relieve  the  sufferer 
from  excessive  pain  due  to  ulceration,  panophthalmitis,  etc. 


Diseases  of  the  Accessory  Sinuses. 


i 


Many  ciuses  of  subacute,  if  not  acute,  inflammation  of  the  frontal 
sinus  recover  spontaneously,  or  under  intranasal  treatment  of  tlie 
exc.ting  rhinitis,  etc..  without  orbital  mischief.  Orbital  periostitis 
and  cellulitis  (which  see)  are  sometimes  set  u])  by  acute  sujjpurative 
inflammation  of  one  or  other  of  the  accessory  sinu.ses.  which  in  turn 
is  likely  caused  by  the  invasion  of  pyogenic  org.-misms  in  the  purulent 
riiinitisof  influenza  and  ethmoidal  and  antral  emi)yema,  pneumonia, 
and  the  exanthemata.  Again,  chronic  cmptjvma  of  the  frontal  sinus  is 
at  tinu>s  a  .sequel  to  the  acute  form,  or  is  latent  in  its  onset  and  course 
and  without  external  sign,  complaint  being  made  only  of  browache 
and  nasal  discharge,  vvhicii.  however,  are  jiresent  in  ethmoidal 
emitvema.  In  case  of  retention  from  im])erfect  vent,  ulceration  of 
the  periosteum  and  caries  and  perforation  of  the  bony  wall  may 
slowly  c'  sue,  and  the  mucopurulent  contents  held  by  the  orbital 
pi'riosteum  and  fascia,  form  a  tense  swelling  along  and  beneath  the 
lirow  or  at  its  inner  half,  whicii  fluctuates  under  pressure.  Now  and 
then  spontaneous  fistula  occurs  beneath  the  brow,  as  in  periostitis: 
but  unlike  it  in  that  the  jirobe  enters  the  sinus  and  the  discharge  is 
mucoid,  i-'istula  orbila'  may  occur  also  in  chronic  enii)yema  of  the 
ethmoidal  or  f'-onto-ethnioidal  cells,  which,  imleed,  sometimes  form 
one  cavity  with  the  frontal  sins. 

Ill  chronic  mucocele  of  the  frontal  sinus,  which  some  embrace 
under  chronic  empveni.M.  though  only  yielding  mucus,  stenosis  of 
the  frontonasal  canal  and  n^sulting  retention  and  distention  cause 
gradual  depression  of  the  floor  (orbital  roof)  and  prominence  of  the 
.'interior  bonv  wjill  with  exoiuthalmos  downwar<l  and  outward,  im- 


wmmmm 


wmmm 


liIUKASKS  OF  ORlilT,  L.ICRVMAL  .ll-PAliATUS,  ASI)  LIDS.     211 

|)aii(Ml  motility,  diplopia,  ptosis,  etc.  The  smooth  swelling  which 
(lips  back  aloiifi  the  oihital  roof  may  fool  hanl  or  may  yield  to  firm 
pressure,  and  the  purulent  nasal  (iiscliarfie  of  emi)yema  is  wanting. 

Treatment.  The  general  inilicatioiis  are  to  open  the  sinus,  remove 
(iiseas<'d  contents,  secure  permanent  frw  drainage,  and  thci  carry 
out  medication,  provided  the  oi)eration  does  not  j)rove  radical. 

Oi'KK.vrioN.  In  acute  empyema  of  the  frontal  sinus,  other  treat- 
ment failing,  an  incision  is  made  in  the  inner  third  of  the  eyebrow 
to  the  side  of  the  mot  of  the  nose,  the  periosteum  sejianited  overa  lim- 
ited area,  and  a  small  opening  made  with  drill  or  chisel  through  the  wall 
just  below  the  sujjra-orbital  ridge  and  external  to  the  me.«ial  line,  the 
lining  membrane  opened,  and  the  cavity  irrigated  with  1 :  40  carbolic, 
1 ;  t(MM)  collyrium  of  mercuric  chloride,  etc.  The  sinus  is  then  exphired 
with  tiie  i)robe,  which  may  carefully  be  ])assed  into  tlie  frontona.sai 
canal  to  test  patency.  I'rotargol.  b  per  cent,  solution,  may  then  be 
injected,  and  medicated  gauze  inserted.  The  latter  should  be  changed 
from  day  to  day,  and  irrigation  and  injection  practised  if  there  is 
secretion,  the  protargol  being  increased  to  10  jjcr  cent,  or  .-stronger 
if  jius  continues  and  there  is  no  undue  reaction.  The  external  wound 
maybe  closed  aft<'r  several  day.-  if  the  discharge  has  ceased:  otherwise 
a  short  tent,  jilug.  or  flanged  "style  may  be  u.<ed.  and  medication  con- 
tinued as  rei|uired. 

Ill  (•/(/•"/(/(■  wuvixrlv  the  ojjeniiig  at  the  end  of  the  brow  in  the  bony 
wall  sliould  be  made  sufhciently  large  to  admit  a  curette  or  large 
trocar,  .\fter  irrigation  and  careful  curetting  to  remove  hyper- 
plasia, mucous  polyi)i,  etc..  a  free  o])ening  is  made  to  the  infundibu- 
lum  with  trocar,  gouge,  or  burr.  Until  recently'  the  rule  was  (as  lii 
empyema,  which  see)  then  to  insert  a  good-sized  rubber  (Irainage- 
tube'.  the  free  ends  being  fastened  alxive  th  •  brow  and  without  the 
nostril.  resiM'ctivelv,^  svstematic  use  of  antiseptic  and  astringent  solu- 
tions forming  the"  aft'er-treatment.  This  may  cover  three,  six,  or 
twelve  months.  .\fter  a  time— one  or  two  montiis— when  the 
lower  canal  seems  .smooth  and  healed,  the  Uuig  rubber  or  metallic  tube 
is  replaced  by  a  short  tube.  plug,  or  .<tylet.  and  worn  in  the  sinus  and 
hidden  by  plaster.  .\s  a  rule,  the  orbital  roof  gradually  rises,  the 
brow  recedes,  and.  the  eve  resumes  its  proper  i)lace. 

In  chronic  etnpvema  of  the  frontal  sinus  freer  access  to  the  cavity 
must  be  had  than"is  needed  in  the  acute  form,  or  in  mucocele  i)roper. 
The  effort  is  now  largely  made  to  render  the  operation  really  rmliml. 
.laiisen  makes  an  incision  under  the  brow  and  cuts  away  the  bony 
floor,  witii  after-treatment  by  repeate<l  packing.  In  Kuhnt's  opera- 
tion the  aim  is  to  obliterate  the  sinus:  the  whole  of  the  front  bony 
wall   is  removed  and  the  mucous  lining  scraped  away.     To  le.><seii 


'  Some  form  nl'  ■'  miiiofti  "  operation  la  now  in  vogui'. 

-  Ill  twi-hf  ni«-».  ini.liT  UK'  Clin-  ol  llie  wriltr.  of  ,Iir.iuio  iiiuft-rf-,-;,-  ,ir  cmrvc— r..  \r::h  raiifgr- 
int-nl,  n-ipiirhiK  o|»'rmi..n.  ilii»  pmowliir"  was  fiillowecl.  The  trefttmciil  liuited  from  a  few  wefkn 
to"vi>lviMnoiitti«iir  loiiKir.  In  only  six  ca«e<  wm  It  lairl>- tested.  »nil  in  I tie»e  the  result  wassalis- 
fa.  ory,— CHnadian  rmctitionc".  May.  1H87. 


212 


THE  EYE. 


ih'forinity,  tho  ju-riostcuin  is  now- 


left.'     To  the  saiiio  ond,  Kijip  spares 


the  upper  orbital  iiiarfiiii. 


In  H.  Tillev's  nioditied  Kiilmr  operatio 


•    heVosn.etie  result  in  tli(-  majority  of  cases  leaves  notlui.f;  to  be 
desired,  and  the  purulent  discluirg.'  is  permanently  eured        W  it  un 
three  weeks  from  the  operation  the  patient  may.  as  a  rule,  be  lUs- 
eharped      The  incision  is  made  from  just  abov,'  the  internal  palpe- 
bral li<'ament,  eomins  upwanl  and  outwanl  just  below  the  line  of  tiie 
evi-brow  to  a  little  bevoiid  the  junction  of  the  inner  and  middle  thirds 
n'r  the  supra-orbital  ridse.    After  retraction  of  the  periosteum  a  Rood 
deal    but  not  the  whole,  of  the  anterior  wall  is  removeu.     After  the 
usual  curetting  to  the  i)eriosteum,  "all  crevices  or  extensions  of  the 
siuus  must  be  .searched  out  with  a  small  curette  or  sharp  sijooii. 
Then  a  free  opening  is  made  of  at  least  one-iuarter  of  an  inch  lumen 
into  the  nose  bv  means  of  curved  burrs  or  a  curette.     To  eflect  this 
and   remove  dis..ased  ethmoidal  cells,  a  small  sepnu'iit  of   the  nasal 
nrocess  of  the  frontal  bone  is  cut  away.     Hcfore  packing  with  anti- 
septic sauzc,  the  sinus  is  dried  a"d  swabbed  out  with  a  solution  of 
zinc  chlori<le,  S  per  cent.,  or  pure  earbolic  acid.     The  soft  parts   in- 
cluding the  periosteum,  are  sutured,  excei)t  at  the  inner  end  where 
the  gauze  projects.     I>ater  a  curved  silver  wire  is  in.serted.  and  daily 
syringing  with  weak  carbolic  acid  lotion,  etc.,  is  i)ractised.     I'lnally, 
partial  obliteration  of  the  sinus  is  secureil  by  firm  external  pressure. 

Corre'-tion  of  intranasal  (Usease  is  an  important  adjunct,  if  not  pre- 
liminary; the  middle  sinus  and  turbinal  recjuire  special  attention. 
(Jriinwald  amputates  the  anterior  half  of  the  mi.ldle  turbinal.  It 
may  be  advisable  (or  necessary,  Turner)  to  remove  the  whole.  Ihis 
is  the  more  im|)ortant  where,  a.s  is  often  the  case,  combined  antral, 
ethmoidal  and  frontal  siimsitis  occur. 

Tille\  rightly  warns  against  septic  osteomyelitis  of  the  frontal  bone, 
which  he  ascribes  (in  eight  or  nine  fatal  cases  eoUated)  to  non-i)ro- 
vision  for  free  drainage  into  the  nose  at  the  time  of  the  «ipcration 
The  external  wound  had  been  tightly  sutured  and  septic  phlebitis  ol 
the  diploic  veins  was  s.'t  up.  The  writer  ha."  und(>r  his  ran-  a  serious 
ease  of  burrowing  subperiosteal  abscesses  over  the  calvarium  from  a 
neglected  frontal  sinusitis.  _         r    ,      r       .   i 

\iiother  form  of  op<'ration,  the  osteojjlastic  opening  of  the  frontal 
sinus-  (S.  S.  (lolovine.  after  Czerny).  which,  the  author  says,"ensim>s 
a  "omplete  cure,  with  no  dei^ression  and  scars  searcely  visible  is 
ilone  as  follows:  A  cutaneous  incision  about  4  cm.  long  is  made  along 
the  upper  edge  of  the  internal  half  of  the  eyebrow,  and  at  its  interna 
,.xtn-mity  another  incision  is  made  ol)li.|uely  to  it  following  the  fold 
of  the  e.'.rrugator  musrle  of  the  eyebrow.  These  two  ineisions  form 
the  letter  T  placed  horizontally,  and  in  dei)th  they  reach  to  the  i)eri- 
osteum  The  soft  tissues  forming  the  ui)per  border  of  the  incision 
can  be  detached  and  lifted  up.     An  urc!ir>l  iueir^ion  of  about  '2  cm. 

1  1„  tw.ntv-tive  (.perRllmis.  tl.irlwi.  on  one  side,  and  twelve  on  l>oll.  si.le!..  the  case,  were  cured  in 
from  ten  days  to  two  weeks.     A  number  were  not  dlsHfjured  by  wan..    (KOPKE  alter  Kl'HNT.) 
.:  Archives  of  Oplithalmology,  vol.  xxvii..  No.  8. 


'f9'^T''V'T'fT^ 


DISKASEii  OF  ORliir,  LACRYMAL  AVPARATVS,  ASD  LIDS.    21:} 

ill  l,..idit  is  then  iimdo  throujjh  the  iH'riostciiin.  the  base  of  which 
.•„nvsp..n(ls  to  the  internal  tliinl  of  th.'  upper  orbital  ridge.  I'oliovv- 
iiis:  the  line  of  ineisioii  made  in  the  periosteum,  a  small  proove  is  liol- 
L.Vved  out  with  a  chisel  which  .l«..es  not  penetrate  farther  than  the 
diploe  Then,  bv  means  of  a  thin,  flat,  and  very  wide  chise.,  h<"  d 
„l'li„uelv,  the  bo'ne  is  cut  out  without  <lanjrer  of  entermp  the  skull. 
This  little  niece  of  bone  formed  from  the  anterior  wall  of  the  smus 
,..,1,  be  raised  an.l  turned  back  like  a  small  shutter,  X\w  periosteum 
nnd  soft  tissu.'  serviiifr  for  hinges  at  its  base.  The  result  of  this  is  an 
'oncniiiK  suflici.-ntlv  large  to  admit  '.f  complete  examination,  an( 
..inbling  one  to  perform  a  thorough  curettement.  A  dram  is  passed 
through  the  nose,  the  small  shutter  is  put  back  into  its  primitive 
place  and  the  w..un.l  is  si  ture.l  and  <lressed.  Daily  lavage  through 
the  drain  with  hvdrogen  peroxide  is  the  after-treatment. 

(lolovine  has  also  used  deam  as  a  caustic  injection  in  eini)yema  ot 
the  frontal  sinus,  jKLssed  thrcugh  a  very  small  trephine-openmg  at 
the  upper  inner  angle  of  the  orbit  or  through  existing  hstula  llie 
i„H,.,i',„  of  the  steam  should  last  from  one-ciuarter  to  <me-half  of  a 
,„i,u,te.  and  mav  be  repeated  ufter  sev.-ral  minutes.  This  otters  a 
MM-e  though  slow  obliteration  of  the  sinus-five  or  six  months  tune, 
i^team  mav  also  be  used  as  an  adjuvant  m  oi)erations. 

Ethmoidal  Sinus.  l-:thnioidal  diseiuse,  /wr  se.  not  myoiving  the 
orbit .  is  tn.ate.1  intranasally.  Secondary  orbital  I'';""^;."'''..''.'''''''*!'; 
and  abscess  r.-quire  oarlv  dee],  incisions,  etc  (See  (ellulitis.)  In 
,lHonic  mucoc-le  or  empyema  of  the  ethmoid  with  distention  and 
tumor-like  projection  into  the  orbit,  a  curved  incision  is  mad.  tr  m 
iust  under  the  inner  third  of  the  eyebrow  to  the  inner  canthus.  ke  p- 
ing  to  the  inner  upper  side  of  the  pulley  of  the  superior  oblique  (H 
Knapp,.  One  mav  thus  explore,  curette,  make  dramway  into  nos 
apply  ..arbolic  acid,  an.l  insert  tent,  the  wound  tu'ing  then  (almost) 
(.{.mM  Aft.-rwanl  irrigation  of  the  ethmoid  from  in  front  is  ,  ..ne 
daily  or  at  short  intervals,  an.l  tli<-  tent  renewe.l  until  th.'  parts  h.'al 
or  iiitraiia.sal  treatment  suffices.  ,     ,  ^         .,,         i  •*     ,„ 

Sphenoidal  Sinus.  The  sinus  may  b.-  reach.".l  from  the  orbit  ,  m 
th..  ethmoidal  .-('Us.  an.l  this  has  now  and  then  been  natuir  s  pa  h«a> 
„r  r..li.-f:  but  except  in  so  far  as  ..rbital  p.-riostitis  an.l  celh. .  s 
(xvlmh  s.>..)  are  s.'t  up  by  it,  th-^  operative  treat,n...t  oi  ^l''''''"' * ; ' 
,.n,pv.'ina  has  b....n  alm.)s^  wholly  intranasal.  Many  cas.^s  ..f  sphen- 
oidal em,.v.-ma  have  b.-.Mi  tr.-at-'.l  with  a  high  pcTcntag.-  of  success 
an.l  fairlvi-n.mpt  r.-civery  by  ..pening  the  anteri.,r  wal  ,  "'"■«"'?. 
and  m.ulicating  (after  ablati..n  of  the  mi.l.Ue  turbinal).  In  f'"■t^-h^'^ 
eas.'s  in  thirty-four  patients  the  time  f.)r  cun-  was  ii.'ver  longer  tha.i 
four  months  (Griinwald;. 


214 


rni:  i:yi:. 


THE  LACRTMAL  APPARATUS. 

Anatomy.  Tin-  hicrymal  uijpanitus  cdiisists  nf  the  lacryiiiiil  rIiukI, 
wliicli  sccri'ti's  the  tears,  and  the  lacrvmal  passajjcs.  throufih  t'lc 
niciliuiii  i)f  wliicli  tlic  tears  are  ilraiiieil  into  the  nose.  The  lacninutl 
(jldnil  is  an  acinous  gland  in  two  |>arts,  tlic  larger  nf  which  lies  in 
a  depression  in  the  i)ony  wall  of  the  upper  eMernal  angle  of  the  orbit , 
while  the  smaller  is  placed  somewhat  inferiorly  to  it,  directly  heueath 
the  mucous  membrane  of  the  fornix. 


■^•' 


o 

t 

k,i  'i 

IWKm' 

Jm  ^jr- 

f 

■    F 

1 

Section  of  lacrynial  sac.    (.\kit,! 

Both  ])()rtions  of  tlie  fjlarid  |)our  out  their  secretion  hy  a  .series 
of  small  ducts  into  the  upper  outer  i^ortion  (jf  the  conjunctival  cul- 
de-sac. 

The  excretory  portion  of  the  lacrymal  .system  consists  of  the  puncta 
lacrymalia  and  the  canaliculi.  The  piindn  are  brought  into  view  by 
everting  the  lids,  and  an'  seen  as  small  i)apilhe  at  the  imier  extremity 
of  the  lids  at  a  point  where  th(>  cartilage  terminates.  T'  ;■  ciirmliculi, 
the  two  fine  canals  which  are  the  continuations  of  the  piincta,  at 
first  run  vertically,  but  .soon  turn  into  a  horizontal  axis  and  empty 


DlaEAalCS  OF  ORUIT,  LACllYMAL  AJ'l'AJUTUS,  AM)  LIDS.    215 

iuti)  tho  lacryniiil  sac  The  laeri/mnl  snc  (Fig.  10'))  is  situated  in  a 
fossa  at  tlie  inner  aiiftl"'  "f  tlie  orbit  ami  terminates  in  the  lacrynial 
duct.  Wiien  distended,  the  sac  is  al)out  12  nun.  ioiif;  and  has  a 
iliaineter  of  about  »>  mm.  It  is  narrowest  at  its  t<Tinination  into 
tiie  thict,  making  tliis  point  a  favorable  one  for  tiie  develoi)ment  of 
strictures.  The  anter.or  boundary  of  the  sac  is  formed  l)y  tlie  in- 
ternal lid  lijiaments.  and  it  is  believed  tiiat  the  contraction  of  these 
aids  the  natural  elasticity  of  the  walls  of  the  sac  in  the  expulsion 
of  its  contents  into  the  nasal  tluct. 


Kiu.  Iii6, 


Diict  seen  through  the  maxillary  sinus.  The  i.n.jei'tion  which  the  caiml  niHkes  in  this  pueition 
forms  a  cone  with  its  base  below  directly  continuous  with  the  interior  meatus.  The  apex  is  directed 
upward  and  anteriorly  into  the  lacrymal  sac.  The  axis  of  the  canal  is  .blique  (rom  above  down- 
wari.  from  before  backward,  and  from  within  outward  ;  continueil  to  the  dental  arch  it  Is  seen  to 
terminate  at  the  second  molar,  while  ita  superior  or  frt)ntal  extremity  bisects  the  superciliary  ridge 
J  cm.  external  to  the  median  line ;  the  transverse  line  traced  over  the  wall  of  the  sinus  indicates 
the  (wint  where  the  canal  empties  into  the  inferior  meatus.  Two  pins  intro.iuce<l  into  the  canalicuU 
show  the  place  of  common  opening  into  the  sac. 

The  duct  (Fig.  106)  varies  in  length  from  12  nmi.  to  20  mm.,  and  in 
diameter  from  3  nun.  to  4  mm.  Its  general  direction  is  expressed  best 
bv  a  line  drawn  from  the  inner  cantb  is  to  the  interval  between  the 
st'cond  iireniolar  antl  the  first  molar  tooth  of  the  upjier  jaw.  It  ter- 
minates in  the  nasal  fossa  below  the  inferior  turbinate  body.  The 
mucous  membrane  of  the  lacrvnial  ap])aratus  is  continuous,  but  differs 
somewhat  in  the  different  parts,  that  of  the  canaliculi  being  lined  with 
laminated  pavement  epithelium,  and  that  of  the  lacrymal  sac  and 
•  luct  with  a  laver  of  cylindrical  ejiithelium.    Owing  to  the  projection 


216 


THE  EYE. 


of  the  iniipoiw  iiiptiibrano  at  ciTtaiii  pdiiits.  a  !»rrics  of  valves  is 
foriiicil,  till"  larfjcst  of  wliu-li.  Masncr's  vaivc  is  situated  at  tlie 
inferior  termination  of  the  liiiet.  In  tiie  liuet  tiie  nnicoiis  nieni- 
hrane  is  conneeteil  i)y  areolar  tissue  wilii  the  periosteum,  but  is 
seiiarated  from  it  by  a' thick  venous  plexus  whieh  has  the  proju-rties 
of  cavernous  tissue. 

ThoURh  the  moistenin«  of  the  eyeball  is  chiefly  effected  by  the 
action  of  the  lacrymal  glatid,  a  serretion  is  poured  out  liy  the  con- 
junctiva and  its  nuicous  jjlands  as  well.  It  is  for  this  reason  that  the 
eye  niav  still  be  kept  moist  after  removal  of  the  ;;i:'.Md. 
"  After  the  tears  have  lubricated  the  eyeball  they  are  sucked  into 
the  canaliculi  by  the  action  of  the  lids  in  forcinj:  the  tluid  into  the 

iimer  angle  of  tiie  "ve   and  through  tl lediutn  of  the  linameuls  in 

dilating  the  sac.  Their  passage  from  the  sac  into  the  nose  is  due 
partly  to  the  weight  of  the  Huid,  but  chiefiy  to  the  elasticity  of  the 
sac. 

Diseases  of  the  Lacrymal  Apparatus. 

Dacryoadenitis.  Inflannnation  of  the  lacrymal  gland  Is  very  rare. 
It  may  be  acute  or  chronic. 

In  the  ucute  forhi  the  outer  end  of  the  ujjper  lid  beneath  the  brow 
becomes  swollen,  re<l,  and  tender,  with  more  <pr  less  severe  pain,  and 
inability  to  raise  the  liil,  save  near  the  imii-r  canthus.  Th"  eyeball 
may  be  displaced  downward  and  inward.  The  focal  swelling  is  not 
in  the  lid  proper,  jis  in  phlegmon  of  the  latter.  The  .adenitis  may  bo 
symmetrical,  so-called  lacrymal  mumi)s.  and  occur  witii  parotitis. 
It  may  be  caused  by  trauma,  toxic  invasion,  cold,  etc.,  and  it  na.s 
occurred  by  metastasis  in  urethral  blennorrhea,  and  as  a  |)riniary 
sy|)hilitic  ''symptom."  It  may  end  in  resolution,  suppuration,  or 
the  chronic  form. 

Treatment.  Leeches,  iced  compresses,  hyilrarg.  subinur.,  sudorifics, 
and  laxatives.  If  the  i)."''n.  swelling,  etc.,  increase,  hot  fotus  and 
cataplasms  should  be  :•  and  on  sign  uf  pointing  the  phlegmon 

should  be  opened,  preii  . !y  in  the  culHle-sac,  to  avoid  external 
fistula. 

Chronic  adenititi  may  l)e  subacute  in  its  oitset,  or  mere'y  show 
slight  redness  of  the  upper  lid.  which  is  more  or  less  prominent. 
The  swollen  gland  can  be  felt  below  the  bony  rim.  and  there  is  little 
or  no  pain  or  tenderness.  Now  and  then  this  form  is  tertiary  anil 
gmmnatous. 

Treatment.  T(H)ically,  ungt.  hydrarg.,  hydrarg.  oleat..  or  tinct. 
iodin.;  internally,  j)otassium  or  .sodium  iodide,  raising  the  dose  to 
gr.  XXX.,  or  e\cn  gr.  Ix..  t.  i.  il.,  if  well  borne,  and  giving  pilocarjji.ie 
in  addition  in  dose  to  cause  i)rofuse  sweating,  daily  or  on  alternate 
days,  for  ten  to  iifti-eii  tinn-.v. 

in  ■•<iipp}iratir('  injlnnimntimi  of  the  accessory  or  palp(>bral  portion 
of  the  lacrymal  gland  there  is  a  tense,  tender  swelling  in  the  outer 
upper  part  of  the  upper  lid,  with  hypera'mia  and  loctlizeil  chemosis 


DISEASES  OF  ORBIT,  LAVRYMAL  APPARATUS,  AyO  LIDS.    217 


at  tho  site  of  tlir  small  ovoid  tumor  which  imgrcts  into  the  cui-di'- 
sac.     "  'lortiy  iHiints  and  opens  into  the  tissurc.     There  is  iittie 

systennc  disturbance. 

Treatment,  liarly  application  of  the  lead-and-spirit  lotion  on  coin- 
pri'sses  may  arrest  it.'     If  ineffective,  hot  fomentations  are  in  order. 

H3rpertrophy  of  the  lacrymal  pland  is  very  rare.  It  may  lie  ilue 
to  recurrent  inflaimnatory  attacks,  occurs  most  of*  'U  in  children, 
and  may  lie  coiiftenital.  The  fjland  iMcreas<'s  in  size  very  slowly,  ami 
there  is  a  iiotahle  absence  of  exti'rnal  sipns  of  inHammatioii.  The 
tumor  is  circumscrilK'd,  somewhat  tirm,  elastic,  and  nodulated.  In 
time  it  may  disjilace  the  eyeball  and  limit  its  movements. 

Treatment.  Treatment  by  jiot.  iodid.,  especially  in  adults,  in  whom 
the  affection  may  really  be  a  chronic  tertiary  adenitis,  should  be 
pushed,  large  dos«'.s  In-ing  piven  if  tolerated.  Kxternal  applications 
of  ungt.  hydrarg.,  tinct.  iodin..  etc..  nmy  Im-  used.  In  genuine  hyjM-r- 
trophy,  however,  o|MTation  is  generally  reejuired,  a  part  or  the  wliole 
of  the  gland  lieing  removed. 

.\trophy  of  the  gland  occurs  in  xerophthalmia.  It  is  said  to  bo 
.secondary  to  destruction  of  the  lacrymal  sac,  but  this  is  certainly 
nut  a  necessary  result. 

Fistula  is  caused  by  injury  or  abscess.  It  may  lie  cured  by  the 
u.se  of  caustic  or  the  cautery  j.oint,  or  by  passing  a  suture  with  two 
needles  into  it  and  on  through  the  conjinictiva,  and  tying  iMitli  ends 
(iver  a  bridge  fif  the  latter  at  the  fornix,  or  by  making  a  counter- 
opening  for  drainagt  .nto  the  cul-de-sac  by  means  of  a  suture  as  a 
seton.  Tliese  steps  failing,  removal  of  the  gland  is  iiaiicated.  In 
one  ca.se  in  which  the  writer  did  extirjiation  the  tears  wen-  escaping 
on  the  temporal  side  of  i\u   orbital  rim. 

Tumors  of  the  lacrymal  gland  are  very  rare.  Adenoma,  adeno- 
angioma,  angioma,  epithelioma,  enchondroma,  osteochondroma, 
Ivmphosarcoma,  carcinoma,  cysts,  and  dernioid  growths  have  been 
reported:  also  miliary  tubercle  in  general  miliary  tuberculosis.  The 
diMgnosis  has  to  Ih'  w'orked  out  in  each  case  as  ''  tr  as  may  be.  and  as 
an  aid  a  tentative  course  of  potassiinn  or  ^  lium  iodide  in  large 
doses  may  be  useful,  if  not  decisive.  Excision  should  be  done  early, 
sii  as.  if  "possible,  to  circumscribe  the  neoplasm.  Calcareous  con- 
cretions (dacrvoliths)  .sometimes  occur  in  the  gl.-uid  or  duct  and  act 
as  foreign  bodi(>s.  They  show  through  the  conjunctiva,  and  should 
be  removed  liy  incision. 

Dacryops.  Cyst  of  the  lacrymal  gland  appears  as  a  bluish-pink, 
<emitransparent,  elastic  sv.elling  of  varying  size  showing  beneath  the 

'  ThfIull(iwinK  anodyne  aslrinKent  mlxtare  applied  on  compreaeM  or  under  an  ice-biiR  i»  very 
useful  in  inilHUiuiHtioti  of  the  eyelids,  tear-sac.  or  gland  : 

Plumb,  acetat.,  fcm  v. 

Add.  sK-tif  tii!..       rCi  V 
Atrop.  sulph.,  (tr  'uUyM. 

Morph.  sulph..  er.  j. 

AI:<ihol.,  SJ 

Aqus.  «d  SJ. 


'AH 


TllK  EYE 


conjuMctiva  at  tlio  rul-df-Hac.  ami  if  larp-  caiisi's  proiniiii-ncc  nf  tlie 

uiMKT  lid.     The  swfllinji  l)<"( irs  at   (iiicf  ilisliiictly   larger  if  tin- 

rtul)iirt  cries  (ir  the  jjlaiicl  is  >tiimilateil  fmni  any  ciiise.  It  is  gen- 
erally <lue  to  cldsure  of  ail  excretory  iliict  with  retention  of  tears  ami 
(list('iitiori  of  tiie  i)art  of  the  iluct  ami  ulainl  involved.  It  may  l)e 
congenital.  The  trr'atinenl  aims  at  securing  a  iieriiianent  opening 
I'y  incision  or  the  u.se  of  a  suture.  l>y  which  tistula  in  the  con- 
junctiva is  produced.  \Vh<-re  there  is  a  cystic  tumor  or  hydatiils 
of  the  gland,  the  radical  operation  may  be  necessary,  or  tre  t- 
ment  of  (lie  lining  .if  the  sac  hy  tinct.  iodiii.,  argent,  nit.,  or  acitl. 
carhol.  after  evacuation,  with  iced  com|ire.sses  to  prevent  umlue 
reaction. 

Dislocation  of  tlie  lacryinal  gland  is  almost  wholly  due  to  trauma 
in  young  subjects,  in  whom  the  orbital  rim  is  ill  developeil.  In  cii.se 
of  lesion  the  gh.  d  may  present  in  the  wouml,  or  there  may  Ik-  an 
almond-like  tunu..  at  the  upper  and  outer  i>art  of  the  eyeball,  or  a 
movable  fmior  under  tiie  lid.     (Iradu.il  luxatiori  may  occur. 

Treatment.  Reposition  may  be  possiiile,  and  if  not,  excision  may 
be  reiiuired:   and,  again,  interference  may  not  be  called  for. 

Epiphora.  Normally  there  is  only  sufficient  lacrynitil  secretion  to 
keep  the  t'Ve  moist,  and  there  is  no  stream  of  fluid  passing  through 
the  puncta.  .\  flow  occurs  only  where  there  is  hypersecretion,  so- 
called  lacrytiiation.  When  there  is  much  lacrymation  the  natural 
lacryinal  p'as.sages  are  inadequate,  and  the  tears  collect  in  the  lacus 
or  they  overflow— a  condition  termed  epiphora.  Defective  drain- 
age does  not  account  for  the  surjilus  often  present;  the  gland  fre- 
quently acts  ill  ca.se  of  stricture  of  the  c:i'';,'iculur--  t  du<'  :'-i  if 
there  were  a  foreign  body  to  1m'  swejit  away.  .\  most  marked  ca.se 
of  e|)ipho.a  of  years'  .standing  was  cured  in  two  ilays  by  simply 
opening  the  canaliculus  into  the  sac.  Kpiphoia  may  result  from 
hypera'mia  or  intlammation  of  the  intra-ocular  tissues  or  of  the  con- 
junctiva, cornea,  and  lid-edges:  injuries  of  or  ton  ign  bixlies  on  the 
eye  or  beneath  the  eyelids,  when  it  will  bi'  sudden;  malposition  of 
tiie  lid-edges  or  of  the  puncta,  and  atresia  of  the  puncta  or  eaiial- 
icn'us;  mucocele  (catarrh  of  the  sac  with  dilatation),  stricture  of  the 
rut.-al  <luct  ;ind  lacryinal  tistula:  also  rhinitis  or  defect  in  the  tiirbinals. 
Voiiiig  subjects  with  chronic  coryza  and  boggy  lurbinals  often  have 
epi|>hora,  which  ceases  when  the  nasal  trouble  is  cufeil.  Lacrymation 
may  also  be  due  to  reflex  irritation,  mainly  through  the  medium  of 
the  fifth  nerve:  syiniiathy  with  the  fellow  eye  and  emotional  cau.ses 
are  well  known.  Eyestrain  as  a  factor  is  to  be  borne  in  mind.  Some 
cases  of  habit  lacrymation  are  due  to  it. 

A  rare  cau.se  of  epijihora  is  blocking  of  the  canaliculus  by  concre- 
tions of  Strejjtococcus  Foersteri.  It  also  arises  from  notching  of  the 
lower  lid,  and  from  flaccidity  of  tin-  !id^  due  to  !o-s  of  unw-  -A  the 
orbicularis,  and  in  paralysis  of  the  latter  it  is  most  annoying,  the 
interspace  between  the  globe  and  lower  lid  being  filled  wi'h  tears 
which  often  overflow— lagophthalinos. 


hlSKASKS  OF  ORIIIT,  h.lCHYM.iL  M'l'AR.iriS,  A.\J>  LIDS.    219 

A!<  (ithcr  fiiul  (<t'ri<>U8  liKTymal  trouldcs  arc  pciu'rally  proccf U-d  l>y 
••|iiplinra,  ilM  caiiw  slioiilil  he  early  foiiiiil  out  and  dealt  with.  'I'liis 
may  re(|iiire  Home  stud.'  Two  or  more  of  tlii'  coiiditiotis  cited  may 
coexist,  either  of  which  would  suffice— #■.  </.,  chronic  conjunctivitis 
and  ciintracted  or  everted  jiunctuni,  rhinitis  and  associated  conjunc- 
tivitis, o|>tical  defect,  blepharitis,  etc. 

I'inuid  (inil  ('(innliciilii.i  Closure  of  the  puncta  (iiiresia)  is  rare 
It  may  he  congenita!  or  due  to  shrinking  after  intlanunation  or  injury, 
malposition,  etc.  The  p'lnctum  should  lie  reojiened  and  stretched 
a  few  times  l>y  a  silver  pin,  blunt  needle,  or  fine  sound.  Small,  even 
minute  puncta  may  not  caus<'  epi)>hora,  but  it  <I(m's  occur  wheji 
their  contraction  arises  from  thickening  of  the  mucous  lining  and 
hypertrophy  of  the  sphincter  fibres,  due  to  chronic  or  recurrent  con- 
junctivitis, blepharitis,  et('.  The  puncta  then  resist  stretching  by 
the  fine  sound,  and  grip  it  like  solid  rubber— too  tightly  for  mere 
spasm.  If  after  several  forcible  dilatations  there  is  but  little  change, 
the  inner  wall  of  the  punctum  should  be  snipped  vertically  with  fine 
scis,sors,  to  make  a  permanent  patulous  slit,  and  in  atresia  prop«'r 
this  has  to  be  done  if  a  trial  of  stretching  fails.  Tlie  treatment  of 
inversion  of  tlie  punctum  is  that  of  the  entroj)i()n,  etc.,  which  causes  it. 

In  ('Version  of  the  punctum  due  to  sagging  of  the  lower  lid  or  to 
slight  ectrojiion,  the  canaliculus  should  be  slit  and  its  inner  lip  and 
a  segment  of  conjunctiva  cut  away,  making  a  triangtilar  raw  surface 
with  base  out.  This  in  healing  often  corrects  the  faulty  position  and 
the  epi|)hora.  Re|)osition  of  the  everted  punctum  caused  by  eczema, 
etc.,  of  the  lid  generally  follows  cure  of  the  latter.  It  may,  however, 
be  neci'ssary  to  open  the  canaliculus  well  down  on  its  inner  wall 
with  sci>;surs.  In  paralvsis  of  the  (trbicularis  (facial)  ni(>re  has  to  be 
liiine,  and  tarsorrhai.l'y  isce)  is  ncdrd,  and  the  In'tter  to  raise  and 
tighten  the  lim])  lower  lid  its  inner  end  is  made  raw  just  Iwlow  the 
canaliculus,  and  is  stitched  to  a  raw  spot  at  the  juncti(Hi  of  the  ujiper 
lid  and  nose,  or  instead  two  small  flajjs  are  made  and  stitched  to- 
gether (H.  Xoyes). 

Stenosis  of  the  canaliculi,  unless  congenital,  is  as  a  rule  at  the 
im\cr  end  next  the  sac,  and  care  is  needed  in  dilating  the  stricture  to 
avoid  making  a  false  pa.s.sage.  The  lid  being  made  taut  by  traction 
with  the  tinger-ti])  on  the  malar  process,  a  small  probe,  No.  2  H. 
or  A  T..'  is  i)assed  vertically  into  the  punctum,  then  horizontally 
along  the  canaliculus  in  the  line  of  least  resistance,  at  the  roof.  a.s 
a  rule,  with  a  rotary  motion,  if  needed,  to  avoid  piercing  the  mucous 
folds.  Then,  if  a  slight  push  inward  or  downward  causes  a  distinct 
wrinkling  of  the  skin  at  the  inner  canthus,  the  .sac  has  not  been  en- 
tered, and  gentle  pressure  shouhl  he  used  to  force  the  constriction. 
Tlie  outer  wall  of  the  .sac  will  often  yield  enough  before  the  jjrobe 
to  mislead  the  inexperienced  operator,  and  the  })oint  being  forced 


1  Theobald's  set  Is  of  16  sizes :  No.  1  has  a  diameter  of  0.25  mm. :  No.  2.  of  O.'iO  mm. ;  and  so  on  to 
No.  16,  whk'h  is  4  mm.  Bowman's  set  Is  of  6  sizes :  "  reaching  from  a  line  hair  probe,  No.  1.  to  one 
III  one  twentieth  of  an  inch  in  diameter,  No.  6." 


220 


TIIK  EYE. 


(lowmvanl,  passes  tlirouRli  tho  wall  ilsdf,  and,  it  may  he,  l)ct\vc(ii 
the  duct  and  the  hoiiv  canal.  To  facilitate  dilatation  of  tlic  stricture, 
a  horiiif!;  motion  mav  he  tried  and  a  smaller  i>rol><'  or  six'Pial  sound 
used  (as  Theobald's  new  model).  The  stricture  should  be  stretched 
to  lake  No.  4  or  5  H.  or  T.,  which  shoulil  be  passed  every  day  or 
two  for  at  least  a  few  times. 

Rarelv  the  canaliculus  is  the  seat  of  a  fungus  (>irei)tothrix),  and 
jiresents  an  ovoid  swelhnp;.  with  viscid  discharfje  from  the  patulous 
punctum:  die  caruncle  and  fold  are  hypera'inic  and  the  eye  irritable 
and  waterv.  The  fuuRous  ma.-is  (dacryolith)  may  be  exi)elle(l  throujih 
the  n.asal  duct  bv  svriiiffinK  per  punctum  In  this  way  in  one  ca.-^e 
of  the  writer's,  witliswelling  of  the  sac  and  seemin>;  inciinem  cystitis, 
a  globular  mass  of  the  size  of  a  lar<re  currant  was  forced  out  whole 
bv  the  anterior  naris,  and  the  one  flusliinj;— with  liq.  hydrarg.  per- 
ciilor.  ilil. -sufficed.  In  another  the  canaliculus  had  to  be  opened: 
the  :umen  was  found  greatly  enlarged,  and  the  lining  much  inflamed. 
The  curette  had  to  l)e  u.-<ed.  with  after-treatiiienl  by  sol.  hydrarg. 
perchlor.  and  jirotargol. 

FIG.  107. 


Ancl's  laiTj-mal  syrinife. 

The  Duel.  The  anatomy  of  the  nasal  iluct  go(s  far  to  show  the 
ea.'^e  with  which  some  fault  may  arise  to  cause  epipiiora.  to  wit.  the 
coiitimiity  of  its  lining  with  that  of  the  n.a.sil  mucous  membrane, 
and  of  its  submucous  venous  plexus  with  the  erectile  cavernous  tissue 
of  the  turb'nals. 

There  is  also  the  fact  of  the  lacrymal  tube  lying  in  a  bony  canal, 
the  periosteal  lining  of  wtiich  may  i)lay  some  part— c  i/..  in  scrofula, 
syphilis,  rheumatism,  etc.  Engorgement  of  the  submucous  caver- 
iio.^a,  e;usily  set  up.  and  catarrhal  infl.'iimnation  of  the  mucous  lining 
by  extension  may  singly  or  together  close  the  himen  and  cause 
epiphora.  Folds  in  the  mucous  membnine  at  the  top  of  the  duct 
where  it  is  narrow,  and  at  its  na.sil  end,  if  not  in  thi>  middle,  a(ld  to 
the  mechanical  elTect  of  inflammation  and  turgesn'iice.  Recurrent 
inllammation  set  up  by  nasal  disease  may  lead  to  structural  changes 
in  the  mucous  rneinbrane  of  the  duct,  infiltration,  swelling,  hyper- 
trophy, anil  induration,  and  also  ulceration  with  dense  cicatrix,  and 


tmmmmt 


mmm 


i>isi:At>i:.s  OF  oRBir,  lachymal  ai'I'miatus,  aM)  lids.   221 


,luis  cause  jiartiiil   stenosis  or  coiuplctc  stricturo,   with  sccotulary 
implication  of  the  sac.     (See  Mucocele.) 

( )ne  can  test  fairly  well  the  ])ateiicy  of  the  nasal  duct  by  .syrinsiiifl, 
the  hlunt  fine  tip  of  a  hypodermic  or  of  a  lacrymal  syringe  (Anel's) 
(Fig.  107)  •"•;•':  i  .■■■'•.,'."  into  ihe  sac:  fluid  injected  under  gentle 
j)ressure  sho  i(  tind  vent  by  ih'  anterior  or  posterior  naris.  To  give 
the  test  val  «:•,  t  ic  canalicu''  •  should,  of  course,  he  patent,  and  the 
other  punct  ,in  iiould  b.'  c  >.se(l  by  pressure.  To  pave  the  way  for 
probes,  and  ■  o  )  U-M  whether  or  not  a  constriction  found  is  due 
to  organic  changes— e.  g.,  .:tricture— or  only  to  vascular  turgescence, 
the  injection  into  the  duct  of  sol.  adrenalin  chloride  1.5  :  S00(),  with 
sol.  cocaine,  5  i)er  cent.,  is  useful. 

To  exi)lore  the  na.sal  duct,  a  No.  4  B.  or  T.  i)robe  is  passed  through 
the  canaliculus  (as  directeil)  and  pushed  on  until  the  finger-nail 
resisttuice  of  the  lacrymal  bone  at  the  inner  wall  of  the  sac  is  felt. 
Then,  the  jjoint  of  tlie  probe  being  kept  against  the  inner  wall  of 
the  sac,  its  a\is  is  changed  to  the  vertical,  and  pressure  is  made  down- 
ward and  slightly  backward,  to  coincide  with  a  line  from  die  inner 
end  of  the  caruncle  to  the  ])oint  of  junction  of  the  ala  and  cheek. 
A  No.  4  Howman  jjrobe  is  safer  to  begin  with  than  a  No.  2,  and 
the  length  as  well  as  the  line  of  direction  of  the  canal  should  be 
k(-|>t  in  mind,  else  a  stricture  at  its  lower  end  may  not  be  passed 
—a  mist  ike  too  often  made.  It  is  a  good  rule  to  gauge  the  buried 
part  of  the  probe;  it  should  reach  from  the  caruncle  to  the  edge 
of  the  ala. 

Treatment.  The  treatment  of  simiile  ejiijihora  due  to  catarrhal 
conditions  in  the  duct  consists  in  a  .short  course  (of  ten  to  twenty 
sittings  in  four  to  six  weeks)  of  Ciireful  probing  of  the  duct  with  the 
largest  sound  the  unslit  punctum  or  canaliculus  will  take,  (i  Howman 
or  .")  Theobald,  and  gentle  svringing  with  mild  a.stringent  .solutions— 
(  ;/  1  gr.  sol.  zinc  sulph..  zinc  chloride,  etc.  This,  with  attention 
to'  a'nv  conjunctivitis,  blepharitis,  nasal  trouble,  or  eyestrain,  will 
tide  not  a  few  over  one,  two,  or  three  years,  and  m  cases  ot  relapse 
a  few  visits  mav  suflice  to  secure  a  like  respite.  Hut  should  a  lair 
trial  of  such  prolies  earlv  fail,  the  canaliculus  should  be  si)lit  (see 
Bowman's  operation)  that  larger  ones  may  be  used.  In  some  ca.ses 
a  short  treatment  every  six  months  may  be  neeiled  to  correct  nar- 
rowing, due  mainlv  to  chronic  or  recurrent  rhinitis. 

Although  the  ep'iphoia  of  conjunctivitis,  blepharitis,  keratitis,  etc., 
is  inciilental,  one  can  at  times  give  relief  and  promote  curt  by  atten- 
tion to  a  contracted  or  (lisi)laceil  punctum,  or  by  enlarging  the  lumen 
of  the  canaliculus  and  <luct  bv  the  use  of  probes.  This  course  .should 
not  be  neglected  in  some  forms  of  chronic  or  recurrent  keratitis  in 
young  subjects  as  well  as  in  adults,  in  which  treatment  also  of  any 
"nasal  atTection  is  a  necessary  adjunct. 

Si.iTTiXG  THK  Caxalhv!  r«  '■  HowMAx's  OPERATION),  The  punctum 
if  contracted  is  first  stietched  with  the  tine  conical  sound,  and  a 
2  per  cent,  to  5  |)er  cent,  solution  of  cocaine  is  then  injcct<»d  into 


222 


THE  EYE. 


tlic  canaliculus,  and  the  patency  of  the  latter  ensured  by  j)assinji  a 
No.  4  B.  or  T.  into  the  sac.  It'  tliis  be  not  done,  a  false  passafie  is 
apt  to  be  made  above  a  stricture  in  the  canaliculus.  The  lower  lid 
beins  made  taut  by  traction  toward  tlu;  malar  process,  and  slifjiitly 
everted,  the  blunt-tijjix'd  or  jtrobe-pointed  knife  (Fifj.  lOS)  is  passed 


Weber'a  canalicular  knilV 

into  the  punctum  vertically;  the  handle  is  then  dii)i>ed,  and  the  knife 
with  the  cutting  edge  up  and  in  is  pushed  on  jiast  the  caruncle  tmtil 
the  sac  is  entereil,  when  the  handle  is  brouglit  ajrain  to  the  vertical, 
the  upper  inner  wall  of  the  canaliculus  beinj;  divided  to  th(>  caruncle, 
or  to  the  sac,  as  desired.  In  cases  of  mucocele.  whiTe  syrinfiing  or 
irrigation  and  the  use  of  larger  probes  will  follow,  a  freer  opening 


% 


Method  of  inserting  Brtwmiii.'s  i>robc.    (Norkis  nnd  oi.ivfh.) 


is  re(|  lired,  and  the  .«ac  should  be  entered  and  cut  upward.  Tare 
should  alvvavs  be  l.-ikeii  not  to  injUlt-  the  (Imn  of  tin-  caiiMiiculu.--, 
which  wouhl  cause  risk  Tnot  imaginary)  of  fusion  of  the  walls; 
traumatic  stri.  ture  is  a  .serious  bar  to  a  good  result.     (Figs.  109  and 


mSEA-SKS  OF  ORBIT,  L.WRVMAL  AI'PARATr^,  A.\I>  LIDS.     223 

110.)  Afiiiiii,  if  a  falso  passapo  is  mado  over  a  stricturo  in  tiic  canal- 
iculii^.  failiirp  is  coiirtfil,  for  a  few  days  after  the  CDursc  of  i>f(il)iiiK 
stops,  tlic  new  canal  may  contract  or  close. 

Some  ]!refer,  as  does  the  writer,  to  use  fine  liiit  not  sliarp-i)ointed 
curved  scissors  in  lieu  of  the  knife  when  the  sac  wall  has  not  to  be 
opened.     W'i*'    *he  lower  lid  everted  and  made  taut,  one  i)oint  being 

pushed  into  canaliculus  with  convexity  toward  the  eyeball,  a 

sinftle  snip  makes  a  curved  cut  on  the  inner  wall,  which  is  liiddeii 
from  view — a  point  in  its  favor  with  females.  The  raw  lips  if  kept 
apart  a  few  days  heal  se])arately  The  majority  of  operators  choose 
the  lower  canaliculus,  but  some  always  slit  the  ui)]ier.  In  this  case 
the  upjier  lid  is  drawn  tightly  toward  the  brow,  care  being  taken  not 
to  cut  the  front  wall  (skin).  Some  open  botli  canals  frarely  needed), 
while  others — not  a  few — will  not  cut  either,  and  u.se  only  such 
probes  in  the  duct  as  can  be  passed  through  the  intact  canaliculi. 


Fio.  m. 


Rouinnn's  iirohe  in  position.  .MiiMcelc. 

Hut  more  violence  may  be  done  by  forcing  prolies  than  by  a  clean 
cut:  besides.  Bowman's  operation  dot's  not  interfere  with  the  normal 
action  of  the  drainage  svstem.  It  also  permits  of  the  use  of  large 
jirobes,  tends  to  ward  off  acute  cystitis,  and  enables  patients  to  use 
the  syringe  themselves  in  the  after-treatment. 

Mucocele.  This  is  a  subacute  cystitis  of  the  lacrymal  sac  in  which 
the  latter  i)ecomes  distended  by  the  ])ent-ui)  secretion  from  its  in- 
ll.imed  lining  mi-mbrane,  together  with  tears.  It  is  secondary,  as  a 
rule,  to  stricture  of  th(>  n.asal  duct,  and  this,  in  turn,  to  recurrent 
or  chronic  rhinitis.  Fortimately,  it  is  often  one-sided,  as  indeed  nasal 
deformity  or  disease  prov(>s  to  be.  Mucocele  mostly  develops  insid- 
iouslv.  as  does  the  na.sal  .stricture,  and  there  is  <<ften  simi>le  epii)hora 
of  varying  degree  due  tt,  the  latter,  for  months,  if  not  years,  before 
•  !;,.  cv-iiti-  "upervenes.  The  retention  of  tears  and  the  presence  r.f 
lirganisms  in  the  sac  tend  to  light  up  hypera-mia  of  its  lining,  with 
secretion  first  of  mucus  and  later  of  mucopus,  and  gradual  (listen- 


224 


TIJE  EYE. 


tioii  eiisiu's.  The  suhjcet  then  tirids  tliat  tlicrc  is  a  iloupliy  swelling 
at  the  innor  caiitluis  which  yields  discharge,  and,  getting  relief  from 
rejieated  emptying  of  tin-  siie  i)y  means  of  the  Hnger-tip.  eontinues 
the  practice.  Inspection  and  jialimtion  show  the  contrast  between 
the  two  sides,  the  lacrymal  crest  and  mouth  of  the  duct  heing 
readily  felt  on  the  sound' side.  If  there  is  a  Imnpy  fi'eling  after  empty- 
ing  there   is  likely   nmch   tiiickenuig   of  the   lining,  or  a  polypus. 

(Fig.  111.) 

.Mucocele  may  persist  for  years,  causing  ami"  ;>  only  by  the 
epiphora  and  the  blurring  of  .«ight  by  Hecks  .  ..ischarge  from 
the  .sac  or  conjunctiva.  Conjunctivitis  and  bh-pharitis  are  often 
present.  If  absent  and  the  punctuni  acting.  ei)ii)hora  itself  may  be 
wanting.  Th(>re  is.  however,  always  the  risk  of  acute  inflammation, 
and  subacute  attacks  are  not  infreiiuent.  Besides,  the  contents  of 
the  .sac  being  charged  with  organisms,  infective  ulcer  of  the  cornea 
may  occur  from  slight  abrasion,  etc..  and  the  eye  be  lost.  The 
subjects  of  mucocele  should  always  be  warned  of  their  danger,  and 


Bovvman'H  [trobes. 

where  it  is  present  the  globe  should,  not  l)e  opened.  Proper  treat- 
ment should  first  lie  instituted.  Many  eyi'S  have  been  lost  by  post- 
operative sejjsis  due  to  mucocele. 

In  the  case  of  a  large  duct  with  ])artial  stricture  the  contents  of 
the  sac  may  escape,  or  be  forced  from  time  to  time  into  the 
nose.  If  this  avenue  becomes  closed,  or  if  in  confirmed  .stricture 
of  the  duct  the  wonted  discharge  by  the  caiialiculi  is  stopj^'d,  owing 
to  swelling,  the  tension  of  the  .sac  may  lead  to  acute  cystitis  or  to 
great  stretching  with  a  ca|)acity  of  a  drachm  or  more.  The  real 
size  often  does  not  show  because  the  .sac  dips  backward.  As  a  final 
.stage  of  neglected  mucocele  atrophy  of  the  thinned  mucous  lining  of 
the  greatly  enlarged  sac  may  occur,  and  the  latter  l)ecome  a  mere 
cistern  for  the  tears  (the  "  .\tony  and  Dropsy"  of  Kuclis). 

Treatment.  This  consists  mainly  in  cure  of  the  stricture  by  the 
.systematic  use  of  probes.  The  first  ste]i  in  a  course  of  probuig  in 
mucocele  is  to  slit  the  canaliculus  (page  221).  and  then  to  wash  out 
the  sac  by  syringing  with  a  4  per  cent.  sol.  acid,  boric,  or  sol.  hydrarg. 
])erchlor.^  1:  .3(MH).  It  is  unsafe  to  probe  the  duct  until  this  is  done, 
unless  it  holds  merely  mucus  and  tears,  and  even  then  it  is  unwise, 


i 


i>y.vi,JNAA  OF  ORBIT,  LAVJtYMAL  AJTAIIATI'S,  AM)  LIDS.    225 

fur  the  sac  liciiig  a  favoraljlc  culturo  bed,  orpaiiisms  may  jjain 
access  to  tlic  tissues  aiKUiid  tlii'uujili  an  al)msi(Hi  or  false  passajje, 
and  set  11])  se|)tic  inflaimnation.  ()rl)ital  cellulitis,  optic  neuritis, 
atrophy,  and  blindness  may  r  <ult.  In  syriiiftiiifj  after  probinj;,  no 
force  should  be  used,  else  weak  s])ots  in  the  sac  wall  may  pive  way 
before  \(Mit  is  had  by  the  lUict.  Where  irrij^ation  is  used  instead 
of  syrinfrinjr.  the  sac  and  duct  l)eing  flushed  with  a  ijuantity  of  fluid 
(iM  the  siplion  plan,  a  method  preferred  by  .some,  the  patency  of  the 
duct  should  be  tested  before  pressure  is  made. 

The  object  of  ])roi)inp  is  to  restore  the  normal  calibre  of  the  nasal 
duct  at  the  strictured  points,  with  a  view  to  present  drainage  and 
future  patency,  \iews  ditTer  as  to  the  best  method:  some  will  not 
slit  the  canaliculus,  others  will  not  use  larger  probes  than  6  Bowman. 
\ot  to  do  the  Bowman  operation  and  to  continue  using  jirobes  which 
will  pass  the  intact  canaliculus,  ignores  cases  for  wliich  the  best  can- 
not be  done  unless  large  ])robes  are  used,  and  such  cases  are  not  few. 
Large  nasal  ducts  are  often  found  in  nmeoccle,  and  with  one  or  more 
ring-like  ledges  having  a  lumen  of  1.5  mm.  to  2  nun.,  which  take  the 
largest  Bowman  j)robe.  (Fig.  112.)  Again,  the  bony  duct  in  the 
same  subj(>ct  may  differ  in  .size;  on  the  side  of  the  large  canal  there 
may  be  mucocele,  and  on  the  other  simple  stricture.  The  latter  will 
probably  j-ield  to  ordinary  probes,  wliidi  would  be  of  little  or  no  use 
in  the  former;  hence  the  eclectic  j)lan  is  a  safe  nile  and  the  best  in 
tlie  end.  Gauge  the  probe  to  the  duct,  and  try  large  ones  when 
smaller  fail.' 

.After  injecting  5  jier  cent,  of  cocaine  and  1 :  5000  sol.  adrenalin, 
a  No.  4  B.  or  5  T.  should  be  tried  first :  and  if  it  tits  tightly,  it  .should 
bo  left  in  a  few  minutes:  if  not,  higher  numbers  are  at  once  tried, 
and  on  the  next  visit  a  size  larger  tlian  that  last  used. 

Probing  should  be  done  on  alternate  days  for  two  or  three  weeks, 
and  then  twice  a  week  for  a  month,  or  until  the  sac  has  ceased  to 
secrete,  when  a  few  visits  at  intervals  of  ten  days  may  suffice.  If, 
after  the  first  two  or  three  visits,  probing  causes  only  transient  pain, 
one  may  then  safely  use  the  largest  size  pas.sed  under  firm  i)ressure, 
the  ])rob('s  being  left  in  fifteen  to  thirty  minutes.  But  if  the  j)ain 
lasts  .several  hours  in  spite  of  cold  compresses,  and  there  is  acliing 
in  the  bone  the  next  day,  there  is  risk  of  periostitis,  and  a  rest  of 
several  days  should  be  given.  Syringing  or  irrigation  should,  how- 
ever, be  kept  up  steadily,  daily  if  possible,  for  its  astringent  and 
curative  effect,  not  only  on  sac  and  duct  prr)per,  but  the  lower  tur- 
binal.  In  young  or  very  nervous  subjects,  and  where  one  is  susked 
to  do  the  most  in  the  least  time  (and  this  occurs  too  often),  general 
ana'sthe.sia  is  re(|uired.  This  allows  rapid  and,  where  needeil,  forced 
dilatation,  and  the  insertion  of  the  largest  styles  taken.     This  plan 


'  Tlie'>l!«l'l  use?  hi"  No.  !6  "  !n  a!-.!".!  two-thirds  of  al!  cases  requlrins  preblnff.  tneluditis  Iho-e  in 
I  'Idren  on  well  as  adults,  and  the  oases  in  which  No.  13  may  not  be  iiaed  with  advantage  are 
ex.remely  pare."  He  reports  the  exceptions  rare  to  peitnanent  cure  where  this  line  Is  faithfully 
followed. 


22(5 


riit:  EYK. 


suits  in  young  f*ul)jofts,  the  style  Ix'inj;  left  in  a  lew  days  at  least 
anil  in  older  ones  it  can  he  raisi'd  daily,  if  needful,  to  empty  or  flush 
the  sat-.     (See  Styles.)     Kleetrolysis  has  l)e<'n  tried  in  order  to  get 
((uicker  and  more"  lasting  etTect  upon  strietures  than  that  hy  simple 
probing  or  the  use  of  styles.     The  negative  pole  is  cotmeeted  witii 
the  prohe  in  situ,  and  tlie"si)onge  of  the  jjositive  is  applied  to  the  eheek 
or  neck,  the  strength,  of  the  current  not  to  exceed  thice  milliaiuperes, 
and  time  of  sittings  from  two  to  Hve  minutes.     The  method,  which 
is  worthy  of  trial,  has  met  with  .some  favor,  though  not  largely  u.scd, 
and  it  is  still  "uh  judicc.     Cataphoresis  is  also  on  trial  to  a  limited 
extent.    Solution  of  nitrate  of  silver  and  protargol  have  been  used  in 
purulent  bl(>imorrh(ra  of  the  .sac  and  duct.    Less  often  than  formerly 
strictures  of  the  duct  are  hrst  freely  divided  to  the  bone  by  the  Still- 
ing or  other  knife,  and  at  once,  or  shortly,  and  fmni  time  to  time,  the 
Weber  biconical  or  other  large  sound  is  |)a.ssed.     .\n  after-course  of 
syringing  may  not  l)e  necessary  when  the  sac  is  not  large  and  the 
secretion  scant  and  free  from  inis:  but,  as  a  rule,  it  is  a  most  useful 
adjunct.     In  view  of  th(>  return  of  the  stricture  and  of  the  blennor- 
rlxea  in  not  a  few  cases  of  mucocele,  even  after  careful  treatment, 
some  are  coiUent  merely  to  slit  the  canaliculus,  dispense  with  probing, 
and  rely  upon  svringing  of  the  sac  with  astringents,  etc.,  at  home. 
The  so-calleil   Berlin  lacryinal  syrir.g.>,  with  bulb  and  two   points, 
li.ard  rubber  and  metal,  is  a  useful  form  for  tiiis  purpose.     Sonic 
excise  a  part  only  of  the  sac  wall,  and  curette  tiie  rest,  or  treat  it 
tojiicidly  with  sol.  argent,  nit.,  etc.,  and  shortly  allow  the  wound  in 
the  skill  to  close.    This  line  of  treatment  suits  some  cases  of  trachoma 
of  the  .sac  or  of  polypus,  wiiich  givi-  a  pulpy  sensation  to  the  finger- 
tip after  emptying  the  sac.  owing  to  a  marked  tiiickening,  etc..  of  the 
nmcous  lining.     (S«'e  Fistula.)     In  lieu  of  ordinary  extirpation,  the 
sac  may  Ix'  entered  and  treated  from  below  by  removing  the  anterior 
part  of  the  inferior  turbinate  jind   the  turbinal  ci.-st    with  a  uouge, 
(>tc.  (T'assow). 

Miiriiccic  in  Injiints.  Tie  short  and  patent  nasal  duct  of  most 
infants  gives  organisms  ca.sy  access  to  the  sac,  which  forms  a  good 
nidus,  .Vcute  or  subacute  dacryocystitis  may  thus  cause  innnilent 
rhinitis  shorily  al'tiT  birth,  as  early  as  one  week,  and  the  diagnosis 
is  i)retty  dear.  But  blennorrhiea  of  the  sac,  which  more  often  results, 
is  a  mild  proce.-;s.  and  the  flat  nasal  liridge  and  relative  prominence 
and  width  of  the  inner  cantluis  tend  to  mask  the  real  mischii'f,  muco- 
cele. Hence,  in  very  young  subjects  without  n-al  or  witli  but  slight 
conjunctivitis  this  is  at  times  mistaken'y  held  to  be  the  cau.se  of  the 
l)urulent  or  mucopurulent  discharge  found  about  the  eyes  now  and 
then  during  thi'  day,  or  gluing  the  lids  in  the  morning.  The  astringent 
collyriui.i  as  generally  prescribed  is,  as  a  rule,  ineffective.  The  cul- 
de-sac  and  inner  canthus  region  should  be  filled  with  i  ni.  sol.  zinci 
chlorid.  or  acetat.,  or  1 ;  12,(XH)  hydrarg.  i)erchlorid.,  and  short,  care- 
ful massage  of  the  sac  done— this  daily  or  twice  a  day. 

It»  persistent  or  recurrent  mucocele  of  infant.s  |)eriodic  medication 


DlHi^AiiEii  OF  ORBIT,  LACJIYMAL  APl'AIiATUH,  ASD  LIDS.    227 


(if  tin'  sac  !)>■  syringing  sufiifcs,  as  a  rule,  and  should  bo  tried.  A 
liypodt-rinic  syringe  answers  well,  the  hlunted  and  smoothed  needle 
being  passed  into  the  canalieulus.  and  sol.  zinci  ehlorid.,  zinci  sulph., 
jduinli.  aeetat.  of  0.5  per  cent,  strength,  sol.  hydnirg.  pereldor.  1 :  .'5(MK) 
or  1  :  40(K),  sh>wly  injected.  If  the  fluid  does  not  i)ass  into  the 
nose,  oiK'  should  make  sure  that  the  tip  is  in  the  sac  before  diag- 
nosing stricture.  If  the  sac  contains  pus,  or  if  there  be  niucopus 
after  a  few  injections  made  at  intervals  of  two  or  three  days,  sol. 
protargol.  10  oer  cent,  should  be  used,  and  20  per  cent,  if  this  fails 
after  one  or  two  trials.  Rhinitis  should  alwa\'s  be  looked  for,  and 
!)(■  treated  (as  well  a.s  in  older  subjects),  vW  the  treatment  may 
prove  futile,  and  this  rule  holds  in  all  young  subjects,  upon  whom 
one  should  be  slow  to  use  instruments.  In  not  a  few  cases  the  free 
end  of  the  duct  is  blocked,  as  it  may  be  in  adults,  by  a  fold  of  mucous 
membrane  which  interferes  with  drainage,  although  yielding  under 
the  |iressure  of  the  syringe.  This  emphasizes  the  need  of  attention  to 
the  nasal  pas.sages  in  lacrymal  cases.  Proper  treatment  of  the 
inferior  turbinals  often  cures  marked  simple  epijihora,  and  is  an 
elTective  adjunct  to  medication  of  the  sac  in  case  of  mucocele. 
In  very  young  subjects  there  may  be  stricture  of  the  duct  with  (and 
without)  mucocele,  which  re(|uires  slitting  of  the  canaliculus  and  the 
use  of  probes,  etc.,  as  in  adults. 

Dacryocystitis.  Acute  inflannnation  of  the  lacrymal  sac  is  gen- 
enilly  a  secjuel  to  mucocele,  although  now  an('  then  it  lights  up 
primarily  as  a  complication  of  acute  coryza  (inllin:iza,  la  grippe), 
especially  in  young  infants:  also  of  erysipelas.  In  scrofulous  or 
syphilitic  subjects  jicriostitis  or  osteitis  in  the  lacrymal  region  al.so 
causes  acute  or  subacute  cystitis.  After  exposure  or  in  the  course 
of  rhinitis,  etc..  the  subject  of  nuicocele  finds  that  pn-ssure  r)n  the 
inner  canthus  does  not  dis]ier.se  the  doughy  .swelling  as  usual,  but 
that  the  latter  has  become  hard,  tender,  and  tun;or-iike.  (juickly 
pain,  often  intense  and  due  to  tension,  sets  ui  with  hiflannnatory 
irdema,  which  in  markeil  ctises  closes  the  eye  and  extends  to  the 
cheek  and  over  the  nasal  bridge,  involving  the  lids  of  the  opjjosite 
side.  With  the  canaliculus  and  duct  closed,  there  is  now  a  virtual 
abscess,  which  if  unrelieved  within  a  few  days  points  and  opens 
below  the  internal  tarsal  ligament,  the  pain,  swelling,  etc.,  (juickly 
subsiding.  The  rapid  onset  and  smooth  glistening  skin  with  bright 
blush  have  time  and  again  led  to  a  diagnosis  of  erysipelas,  but  the 
history  of  epiphora  and  mucocele,  and  the  intense  localized  pain 
and  ex(iuisite  tenderness  at  the  site  of  the  sac,  .should  give  the  clue. 
( ienerally  the  breach  soon  closes,  and  there  is  once  more  nuicocele 
or  simple  cystitis,  which  may  later  lapse  again  into  the  acute  form. 
Very  rarely  the  sac  resumes  the  normal  cond.tion.  Sometimes  the 
opening  in  the  skin  persists,  giving  vent  to  the  tears  and  mucopus 
(hstula  lacrymalis),  a  sure  result  in  bone  di.sease,  which  may  be  the 
effect  as  well  as  the  cause,  as  already  stated,  of  acute  cystitis.  In 
a  f(>w  ciises  there  is  a  dissecting  infiltration  of  the  skin  down  and 


22H 


nit:  EYi:. 


; 


(Hit  Iroiii  tlif  iiiiiir  caiitluis,  furiiiiiif;  a  doiinliy  limad  riilf;<'  lor  I'vcti 
an  iiifli,  like  a  lii'sli  keloid  cicatrix.  In  utlicr  cases,  and  rarely,  tlie 
fistula  contracts  initil  tliere  is  i)iit  a  very  tine  (ineniiijj  in  healthy  skin 
through  which  tears  only  can  ooze  -cai>illary  listula. 

Treatment.  In  mucocele  with  incipient  acute  cystitis  the  rule  is 
promptly  to  slit  the  canaliculus  into  the  .sac  when  great  swi'lhng  of 
the  parts  does  not  prevent  it.  The  tension  of  the  sac  is  thus  relieved, 
vent  given,  and  i)ain  relieved.  Other  step;*  are  gentle  syringing  with 
warm  boric  acid  sol.  ;}  per  cent.,  or  1:  S(MK)  merciu-ic  chloiitle  .sol.,  if 
not  too  painful;  also  the  injection  of  10  per  cent.  sol.  protargol,  and 
the  u.se  of  dressings  wet  with  atrojiine,  lead-and-spirit  lotion,  over 
which  a  small  ice-bag  isjilaced,  orai>ieceof  ice  in  a  small  gauze  sling; 
calomel.  Seidlitz  powders,  and  pulv.  Dover.,  with  other  anodynes, 
may  la'ove  useful.  If  cold  is  not  grateful,  hot  fotiis  now  and  then 
.should  be  used.  The  canaliculus  should  be  kept  open  and  the  sac 
washed  out  daily  with  warm  boric  acid  sol.  .\  i>er  cent.,  or  1:S(K)0 
to  1:4(MK)  mercuric  chlori<le.  and  protargol  10  |icr  cent,  to  20  jht 
cent,  be  inj<'cted  if  pus  continu(s.  In  primary  acute  attacks  in 
infants,  and  sometimes  in  adults,  when  of  a  mild  tyite,  palliative 
treatment  by  iced  C()mpres.ses.  etc.,  may  sullice  without  slitting. 
The  sac  should  be  syringed  with  warm  boric  acid  .sol.  through  the 
dilated  canaliculus,  and  10  |)er  cent,  protargol  or  argentamine  then 
injiTted.  If  the  c;use  is  not  seen  until  too  late  to  reach  the  puncta, 
aiid  the  inflammation  is  jirogressing.  one  sho\ild  anticipate  ru])ture 
through  the  skir\  by  cutting  straight  into  the  sac  below  the  palpebral 
ligament.  After  gently  syringing  with  boric  acid  sol.,  hydrarg.  per- 
chlori<l.,  etc.,  aseptic  moist  (Ir  "ssings  should  be  ajjpiied  and  hot 
fotus  used.  Irrigation  shouUl  be  jmictised  daily.  The  canaliculus 
.should  be  .slit  into  the  sac  as  soon  as  feasible,  for  vent  given  in  this 
way  promotes  thorough  cleansing  and  the  healing  of  the  sL.n  wound, 
and  I'xiiedites  the  necessary  resort  to  systematic  probing  for  the  cure 
of  the  stricture.  The  us<'  of  probes  should  be  begun  as  soon  as  the 
active  stage  has  pas.sed. 

Fistula  Lacr3nnalis.  This  often  needs  no  special  treatment,  and 
heals  when  the  canaliculus  is  opened,  or  the  patency  of  the  duct  is 
restored  by  i)robing.  Now  and  then  fungous  tissue  within  and  at 
the  mouth  of  the  canal,  or,  again,  the  smooth  lining  of  an  old  fistula, 
re(|uires  to  be  removed  by  cuistic.  cautery,  curette,  or  scissors,  to 
ensure  healing.  But  if  the  sac  is  large  anil  .secreting  |)us,  it  should 
he  opened  by  enlarging  the  fistulous  canal  freely,  and  the  disea.sed 
lining  swabbi  d  with  sol.  argent,  nit.  2  per  cent,  to  10  per  cent., 
zinc,  chlorid.  5  per  cent.,  or  tinct.  iodin.,  or  lightly  touched  with 
argent,  nit.  .lO  per  cent.,  in  the  form  of  a  bead  fused  on  the  eiul  nf 
a  probe:  or  if  tr.achomatous.  curetted,  irrigated  with  sol.  hydrarg. 
perchl'ir.  1  :  1000,  liried,  treated  with  vaseline,  and  packed,  and  cold 
dressings  put  on.  One  or  other  of  the  above  may  be  needed  several 
times  at  short  intervals  before  the  discharge  cea.ses  or  so  abates  as  to 
allow  closure  of  the  wound.     A  jiressure  pad  then  jjromotes  healing. 


IHSEASt:.S  OF  nUlilT,  LlCliYMAL  AlTAUATiS,  AM)  LIDS.     22!> 


vent  liciiij:  liiid  lln(ui<;li  the  caiialiciiliis  jilrcady  (ipcriid.     An  altcr- 
iM)uis(    (if  |)rol)iii);  is  usclul.     In  tin-  event  of  inii>eri'ect  liealin);  of 


fresli  oiithreak  of  cystitis,   caries   in   tlie  iluct   or 

wltli    internal   tislula.    will    likely  tic    found 

rifice  of  tlie  sac,  willi  careful 


tlie   tistnia   or  a 

of   tiie  lacryina 

.vitli  the  probe,  a  fair  indication  lor  sacrifice  of  tlie  sac,  willi  car 


scrapnif;  ol  the  carious  sj 


ts,  etc.     In  'his  condition,  however,  forced 


dilatation  ( 


cure  nianv  case? 


f  the   strictured  duct   has   been   found  l>y  Theobald   to 
and    this  inethoil   should,    therefore,    have   jirece- 


ileiice. 

Iiarelv  a  fistula  exists  at  the  inner  canthus  near  the  sac.  but  uncon- 
nected with  ilie  latter  and  leadinjj  to  a  carious  spot  at  or  within 
the  inner  iiiarpii  of  the  orbit,  or  even  into  the  anterior  ethmoid  cells, 
as  shown  by  the  probe.  Afjain,  in  nuicocele  of  the  ante  rior  ethmoid 
cells  thi-re  may  be  a  swellinj!;  just  behind  and  above  the  lacrvinal  sac 
which  siimilates  mucocele  of  the  latter.  The  absence  of  lacrymatiou 
and  escape  of  the  di.-ich;irf;e  jier  punctuin  <in  pre.s,«ure,  and  the  pas- 
.sifre  of  flui<l  into  the  nose  on  syringiuft,  together  with  deeii  paijiation, 
should  distinguish  the  condition. 

Stiilis.  These  may  be  hollow  or  solid,  and  are  preferably  of  soft  vir- 
gin silver  oraluniinum:  lead  wire  often  isu.sed;  some  employ  gold,  and 
others  hard  rubber.  The  crook  should  be  sufficiently  long  to  reach 
neariv  to  the  i)unctum,  lying  in  the  canaliculus,  so  as  just  to  avoid 
touching  the  cornea  in  extreme  adduction,  and  the  stem  should  about 
reach  the  floor  of  the  inferior  nasal  meatus.  They  should  be  made 
perfectly  smooth,  so  as  not  to  tear  the  mucous  membrane.  The  stvle 
should  !«•  as  large  as  will  tightly  fit  the  duct  under  the  u.-^e  of  cocaine 
anil  adrenalin,  and  not  .smaller  than  No.  4  H.  At  short  intervals 
larger  sizes  can  be  put  in  as  .stricttire  or  hyijertrojiliy  yields,  and 
when  of  large  calibre  that  of  the  crook  should  be  reduced.  If  too 
short  in  crook  and  stem,  the  styh'  is  ai>t  to  slip  down,  especially  if 
heavy,  as  of  leail,  and  the  crook  become  encysted  in  the  sac  wall. 
It  will  til  act  as  a  foreign  body,  and  will  need  to  be  cut  out  of  its 
bed.  II  .How  styles  .^lipped  into"  i)lace  over  a  probe  already  jiassed 
(Bickerton)  are  "useful,  but  jirominence  of  the  brow  may  be  a  bar. 
Where  there  is  mucocele  or  blennorrlKca  the  styles  should  be  drawn 
up  or  removed  daily  and  the  sac  irrigated  with  an  astringent  solution. 
Patients  who  learn  to  in.sert  them  themselves  have  the  best  results. 
In  organic  strictvire  styles  should  be  worn  if  jiossiblo  for  six  months, 
•ind  if  used  for  other  cases  arc  to  bo  worn  four  to  six  or  eight  wet  ks, 
a  trial  resjjitc  for  two  or  three  days  being  given  now  and  then.  Un- 
fortunately, in  many  cases  styles  are  not  tolerated,  and  in  not  a  few 
the  tendency  to  the  formation  of  gramilatioiis  prevents  their  use  for 
more  than  a  few  days  at  a  time. 

With  the  proviso"  that  a  fair  trial  of  probing,  styles,  syringing, 
etc..  treatment  of  nasal  passages,  etc..  has  lieon  given,  the  indications 
for  extiri)ati(Mi  or  obliteration  of  the  sac  are:  bony  stricture  of  the 
nasal  duct,  with  constant  epi|)hora.  with  or  without  nuicocele;  recur- 
rent stricture  of  the  duct  and  purulent  blennorrhcea ;  persistent  muco- 


2;io 


77/ A'  /;  YK. 


I'liiT  i 


;)!!' 


I 


cclc,  with  roiicMtcil  attacks  of  ai-iitr  iiillaiiimatinii— [ihlcjiiiionoiii: 
piTsistciit  ti.stiila,  witli  invctcratf  miicipci'lc.  etc,;  markcil  (iri>i>sy  uf 
the  sac. 

C.  Hdlmi's,  will)  iirfjcs  and  practi^'s  cxtiipatidii  uf  tlic  lacryiiial 
jllaiid  anil  sac  tofti'tlicr,  oWscrvcs  tlic  fcillowinji  indications  for  tli<' 
latter: 

1.  IniiHTativc  oixrations  for  cataract,  glaucoma,  etc.,  in  the  pres- 
ence of  l)!ennorrlui-a,  etc. 

2.  In  patients  who  cannot  devote  the  time,  (ir  submit  to  treatment 
l)y  prohinn,  etc. 

3.  In  ail  ca.ses  where  conservative  treatment  lias  faih-d  to  euro 
within  a  rea.xonable  time. 

HxTiiU'ATioN.  The  canaliciili  are  destroyed  hy  tlie  jrlowing  wire. 
The  lower  end  of  the  iia.sal  duct  is  .sealed  by  packing  jjauze  under 
the  inferior  turhinal.  A  careful  incision  is  made  from  a  point  just 
beneath  the  centre  of  the  lower  border  of  the  tendo  oculi,  dissecting 
obli(|U<'ly  inward  and  backward  and  in  line  with  the  fibres  of  the 
orbicularis,  exposinj;  the  sac  u])  to  its  dome  The  lii)s  of  the  wound 
i)einfi  retracted  and  the  bleedinj;;  .stoppeil:  the  sac  is  then  freed  by 
a  blunt  hook  and  cut  off  at  the  edpe  of  the  orbit.  If  this  is  not 
feasible,  the  sac  should  be  cut  out  i>iecemeal.  and  any  carious  bone 
shouK  '  '  scraped,  to  secure,  if  possible,  healiu};  by  first  intention. 
Th     I  is  now  curetted  and  the  parts  irrijiated.     The  wound  is 

closed  l)y  sutures  and  the  dres.sinjjs  ai)plied,  jires-sure  i)einp  made 
Iv'  a  compress  and  strapping.  The  stitches  may  be  remove<l  in 
three  or  four  days.  The  nasal  passage  shoulil  be  kept  as  aseptic  a.s 
possible  until  scar  ti.s.sue  has  blocked  the  way  to  the  soft  parts  at 
the  top  of  the  duct. 

()Bi.rrKH.\Ti<)\.  To  this  end.  caustic  and  the  cautery  are  used,  to 
cause  sloughing  of  the  mucous  lining  of  the  upper  end  of  the  duct 
and  of  the  sac.  and  fusion  of  its  walls.  The  canaliculi  should  first 
be  sealed  by  the  careful  use  of  caustic  or  the  fine  glowing  wire. 
Isually  the  .sic  is  cut  into  just  below  the  palpebral  ligament,  or  a 
fistula  is  enlarged,  bleeding  is  stopju'd,  .md  the  sac  cleansed:  oil  or 
vaseline  is  applied  around  the  opening  and  just  within.:  the  cut  is 
made  to  gape,  and  argent,  nit.,  in  the  form  of  small  beads  fused  on 
the  end  of  probes  or  crystals  held  in  fine  forcei)s,  is  freely  applied 
within  the  .sac;  similarly  pota.ssa  cum  calce  or  acid,  nitric,  on  a  small 
tuft  of  absorbent  cotton  may  be  used:  al.so  acid  nitrate  of  mercury, 
zinc  chloride  paste  Clii  per  c.<'nt.K  and  potassa  fusa. 

The  .sac  cavity  may  al.-io  be  readied  by  cutting  through  the  floor 
of  the  canaliculi  iV.  W.  Agnew),  and  caustics,  etc.,  may  be  safely 
a])])lied,  but  care  is  needed  to  spare  tlie  conjunctiva  and  to  avoid 
the  formation  of  a  scar.  The  thermocautery  and  gal va no-cautery 
may  also  be  u.-cd  to  de.-;troy  the  sac.  but  the  whole  sac  lining  cannot 
be  so  readily  reached  .-is  with  ditTusil)le  caustics.  In  either  case,  cold 
compresses  are  apjilied  for  a  few  hours  to  limit  reaction,  and  then 
warm  |>oultices  of  sli])pery-elm  in  small  muslin  b;ig  for  sev(>ral  days. 


j>isi:a.^i:s  df  (tiuiir,  A.ir/n'.w.i;.  .i/'/m/m //■>•,  .i.v/>  lids    2.;. 

Tlir  I'scluirs  sliDuld  lio  roniovod  lis  soon  as  .■•(■paraljlc,  and  a  pn'>s'iri> 
(•(.itipn'ss  a|)|ilit'd  over  vaseline  dressing,  to  promote  healing.  This 
eovers  two  or  three  weeks  from  tiie  start;  extirpation  requires  oidy 

one. 

The  foilowiiin  ne<.|,lasms  have  In'en  foiitid  in  the  hicrynial  sar; 
saivoma,  epitiieiioina,  angioma,  tihroina  ravernosa,  rhinoscleroma : 
tliev  are  very  rare  oxeejit  l>y  extension  in  the  case  of  the  two  first. 

l";iiipli(>ra"frei|iiently  persists  after  destroying  or  removing  the  sac. 
or  it  often  occurs  from  siifiht  exciting  cau.ses:  sacrifice  of  the  gland 
at  the  same  time  is,  therefore,  iirjied  hy  some  !is  a  rule  of  practice, 
and  the  more  hecause  under  strict  a.sepsis  extirp!>tion  is  a  safe  opera- 
tion.' Hut  lacryination  is  not  always  a  sccjuel  to  loss  of  the  sac,  and 
some  seemingly  intractable  cases  under  the  usual  treatment  are 
cured  hy  forcible  dilatation  of  the  strictured  duct  with  large-sized 
probes  (Tiieol;ald).  Hence  the  gland  may  well  be  spared  for  a  time 
until  this  jjrocedure  has  been  tried. 

KxTiHPATioNoK  thkLachvmai.Oi-.vm).  The  parts  being  surgically 
clean,  a  cut  is  made  just  below  the  outer  half  of  the  eyebrow  to  the 
margin  of  the  orbit,  exposii\g  the  septum  orbita-,  which  is  thendiviiled 
close  to  the  bone,  with  just  sufficient  edging  to  hold  sutures.  Fatty 
tissui'  may  present,  but  shoulil  oe  left.  The  lower  edge  of  the  gland 
does  not,  "as  a  rule,  reai'h  to  the  bony  rim,  but  entire  removal  .should 
l)e  aimed  at,  and  can  with  care  l)e"efTected  by  scis.sors,  hooks,  etc., 
and  without  injuring  the  levator  i)aliH'l)ru"  or  external  rectus.  All 
bleeding  should  be  stopjjcd.  The  palpebral  iM)rtioii  (inferior,  second- 
ary or  acces.sory)  need  i;ot  be  removed.  Careful  stitching  of  the 
skin  wound,  the"  fascia  being  first  united  by  buried  catgut,  and  asep- 
tic dressings  under  conii)ress,  ensure  prompt  healing  and  but  little 
after-sign. 

THE  EYELIDS. 

Anatomy.  The  evelids  are  two  folds  of  skin  which  cover  the  eye- 
ball, and  bv  their  me'-nbranous  attachments  close  in  the  orbital  cavity. 
The  lids  o'we  their  iorin  and  .stiffness  to  cartilages  or  tnrxi,  as  they 
are  called  (Fig.  li;?);  thes<>  are  the  framework  of  the  lid,  and  when 
they  liave  been  distorted  as  the  result  of  disease  or  accident,  inter- 
fere" seriouslv  with  the  lid  performing  its  proper  functions.  The 
cartilages  are  covered  externally  by  the  skin  and  the  orbicular  muscle 
externallv  bv  the  conjunctiva,  the  borders  of  the  lids  are  fringed 
with  short  hairs,  the  lashes,  or  rilia.  These  are  directed  forward 
and  are  more  numerous  upon  the  upper  lid.  As  is  shown  by  the 
accompanying  illustration  (Fig.  114).  there  is  a  <lepression  or  sulcufs 
j\ist  below  J,  which  represents  the  opening  of  a  sebaceous  gland.  The 
cilia  are  ?een  at  n,  with  nifMlified  -^wovti  ,ind  Zeiss  glands  about  them. 
Heneath  the  skin  lie  the  transversely  divided  bundles  of  fibres  of 

'  "  Primary  Union  in  Eighteen  Caies  out  of  Nineteen."    C.  Holmes. 


•J:f2 


77//;  /•»■/.. 


Ihi    iirhiciiUin"  ill).  <<(    whicli  tlin>f   |)l;i('ril    iiitrriiiilly  il>')   furni  ^Ac 
m((.vri(/i/.<  ciliiiris  Uiolant.     The  jxistorinr  part  nt"  the  lid  is  covfrfd 


Ki...  lU. 


Helativt?  ncwltion^  ami  wiw  of  t'yi'li'l« 

I  M  ERK  F.I.. ) 


l)y  coiijuiictiva,  whu-li  is 
clnscly  adiiciciit  to  tlic  tiiisus. 
The  Ml  ilioniidn  ijliinil.-<  luivc 
tlK'ir  urilicfs  in  front  of  the 
posterior  ('<lgc  of  llic  lid  : 
al)ovo  tiicMi  lie  till'  niiicDiis 
(/Id mix  (k),  and  still  hifjhor 
Mailer's  iiniscif  mn\  the  Ivralor 
of  tlio  lid.  The  Mcilioitrian 
illnnil"  (I'ij;.  lloi  arc  modified 
sebaceous  };l;ii"l^.  !"i"l  secrete 
a  sebum  wliicli  bathes  the 
margin  of  the  lids  and  pre- 
vents o\-erflo\v  of  the  tears. 
The  closure  of  the  lids  is  ef- 
fected by  the  orhitiiUiris  mitsclf.  The  fibn's  of  liiis  muscle  form 
more  or  less  of  a  s])hincter,  extend  itito  tiie  subcut.'ineiius  tissues 
surroundinf;  the  lid.  and  are  iiiserteil  into  a  tendon  wliich  adhen's  to 
the  lacrynial  bone.  The  '.rl)icularis  is  supplied  by  the  scventii 
nerve,  and  v''  'ii  this  nerve  is  jiaralyzed  the  lids  refuse  to  ch)se,  a 
staring;  expi    ■    on  being  given  to  the  eye. 

Diseases  of  the  Lids. 

Lagophthalmos,  or  incomplete  closure  of  the  palpebral  fissure,  is 
usually  occasioned  by  peripheral  palsy  of  the  seventh  nerve,  resulting 
from  hitracrauiul  causes;  it  may,  however,  result  from  narrowing  of 


Vcrtk'H 


t-'ftiiin  IlirotiKli  upp--  ■  t'vt'lUl. 

(SlIAKKR  I 


I)Isi:asj:.s  or  ttiniir,  i.m  hvmai.  .i/'/m/.m/tn,  .i.v/»  /,//<>    2;5.J 


till'  lids  hy  injury  or  iiiriTalion,  or  liy  tlic  inrriiMtiini  of  cicitric'i's 
(licitlriniil  i'flriii>i<iin,  and  it  may  I'lisnc  wIh'Ii  the  cscliall  is  ('iiiarp'il 
IT  |pu>1ici1  I'lirwanl  [iintiilnsis).     (i'in.  IKi. ) 


Flo.  II.'.. 


Punrtii  huhnjmalia 


I'ljflltlon  of  Meibomian  ^lao-        iAk.sold.) 

Whfii  laRoplithaliiiiis  is  prcsi'iit  as  the  ri'stilt  of  an  iiitracniniai 
Icsiun,  it  may  !«'  acci)iii|iaiiii'il  hy  h('iiii|ii('gia  of  tlic  .same  nr  niiposite 
side.  Thus,  a  ii-sioii  .■"itcriur  U\  tlic  jMins  or 
ill  its  aiiti'i'inr  pDrtimi  \vi!l  caiiw  jjalsy  of 
tlic  seventh  nerve  of  tlic  same  side  as  tin; 
lieiiiiplci;ia.  wlicrcas  a  lesion  pustirior  to  the 
pons  orin  its  posterior  portion  will  occasion 
palsy  of  the  (ip|)ositc  side.  On  account  of 
the  exjMisurc  to  the  eye  which  lanophthal- 
iiios  occasions,  disease  of  the  cornea  and 
conjunctiva  is  freijueritly  provoked.  W'iien 
the  condilion  is  due  to  facial  pal.sy,  active 
measures  should  he  instituted  at  once  for 
its  relief:  these  include  leeches  and  hot 
stupes,  mercury  and  the  iodides  in  siM'cific 
cases:  later  the  contiiuious  current  and  hypodorniic  injections  of 
strychnine.  I'ntil  closure  of  the  lid  has  been  effected,  the  eye  should 
he  ke]it  l)anda<;ei|.  If  thi'  cornea  !>e  threatened  or  if  the  condition 
becomes  pirmanent,  a  tarsorrhaphy  should  he  jwrfornied. 

TAitsoiiUUAi'iiv.  The  simplest  way  to  shorten  the  palpebral  aper- 
ture is  to  pare  lifihtly  the  inner  lips  of  the  uiijier  and  hiwer  lid-margins 
from  the  aufile  for  3  to  ()  mm.  or  more,  and  then  stitch  them  tofjether 
without  rensoviii-:  the  eyeiashc-  -fde  Weckcr,  Nnyes).  Tar^orrh.aphy 
is  usually  done  as  follows:  After  gauging  the  length  of  the  line  of 
union  required  the  lid  is  slightly  everted  and  made  tense — some 
stntcli  the  canthus  by  inserting  a  spatula  behind  it.     The  margin  of 


I.n|fOl»lithiilnios. 


234 


THE  EYi:. 


i'lifh  lid  is  split  with  ii  fine  knife  just  hcliiiul  the  row  of  cilia  anil  suffi- 
cicutlv  ilccp  to  iiichulc  tlic  liair  bulbs.  The  narrow  Haps  of  skni  with 
bulbs  "arc  then  removed  bv  incisions,  meeting  a  little  beyond  the  coin- 
iiiissure.  The  inner  lii^s  are  lightly  pared  froni  the  latter  to  a  point 
several  niillinietres  bevond  the  end  of  the  flap  wounds.  The  raw 
surfaces  are  then  carefully  coapted  bv  silk  sutures  j.assed  obluiuely 
up  ior  iown)  and  in.  and  made  to  Kraze  tlie  inner  lip.  Traction  is 
relieved  bv  compresses  and  J'laster  for  three  or  four  days,  when  the 
sutures  are  removed.  To  make  tarsorrhaphy  more  eficctiv,  I-uchs 
cut.s  awav  the  flap  with  the  hair  bulbs  fro:n  the  upi)er  hd  only,  splits 
the  lower  lid,  and  frees  the  anterior  flap  by  a  vertical  cut  at  ihe  inner 
end  of  the  slit.  The  inner  surface  of  the  anterior  flap  is  then  stitched 
to  tlie  raw  ujjper  wound.  ,•  i     r 

Tarsorrhaphv  is  indicated  in  the  relaxed  or  everted  lower  lid  ot 
senile  and  i)aralvtic  cases,  in  laRophthalinos,  in  proptosis,  and  exoph- 
thalmic goitre;  it  is  done  often  as  an  adjunct  in  blephar()|)lasty. 

Blepharospasm,  or  spasm  of  the  orbicularis,  may  be  either  .s7/m/>- 
tonmtic  of  other  ocular  disease,  or  essential.  The  latter  variety  is 
rare  and  is  often  hy.sterical,  while  the  former  is  a  frequent  accom- 
paniment of  manv  forms  of  ocular  disease,  especially  where  there  is 
much  drea.l  of  lifjht,  as  in  phlyctenular  keratitis,  and  where  a  rel  ex 
irritation  of  the  Hbres  of  the  trigeminus  has  b.en  excited.  In  tins 
connection  should  be  mentioned  the  fibrillary  C( .   1  raction  which  occurs 

s(,  frequently  in  a  localized  portion  of  the  -  umIc.  Apart  from  the 
annovance  which  this  occasions,  it  is  u.,t  signilicant,  and  can 
usually  be  ma.le  to  disappear  by  tl'  a.ljustment  of  glasses  to  correct 
any  existing  error  of  refraction,  of  similar  origin  iire  the  attacks 
of ''bUnking''  ■'hich  occur  in  school-children.  Not  inrre(iuently  these 
are  acconii)anie(l  bv  choreic  movements  in  the  muscl<'s  of  the  face. 
In  adults  blepharospasm  often  is  associated  with  tic.  Blepharo- 
spasm is  due  not  infre(iuently  to  hysteria,  in  which  event  "pressure 
points"  may  Ih>  found  in  the  region  supplied  by  the  trigenunus, 
which  will  occasion  opening  of  the  lids  when  they  an'  pressed  upon. 

Treatment.  Treaunent  of  blepharospasm  will  depend  upon  tlie  cau.se 
If  the  jiatient  be  aiwinii',  tonics  should  be  administered:  arsenic  is  of 
value  in  choreic  cases:  all  errors  of  refraction  should  be  carefully  cor- 
recteil.  In  cases  arising  fnmi  reflex  irritation  of  the  fifth  nerve  all 
possible  foci  of  disease  should  be  investigated  and  removed,  (ial- 
vanism  is  useful  in  the  later  stagi's. 

The  lids  are  opened  by  the  action  of  the  levator  paliwbra"  sujie- 
rioris  and  by  the  sinking  o''  the  lower  lid  by  its  own  weight.  The 
levator  Mrises  at  tin'  ai>ex  (if  the  orbit  and  is  in-.rted  into  the  upper 
edge  <.f  the  tarsus  bv  three  attachments.  It  is  supplied  by  a  twig 
fpMU  the  third  m-rve,  and  when  panilyzed  the  upper  lid  cannot  be 
,..,;.;,,,!    :,n,l  the  condition  called  ptosis  or  drooi)inji  of  the  upper  lid 

Ptosis  may  varv  in  degree  from  !i  slight  droop  of  the  lid  to  the 
comi)lete  covering  of  the  eyeball.     It  may  b.-  congenital,  when  it  is 


l)J^i:Ali£S  OF  ORBIT,  LACRYMAL  APPARATUS,  AXD  LIDS.     235 


usually  associated  with  cpicanthus  and  affects  both  lids;  usually, 
liuwcver,  it  is  ac(iuii'ed.  Acquired  /j/o.v/.v  may  result  from  palsy  of 
the  hraiidi  of  the  third  nerve  supplyinji  the  levator  of  the  lid.  It 
may,  however,  he  due  to  local  chaiiftes  in  the  upper  lid,  which  increase 
its  volume  or  weight,  such,  for  example,  as  occur  in  trachoma  and 
various  tumors  of  the  lid.  Paralytic  jilo.iis  may  he  due  to  periph- 
eral or  central  cause,  and  is  a.ssociated  frequently  with  palsies  of 
other  branches  of  the  thin!  ner^•e.  If  isolated,  it  is  due  usually  to 
an  intracranial  lesion. 

Treatment.  Antisyphilitic  ami  antirheumatic  treatment  should  be 
tried  in  suitable  cases;  galvanism  and  hypodermic  injections  of 
strychnine  are  of  value  in  the  later  stages.  For  slight  degrees  of 
])tosis  resulting  from  inefficiency  of  the  levator,  owing  to  injury  or 
ancient  trachoma,  etc.,  the  removal  of  a  narrow  horizontal  strip  of 
skin  and  muscle  may  suffice  with  insertion  of  the  deeply  j)lace(l 
sutures  brought  out  high  uj)  on  the  lid.  This  ojteration  is  more  cer- 
tain if  a  piece  of  tarsal  cartilage  also  is  excised,  as  in  the  Gillet  de 
(ir.mdmont  operation  (Harlan),  in  which  case  the  horizontal  tarsal 
wound  is  united  by  buried  catgut  sutures.  Advancement  of  the 
levator  by  the  Kversbu.'ich  (which  see)  and  the  Snellen  methotis  also 
gives  good  results. 

I'lof^is  Atonicn  (Hotz).  In  this  condition  the  skin  of  the  upj)er  lid 
hangs  down  over  its  free  edge  when  the  eye  is  open,  and,  instead 
of  following  the  upwanl  movement  of  the  tarsal  cartilage,  remains 
stationary.  It  is  due  to  loss  of  the  normal  connection  between  the 
skin  and  tarsus,  and  is  corrected  by  the  Hotz  operation  used  in 
trichiasis  and  entroi)ion. 

/'/o.v/.v  ndiposa.  in  which  a  layer  of  fat  beneath  the  skin  acts 
mechanically  and  causes  falling  of  the  lid,  if  not  overlapi)ing.  is 
relieved  by  removing  tiie  ma.ss  of  adipose  tissue  through  an  incision 
in  tlie  skin. 

To  ciirrect  nnich  droo])ing  of  the  lid  after  tri'choina,  Gruening  em- 
ploys a  modified  Hotz  suture.  "An  incision  is  made  just  below  the 
up])er  I'dge  of  the  tarsus  and  ])arall<'l  to  it.  Some  orbicularis  fib.res 
may  be  excised.  \\'ith  a  sharjily  curved  needle  the  thread  is  jjushed 
.along  the  surface  and  upj)er  e<lge  of  the  tarsus  through  the  conjunctiva, 
until  il  loops  tip  the  cul-de-sac  and  returns  ui)on  itself  beneath  the 
skill,  to  come  out  at  the  upper  |)art  of  the  wound.  It  never  traverses 
thi'  skin.  Three  sutures  may  be  u.:'d.  They  are  tied  tightly  and 
allowed  to  remain  two  to  five  days,  according  to  the  amount  of  re- 
action "  (Xoyes). 

livers' I- iscli's  oj)eration  in  jiartial  ptosis  has  given  excellent  results. 
.\  horiziiiital  incision  is  made  across  the  lid  and  half-way  between  the 
lid-margin  and  the  eyebrow;  the  tissues  are  then  .separated  so  as  to 
exiMise  a  strip  of  contiective  tissue.  A  strong  |)iece  of  catgut  with  a 
(•urvi(i  needle  at  eitlier  end  is  u.sed.  One  needle  is  passed  into  the 
tendinous  tissue  as  far  as  ]ii)ssilile  and  brought  out  again  a  few  milli- 
metres from  tlie  point  t\*  whii-h  it  wa.«  introduced.     Both  needles  are 


2:5(3 


THE  EYE 


tlicii  passed  parallel  tn  eacli  other  and  al  2  or  ^.^  iiini.  distance  ai)art 
heUnv  the  skin  and  nuisele  of  thi'  lower  i)ortion  of  the  lid.  alon^  the 
surface  of  the  tarsus,  and  hrovifiht  out  at  tlii'  free  niarjiiii  of  the  lid. 
Similar  loops  are  next  jiassed  to  the  inner  and  outer  sides  of  this 
central  one.  The  damp  is  then  remove<l,  the  lileediiifl  stopped,  and 
the  edfies  of  the  woinid  in  the  skin  hroufiht  tojiether  with  stitches. 

Hownian  hrst  sufjfjested  the  shortening  and  readjustment  of  the 
levator  palp,  va'  (Snellen).  In  Wolff's  oi)eration.  in  which  this  is 
done,  the  tendon  of  the  levator  is  exposed  hy  a  transverse  incision. 
It  is  then  undermined  aiul  two  strabismus  hooks  are  pa.^sed  horizon- 
tally beneath  it  and  apart  as  far  as  the  (hfference  in  hei^rht  of  the  two 
lids'.  Two  (louble-needle(l  catpit  sutures  are  put  into  the  tendon  at 
the  line  of  the  uijjier  hook,  and  it  is  then  cut  across  just  hdow  the 
latter  and  is  tucked  behind  the  stump.  The  needles  ;u-e  then  passed 
throufih  the  base  of  the  stump  and  the  sutures  tied.  The  skin  wound 
is  stitched  .separatily. 

Miles'  Opkkation  kou  Ptosis.  To  secmc  the  liftinj:  action  of 
the  frontalis,  Mules'  inserts  a  permanent  subcutaneous  wire  loop, 
"having  its  fixed  points  between  the  frontalis  tendon  and  the  lid  car- 
tilafie.  Hy  this  wire  the  lid  is  raised  and  maintaine(l  with  jii''"'t  ex- 
actitude at  a  litie  whence  a  slijiht  effort  of  the  frontalis  is  sufficient 
to  lift  it  to  any  r"quired  elevation.  .\t  the  same  time  its  folds  are 
re-established  and  its  normal  ai)pearance  refrained.  "  Hy  means  of 
needles  with  eyes  at  their  points  the  two  ends  of  a  fine  wire  (gilded 
iron  or  silver),  which  is  inserted  at  a  \w\nX  in  the  tarsal  i>late  near  the 
ciliarv  border  are  brought  nut  one-third  of  an  inch  al)ove  the  brow 
and  one-half  of  an  inch  apart.  The  ends  are  drawn  uj)  (the  next  day, 
\.  S.  Morton)  until  the  lid  is  raised  as  desired,  w'  n  one  is  run  under 
the  skin  to  the  other,  and  they  are  then  twisted  and  buried.  Result 
very  satisfactory  (\V.  .1.  ("ant,  \.  S.  Morton). 

MorMs'  ( )i'i:i{ATiox.  .Motais  has  designed  an  ingenious  operation 
for  raising  the  upper  lid  in  congenital  ptosis,  by  resecting  a  tongue- 
shaped  flap  from  the  centre  of  the  tendon  of  the  superior  n>ctus  and 
attaching  it  beneath  the  jjalpi'bral  conjunctiva  to  the  fascia,  so  as  to 
act  as  a  lev.ator  to  the  tarsus. 

PA(iK\»TE(iiKH's  Oi'KKAriox.  Pageiistecher's  method  of  utilizing 
the  frontalis  in  paralysis  of  the  levator  aims  at  securing  a  vertical 
subcutaneous  cicatrix  coimecting  tli<'  former  with  the  li<l.  He  pas.ses 
a  needle  c;irrying  .a  thick  ligature  under  the  skin  of  the  forehead  about 
one-half  an  inch  above  the  centre  of  the  eyebrow,  and  subcutaneously 
as  far  as  the  margin  of  the  lid  at  its  middle  point.  The  suture  is  tied 
an<l  tightene(l  from  day  to  <lay  until  it  has  cut  its  way  out. 

(Iradle's  modification  is  the  insertion  of  permai.'iit  aseptic  sub- 
cutaneous sutures. 

{»\\\.c'  Mkt?!'!!!  Ill  this  operation,  which  has  pleased  many 
o]ierator«,  the  skin  of  the  brow  and  ey(>li<l  is  steadieil  by  pressure 


N'inth  IiUcrliMlliiiml  ophlhaliiiiilipKiial  '■i>rigreRS,  1«U4. 


DJti£:AS£:i>  OF  ORBIT,  LACKYMAL  -l/'iMiJJTLA',  AM)  LWS.    237 


across  tlic  fori'hciul.  Two  horizontal  incisions  arc  made,  the  lower  at 
the  orbital  margin,  and  along  the  toj)  of  the  flap  with  a  slight  con- 
vexity ujjward,  and  not  (juite  an  inch  long:  the  higher  one  a  littK 
longer,  and  at  the  ui)j)er  border  of  the  eyebrow.  A  tlaj)  of  the  skin 
and  imiscle  is  now  dissected  from  the  tarsus  down  to  its  ciliary  border, 
but  the  sejitum  orbita'  (suspensory  ligament)  of  the  lid  is  not  dis- 
turbed. The  bridge  of  tissue  between  the  two  horizontal  incisions 
is  und'rmined  without  cutting  the  periosteum  or  .septum  orbita-. 
The  fl;ip  is  then  drawn  up  under  the  bridge  by  means  of  sutures  and 
fastened  to  tiie  up|)er  edge  of  the  higher  incision.  Wlien  the  flap  is 
.■<o  fixed,  the  traction  tends  to  cause  ectropion,  and  a  suture  is  therefore 
placeil  at  each  side,  ])assing  deeply  througli  the  se])timi  orbita'  and 
conjunctiva,  but  not  the  skin,  and  it  also  is  insserted  in  the  upper  lip 
of  the  higher  incision,  so  as  to  coirect  the  tendencj-  to  eversion. 

WiLDKKs  ()PKK.\TiON.  For  the  relief  of  complete  i)to.sis  W.  H. 
Wilder  has  devi.sed  a  methotl  whicii  "consists  in  fokling  upon  itself 
the  tarso-orbital  fa.scia  that  connects  the  margin  of  the  orbit  to  tiie 
tarsus  and  acts  as  a  suspensory  ligament  for  the  upper  lid."  By 
shortening  it  with  buried  sutures  the  lid  may  be  raised  as  desired, 
and  in  a  number  of  cases  the  result  has  be(-.  satisfactory.  The  eye- 
brow is  shaved,  an  incision  one  and  one-half  inches  long  is  matle 
parallel  to  the  orbital  margin  and  a  little  above  it  to  the  periosteum. 
The  lower  lip  of  the  wound  i.s  drawn  down  and  the  skin  and  nmscle 
are  carefully  di.ssected  from  the  fa.scia,  and  the  tarsus  '^xpo.sed.  Su- 
tures of  fine  sterilized  catgut  or  silk  armed  at  each  end  with  a  curved 
necflle  are  passed  in  the  following  manner:  The  first  needle  is  intro- 
iluced  sufficiently  deej)  into  the  tarsus  to  secure  a  firm  hold  at  a  point 
about  at  the  junction  of  the  outer  and  middle  third  and  a  little  dis- 
tance from  its  convex.  It  is  then  drawn  through,  and  with  it  several 
gathering  stitches  are  taken  in  the  tarso-orbital  fa.scia,  after  which 
the  needle  is  made  to  pii.ss  tl  .')ugli  the  muscle  and  connective  tissue 
of  the  up|)er  lip  of  the  woimd.  The  other  needle  on  the  same  suture 
tollows  a  parallel  course  in  the  same  maimer,  entering  the  tarsus  about 
•5  mm.  from  the  point  of  entrance  of  the  first,  then  gathering  the 
fascia  into  small  folds  and  emerging  in  the  tissue  above,  thus  making 
a  loop  by  whicli  the  lid  ni;ty  be  drawn  up.  The  second  suture  is 
p.Ms.sed  in  the  same  way,  making  a  loop  at  the  junction  of  the  middle 
and  inner  third  of  the  tarsus.  The  re<|uisite  elevation  of  the  lid  may 
be  now  secured  by  dniwing  on  the  loops  and  tying  the  sutures,  which 
are  to  be  buried  in  the  woimd.  The  lower  lip  of  the  wound  is  now 
united  to  the  upper  with  fine  sutures.  The  slight  scar  that  remains 
alter  healing  is  ;dinost  entirely  hidden  when  the  eyebrows  grow  ag;iin. 
Ihe  buried  sutures  become  encapsule(I  and  give  addition.al  strength 
to  the  folds  of  fascia  that  hold  up  the  lid.  The  orbicularis  is  unin- 
jtuiMJ.  so  that  the  patient  retains  to  a  certain  extent  the  power  of 
closing  the  lids. 

I  he  movements  of  the  eyelids  are  both  voluntary  and  involuntary. 
"l\  inking  is  usually  voluntarv,  but  mav  lie  the  result  of  a  reflex  action. 


238 


THE  EYE. 


Flo.  117 


When  the  latter  is  the  case,  it  is  aiToiiiplishe.l  throusli  the  fibres  of 
tlie  fifth  nerve,  whicli  suiiply  the  eornea  and  ocuhir  conjunetiva, 
actinj;  U{)()n  the  orbicularis.  The  liils  protect  the  eyeball  from  in- 
jury and  excessive  light.  They  aid  also  in  lubricatinj!;  the  globe  by 
distrii)Uting  the  tears  over  it  and  mechanically  brushing  away  for- 
eign substaiices  which  may  have  intruded  tlu'Miselves  under  the  lids. 
The  arteries  of  the  lids  are  ilerived  chiefly  from  the  ophthalmic 
artery;  the  veins  are  very  plentiful,  and  empty  i)artly  into  the  veins 
of  the  forehead  and  partly  into  the  ophthalmic  vein. 

Congenital  Anomalies  of  the  Lid.    Crijplophthalmox  refers  to  the 
stretching  of  the  .skin  over  the  orbit  covering  the  eyeball. 

Colohoma  is  a  fissure  in  the  lid, 
triangular  in  shape,  with  the  base  at 
the  border  of  the  lid,  the  apex  point- 
ing U)ward  the  luaigin  of  the  orbit. 
It  is  a  rare  alTcction,  and  occurs 
usually  in  the  ujiper  lid.  (Fig.  117.) 
Ejucantluis  is  the  name  given  to 
crescentic  folds  of  tiie  skin  which 
project  on  both  sides  of  the  face 
from  the  inner  angle  of  the  brow. 
I%])icanthus  is  fre(iiiently  a.ssociated 
with  ptosis. 

Treatment  consists  in  excising  an 
elliptical  |)iece  of  skin  from  the  root 
of  the  nose,  ''.nitlidplasty  at  the 
outer  angles  will  oft(>n  benefit  the 
deforniity. 

Cantmoi'I.astv.  .\s  a  rule,  tiie 
operation  fnr  the  exti-nsion  of  the 
palpebral  tissuie  and  the  weakening 
of  the  orbicularis  is  not  a  plastic  one, 
and  it  is  better  styled  cinthotomy. 
Cocaiii'',  10  per  cent,  .solution,  is  applied  on  a  ])ledget  within  an<l 
without  the  external  canthus,  the  spring  speculum  is  inserted  or  the 
liils  stretche(i  .i|/art,  one  bl  le  of  the  scissors,  which  are  held  hori- 
zontally, is  pushed  behind  the  outer  canthus  toward  the  bony  rim, 
and  a  quick  snip  sulfices.  The  conjunctiva  is  freed  slightly,  and  is 
then  stitched  at  three  |ioints  to  the  skin  edge,  at  the  angle,  above, 
and  below.  If  the  orbicularis  is  hypertrnphied  and  eatising  i)re.ssure 
on  the  globe,  the  external  |ialpebral  ligament  is  snipped,  the  scis- 
sors' points  being  i)Ji.xsed  into  the  wound  vertically  behind  the 
Miusele,  the  lid  being  drawn  outward  (C.  R.  .\gnew).  When  there 
have  been  atrojihy  and  shrinkage  of  the  conjunetiva,  it  may  be 
Tiecess:iry  after  the  section  t"  stitch  a  piece  nf  transplanted  skin 
into  the  angle  or  adjust  a  small  Thiersch  shaving— eantho|)la.sty. 

Caxthotomv  is  a  useful  adjunct  in  some  ca-ses  of  blepharospasm 
from  keratitis,  to  relieve  |)ressure  in  purulent  conjunctiv-*--!  and  as  a 


inmirthc  liils 


VlilE.lSES  OF  ORBIT,  LACIIYMAL  AI'l'MtATUS,  AM)  LIDS.     2;3S) 


Pio.  118. 


stf'p  in  enucleation  or  exenteration.  It  is,  as  a  rule,  neee.ssary  in 
entropion,  espeeially  of  the  lo\>er  lid,  anil  sutures  are  always  used 
when  a  permanent  effect  is  de.sired.  The  latter  is  the  more  sure  if, 
as  .Fackson  points  out,  a  broad  edsiiig  of  the  conjunctiva  is  taken  up 
in  the  stitch. 

Inflammation  of  the  Lids.  The  integument  covering  the  lids  i.s 
liable  to  be  affected  by  disea.se  connnon  to  the  skin  in  general,  such 
as  erysipelas,  herpes,  and  eczema. 

When  the  lids  are  involv(>(l  in  erysipelas  secondary  to  a  similar 
condition  of  the  face,  they  may  1m>  ho  swollen  that  the  ball  is  com- 
])letely  hidden,  and  at  times  the  process  is  so  active  that  the  inHam- 
niation  spreads  into  the  deep  tis.sues  of  the  orbit,  causi'ig  absces.s 
and  not  infreiiuently  blindness  by  involvement  of  the  optic  nerve  in 
the  orbit.  I'rimary  erysipelas  of  the  lids  is  extn-mely  rare.  The 
treatment  is  that  of  erj-sipelas  els<>where  in  the  body,  both  a.s  to 
local  a|)plications  and  general  medication. 

Eczema  of  the  lids  also  u.sually  participates  in  a  general  eczematous 
eruption  upon  the  face.  It  occurs  commonly  in  children  as  a  moist 
eczema  icrustn  lactca),  when  it  is  usually  accom])anied  by  a  similar 
form  of  conjunctivitis.  Di.sease  of  the  lacrymal  afjparatus  in  adults 
not  infrei|uently  gives  ri.se  to  eczema, 
jiarlicularly  of  the  lower  lid,  by  the 
irritation  provoked  by  the  overflow- 
ing tears.  Treatment  cfnisists  in  the 
proper  cleansing  of  the  skin  by  alkaline 
washes,  followed  by  the  application  of 
an  ointment  of  oxide  of  zinc  or  of  a 
solution  of  nitrate  of  silver  (10  to  20 
grains  to  the  ounce).  In  the  chronic 
form  when  theiv  is  much  itching,  car- 
bolic acid  may  be  added  to  the  zinc 
ointment  in  the  strength  of  o  grains  to 
the  ounce. 

Herpes  zoster  (Fig.  US)  not  infre- 
(|iieiitly  is  the  result  of  an  inflamma- 
tinii  which  is  situated  either  hi  the 
trunk  of  the  Hfth  nerve  itself  or  in 
the  (iasserian  or  ciliary  ganglia.  A  number  of  vesicles  forin  along 
the  lermin.'il  exjiansion  of  the  trigeminus:  at  times  these  vesicles 
are  limited  to  the  distribution  of  the  upper  or  the  lower  branch 
of  the  nerve:  at  times  both  of  these  branches  are  affected  simulta- 
neously, but  it  is  rare  that  the  inferior  division  is  affected  in  common 
with  the  two  su|)erior.  The  efflorescences  never  extend  beyond  the 
median  line  of  the  face.  !'or  several  ilays  preceding  the  eruption 
there  are  seven"  pa'"'  in  the  course  of  the  nerve  and  .some  febrile  reac- 
tion, and  the  skiii  be.  nies  red  and  swollen,  resembling  erysipelas.  In 
severe  cases  an  ulcer  forms  at  the  base  of  the  vesicle,  due  to  involve- 
ment of  the  coriuni  in  the  process  of  suppuration,  and  a  deep  scar 


Uerpes  zoster  opbtbalmus. 


•2A{) 


THE  EYE. 


l(.riiiM  in  inildtT  cases  tlic  vesicles  .lisapix .  r  wlilioiit  uavi/ip;  any 
mark  Analogims  affections  of  tiie  cornea,  conju.icl.-. .',  ano  ins  may 
complicate  the  .lisease  and  pive  rise  to  cell ul it i>  :i'id  ..■.••"".t  ,  .vhu'li 
render  the  i)rofjnosis  most  unfavorable.  The  tr;'a-,m(|iit  is  |)iiivly 
palliative,  cunsisting  in  the  ai-jilication  of  a  powder  of  rice  starch  or 
of  an  ointment  of  zinc,  to  aid  in  the  dryiiifr  up  ol  the  vesicle.  Ihe 
vesicle  .should  iie%er  he  opened.  If  tlu  corne.".  ixromes  affected, 
ai)i)ropriate  remedies  should  he  employed.  I.ar^e  doses  of  (luiiiine 
and  «)f  .salicylic  acid  are  often  of  service.  Calvanism  may  lie  u.sed  for 
the  relief  of  persistent  i)ain  aloiift  the  cour.se  of  the  nerve. 

Abscess  of  the  Lid.  This  is  generally  the  result  ot  injury,  although 
it  may  he  tlue  to  caries  of  the  orbit,  to  periostitis,  and  to  (lisease  ot 
the  accessory  sinus<'s.  It  inav  he  a  comi)licatioii  of  erysiix'las.  In 
the  first  stages  there  are  diffuse  infiltration  and  redness  of  the  hd. 
],ater  a  localized  swelling  api>ears  which  points  in  some  casi's,  but 
spn-a.ls  in  others,  involving  the  whol<>  lid  in  a  gangrenous  proc.os. 
In  the  latter  case  (extensive  damage  is  wrought  to  the  hd,  and  de- 
formities n'sult  which  may  occasion  lagophthalmos  aiid  ectroi)ioii. 
Treatment  If  seen  in  the  earlier  stages,  attempts  should  be  niaile  to 
abort  the  inflammation  by  mean.s  of  ice-jjacks:  if  induration  be 
present,  free  incision  should  be  made  with  a  view  to  checking  further 
spread  of  the  disease. 

Furuncle,  carbuncle,  and  anthrax  pustule  are  rare.  The  two  forriior 
present  much  the  same  symptoms  as  abscess,  with  the  distiiictioii 
of  being  a','comi)anieil  by  a  small  gangrenous  slougii  or  "core;" 
the  latter  is  due  to  inoculation  by  the  Bacillus  aiithracis,  and  occurs 
in  i)ersons  who  are  occujjied  with  the  care  of  animals. 

Ulcers  of  the  Lid.  These  may  be  the  result  of  local  cause,  such 
as  injury  or  manifestations  of  a  general  disease—/,  c,  syphilis,  lupus, 
scrofuli',  herjM's.  The  most  freciuent  of  the  constitutional  sores  is 
the  seco'n.iarv  ulcer  of  syphilis.  This  is  usually  foum'.  ujotii  the  skin 
near  the  margin  of  the  I'i  I  or  below  the  inner  canthus;  it  occurs  late, 
and  might  almo.st  be  regarded  as  a  tertiary  lesion. 

Vaccina  and  smallpox  not  infre(|uently  give  rise  to  erui)tions  upon 
the  lids.  As  the  result  of  the  cicatrization  caused  by  these  ulcers 
itKKhiro.^ls.  or  loss  of  the  eyelashes,  may  occur,  together  with  ectnipion. 
.\  true  vacciiu'  ulcer  ircrciiiin  oj  the  cijclid)  may  be  caused  by  inlec- 
tioii  from  a  vaccination  sore.  The  border  of  the  lid  usually  is  affected, 
and  considerable  swelling  and  redness  and  involvement  of  the  I)re- 
anricular  and  submaxillary  glands,  with  constitutional  symptoms, 
accompanv  the  ulcerous  process.  In  the  early  .stages  the  pustules 
are  i'h;ii:icteristie.  though  later  they  may  res<'mble  a  syphilitic  .sore. 
(Edema  of  the  lid  may  be  a  •<ymi>tom  of  a  neighboring  local  disease, 
such  as  disease  of  the  lids  themselves  or  of  the  conjunctiva,  or  orbit, 
or  it  may  U'  a  manifestation  of  sy.stemic  disorder,  such  as  di.sease 
of  the  heart  or  kidneys.  It  may  Im'  an  accompaniment  of  an  active 
iiiHammation  of  neighboring  i)arts,  or  it  may  be  due  to  simple  venous 
congestion. 


DISEASES  OF  ORBIT,  LACRYMAL  APPARATUS,  AND  I.IDS.     241 


Recurrent  necrotic  adenia  of  the  lids  is  associated  fr('(|ui'iitly  with 
similar  swollinps  elsewhere,  and  is  to  Ik>  imputed  to  a  temi)orary  dis- 
turliaiiee  in  the  vascular  innervation. 

Sjrphilis  of  the  Lid.  In  addition  to  the  ulcers  mentioned  above, 
tiie  lid  may  be  the  seat  of  a  primary  sore.  An  ulcer  in  this  position, 
with  a  hard,  indurated  l)a.se,  ap|H'arinji  without  the  history  of  injury, 
but  followed  by  secondary  manifestations,  should  always  excite  suspi- 
cion of  syphilis.  Soft  chancres  also  occur  upon  the  lid.  Tursilis  "mihi- 
litica  is  a  tertiary  manifestation  of  syphilis  affectiii};  the  cartilage  of  the 
lid.  One  or  both  lids  may  l)e  affecte(|.  The  lid  Ix-comes  swolleti  and 
ten.si>  and  the  skin  reddened;  the  cilia  drop  out.  In  favorable  c:ises 
the  swelling  prailually  subsides,  leaving  tiie  lid  in  its  orifthuil  cdndi- 
tion;  in  others,  however,  the  tjirsus  iH'comes  much  distorted,  and 
entropion  results. 

Blepharitis.  (Fig.  119.)  On  account  of  the  presence  of  the  cilia 
and  the  hair  follicles  with  their  glands  upon  the  margins  of  the  lids, 
this  ])ortion  of  the  lid  is  not  infre(iuently  the  seat  of  inflannnation. 
lijipvramio  of  the  margin  of  the  lid  usually  attends  all  fonns  of 
conjunctivitis:  it  is  a  fre(|uent  index  of  eyestrain,  and  may  be  occa- 
.sioned   in    certain    individuals 

by  slight  cause,  such  as  dust,  Fia.  iw. 

.smoke,  or  foul  air.  The  most 
cnmmon  vari(>ty  of  inflamma- 
tion of  th(  lids,  lilcphnrilin, 
consists  in  a  chronic  condition 
wi.icli  is  a.-;.<ociated  with  the 
formation!  of  scales  and  crusts 
at  the  ba.se  of  the  cilia.  Bleph- 
aritis occurs  under  two  forms: 
the  sii iHT(ici<tl  or  luin-iilcinitife, 
and  the  ileefi  or  ulccratire.  In 
the  first  variety  the  margins  of 
the  lids  are  red  and  swollen  and 
are  covere(|  with  numerous 
whitish  scales.  If  these  are 
washed  away,  a  few  cilia  drop 
out,  but  some  grow   in  again. 

In  the  second  variety  the  hair  follicles  become  destroyed  by  ulcers 
which  form  alumt  "the  roots  of  the  cilia,  so  that  the  lashes  fall 
out.  This  may  occasion  jjermanent  loss  or  ilisi)lacement  of  the  cilia, 
hypertroi)hy  of  the  margin  of  the  lid,  and  ectropion.  In  the  milder 
cases  of  l)le])hariiis  the  iiatients  suffer  but  slight  discomfort,  but 
when  the  inflammation  has  Imhmi  of  long  standing,  increased  lacry- 
matioii,  sensitiveness  to  light,  itching,  and  burning  render  the  patient 
very  miserable.  The  causes  of  blepharitis  may  be  general  or  local. 
.\niuiig  the  former  may  be  iiieiitioiied  the  exanthemata,  especially 
measK's,  a  deliilitate<l  system,  and  unhygienic  surroundings:  uncor- 
rected errors  of  refraction  are  a  fnHjuent  cause.    The  local  condition? 

II! 


Blepharitis.    (Dai.rymtl*.) 


242 


THE  EYE 


wliicli  may  dccasidn  it  csiKrially 


ire  ilisoi  cr 


ill  til 


iTViiiai 


nitus  anil  cuiijuiictiva.     Mi(•l)haI■itl^  is  frt'tiuciitly  iHTcilitary.  and 
more  coniinnn  in  cliililicii  than  in  adults. 

Treatment  consists  in  tlic  ri'inoval  "f  tlic  cause  The  correction 
of  errors  of  refraction  and  attention  to  tlii'  sy-teniic  condition  should 
he  insisteil  upon,  and  in  many  cases  a  cure  will  lie  accom])lislie<l 
without  resortins:  to  other  measures.  If  the  hlepharitis  Iw  due  to 
lacryinal  or  conjunctival  disease,  tliese  should  he  coiuhated  hy  proper 
local  treatment.  Before  making  any  applications  to  the  edfie  of  the 
liils  it  is  first  necessary  to  remove  all  scales  and  crusts  adherent  to 
them.  This  may  Ih'  accomplished  hy  washiiifr  the  lids  thoroujihiy 
with  soaj)  and  water  or  with  water  contaiiiiii<:  horax.  In  the  super- 
ficial variety  of  hh-pharitis  a  salve  of  mercury  (yellow  or  red  oxide, 
gr.  viij,  vaseline  .">j;  or  the  aminoiiiated  chloride  of  mercury  in  the 
same  streiijith)  should  he  apjilied;  in  the  ulcerative  variety  an  appli- 
cation of  a  solution  of  nitrate  of  silver  (1  to  .i  [mt  cent.)  to  the  raw- 
spots  on  the  lid  is  often  of  service.  This  should  he  followed  liy  an 
i<l)plication  of  m-rcurial  ointment  smeared  thickly  iijion  lint  ami 
liftlitly  handafred  upon  the  eyes  over  iii>:lit.  If  alisce.ss  occur,  the  cilia 
should  l)e  removed  hy  means  of  ])ro])er  forcejis  {ciiihilioit). 

Phthiriasis  Ciliorum  (Blepharitis  Pediculosa).  This  is  an  affec- 
tion of  the  margin  of  the  lid  due  to  the  presence  of  the  I'ediculu.s 
])uhis  in  the  lashes.  It  is  fr(>(|uently  mistaken  for  hlepharitis,  and 
usually  occurs  in  children.  Treatment  consists  in  cleansing  the  lids 
with  a  solution  of  mercuric  chloride,  1  ;  4(H)0,  and  suhse(|uently 
ruhhiufi  one  ot  the  mercurial  ointments  into  the  horder  of  the  lids. 
Hordeolum  (Stye).  This  is  a  hard  circumscrihed  swellinj;  on  the 
lid  margin,  a  grain  of  harl(>y  in  size,  which  generally  suppurates. 
The  inflammation  occurs  in  the  tissu(>s  ahout  a  hair  follicle,  the  Mei- 
homian  glands  not  hein  mvolvecl.  Owing  to  the  tension  which  is 
created  hy  the  ])ushet\'  en  the  tarsus  and  the  skin,  there  is  usually 
considerahle  pain  until  lue  contents  of  the  stye  have  heen  evacuated. 
As  a  rule,  the  process  la.sts  four  or  five  days.  Repeated  attacks  are 
common.  Hordeolum  occurs  usually  in  the  young,  e.s])ecially  in  those 
who  are  aiuemic  and  dehilitated.  lurors  of  refraction  may  induce 
the  condition,  as  well  as  exjiosure  to  local  irritation,  such  as  heat  and 
dust.     Hlejiharitis  is  a  not  infre(|uent  cause. 

Treatment.  Ice-packs  may  he  used  as  an  ahortive,  hut  as  soon  as 
swelling  appears  hot  apjilications  are  to  he  em|)loyed  to  favor  su])- 
puration.  Evacuation  of  the  contents  slmulil  he  practised  hy  inci- 
sion as  soon  as  a  yellow  spot  forms.  .\lt  refnictive  errors  should 
carefully  he  corrected  and  the  general  health  cared  for.  Calcium 
sulphide,  one-eighth  grain  three  times  daily,  is  of  service  in  recur- 
rent cases. 

Chalazion  (Fig.  120)  is  a  chronic  dise^e^e  of  one  of  the  Meihoniian 
glands  as  a  conse(|uence  of  the  stojjpage  of  its  duct,  and  results  in 
the  formation  of  a  small  tumor  in  the  lid.  The  growth  of  the  tumor 
is  slow,  with  moderate  or  no  signs  of  inflanunation  until  at  the  end 


DISK.ISES  OF  OIIUIT,  LACRY.MM.  AI'l'ARATCS,  A.\D  LIDS.    2-13 

of  ;i  l'<'\v  Weeks  or  iiidiiilis  it  has  attained  the  size  of  a  large  pea. 
Chalazia  adhere  to  the  tarsus,  Init  the  skin  is  nioWile  over  them,  and 
they  are  not  usually  sensitive  to  the  toueli.  Tliey  may  hecoine  al>- 
sorhed  and  disap|H'ar  spontaneously:  hut,  as  a  rule,  they  lireak  down, 
sup|>Mrate,  and  disehar<r(,' their  eonfnts  either  tliroufrli  a  skin  or  oon- 
lUMctiva!  openinji.  Chalazia  are  found  in  aduhs  partieulaily.  They 
rarely  oeeasion  pain,  hut  are  dis(i>;urin<:  and  may  ea use  syniptonis  of 
eyestrain  by  the  pr-ssure  whicli  they  exert  uiion  the  eyeball. 

Fm.  120. 


Chalazion. 

Treatment.  Unlcs-s  pivinj;  rise  to  irritation,  snial'  chalazia  need 
not  be  interfered  with;  lurff'  ehalazia  should  be  removed  by  incision 
throufih  eitli  ■■  the  skin  or  conjunctiva. 

Chalazion  -  removed,  as  a  rule,  throuph  the  conjunctiva.  The 
lid  is  even  and  the  free  edjie  jires.sed  well  back,  cocaine  hydro- 
chloride applml  to  the  site,  and  a  droj)  or  two  of  10  per  cent,  solution 
of  cocaine  injected  hy])odermically.  A  siiort  vertical  cut  is  made 
from  within  out,  and  the  tumor,  if  small,  is  then  emptied  with  a  fine 

Flo.  121. 


Deflroarrea'  chalazion  forceps. 


serrated  or  sharp-edjred  scoop.  When  large  and  with  thick  wall, 
the  latter  is  jiriisper!  with  fine  fixation  forceps  and  cut  out  with  a  sharp- 
curved  scissors.  If  only  in  part,  the  cavity  is  scraped  to  remove 
acini,  and  the  contents  packed  at  tlie  sides.  Bleeding  is  often  free, 
when  adrenalin  chloride,  1:5(KK),  applied  early  and  also  presseil  into 


244 


THE  EYE. 


the  cavity,  is  of  use.  Homnrrhajrc  iiuiy  also  bo  contrnHcd  ami  tlio  ticlil 
of  opcrutioii  rciulcrcd  li!iMMil('s,i  hy  applying;  a  Dcsmairi's  chalazion 
forceps.  (Fin.  121.)  If  there  are  .several  chalazia  in  a  l)Uiicli.  a  lit! 
clamp  or  riiij;  forceps  is  ii.sed.  If  the  chalazion  is  hirni-  and  hunl,  or 
shows  sijtns  of  pointing  e.xternaliy,  it  may  hi'  removed  through  the 
skin  by  a  horizontal  incision  wjtli  use  of  clamp.  Fine  stitches  are 
then  inserted.  Iced  compresses  for  a  few  hours  are  .^oothinjj.  If 
the  chalazion  is  near  the  free  edp',  it  may  be  opened  with  a  tine 
cataract  knife  through  the  lid  margin,  the  lid  beint;  clamped  between 
the  index  tin(ier-ti|i  in  the  {■iii-de-sa<- anil  the  thumb  (('.  H.  .\pnew). 

Tumors.  lii'iiii/n  tinnrthx  include  xanthelasma,  moiluscum.  cysts, 
warts,  and  cutaneous  horns,  and  va.scular  tumors  or  aiifriomata. 
Xdiilhclasnid  is  a  flat  yellowish  placjue  s!i;;htly  raised  above  the  skin, 
which  occurs  most  frei|uenth'  in  women  and  at  the  iinier  canthus. 
These  phuiues  are  often  .symmetrical.  They  are  caused  by  dejien- 
eration  of  the  muscle  fibres.  Their  growth  is  slow,  and  as  they  occa- 
sion no  bad  results  otluT  than  disfijiun'ment,  they  need  be  removed 
only  for  cosmetic  etTect.  Mdlliiscnm  is  a  small  white  jtrowth  which 
forms  on  the  lid  as  a  result  of  a  dis"a-;ed  condition  of  the  seba- 
ceous glands.  It  occurs  in  two  forms:  nmlliisnini  <<mt(i(ii<isum,  in 
which  variety  the  tumor  is  without  a  [MMlicIe,  .and  has  an  umbili- 
cated  depn-ssion  in  its  centre;  and  ihnlhisrinn  simpler.  In  the 
latter  variety  the  tumor  is  ])odiculated,  hanging  from  the  lid  like  a 
pouch. 

Cysts.  Among  these  may  Ik-  mentionetl  dermoid  cysts,  inilia,  and 
antharomata. 

Angiomata.  These  comprise  tclannicrtnsis  and  /(/worc.x  nirfrno-^i 
The  former  occur  as  small  bright-red  growths  in  the  .skin  of  the  lid, 
and  an-  due  to  dilatation  of  the  bloodvessels.  The  latter  are  dis- 
tended venous  channels  beneath  the  skin.  Both  \arieties  are  usually 
congenital  and  occur  after  birth,  ('are  should  be  exercised  in  their 
removal,  to  avoid  cicatrices.  Small  telangiectases  ni.ay  be  removed 
by  the  thermocautery  or  by  cauterization  with  nitric  jicid:  large  ones 
should  be  .seared  to  foster  contraction  and  obliteration  of  the  vessels. 
Cavernous  tumors  are  removed  best  by  electrolysis. 

Malignant  Growths.  These  include  the  sarnniHiia  and  curcitto- 
iimta.  The  former  are  rare,  the  latter  more  conuiion.  and  <K'cur  under 
the  form  of  roilcnt  ulcrr.'<.  These  ulcers  are  seen  ui'on  the  margin  of 
the  liil  as  a  small  pimple,  which  breaks  down  into  an  ulcer  with  indu- 
rateil  walls.  These  ulcers  slowly  sjjread  over  the  lids  and  occasionally 
dij-.  'lowii  deep  into  the  orbital  tissues.  Treatment  of  both  form.s  of 
tumor  consists  in  their  early  and  complete  removal  by  surgical  inter- 
vention. 

HlcphunipUist]!.  To  m(>et  the  loss  of  lid-tissue  fr(>m  disea.se  and 
injury,  or  its  n'Tcs^ary  sacrifice  in  removing  neoplasm.-,  etc.,  new 
material  has,  of  course,  to  be  fjrovided.  I'nless  the  ga)i  in  the  lid  is 
such  as  permits  closure  by  stretching  what  is  left,  new  material  hvs 
to  be  socuretl,  either  from  adjoining  parts — the  forehead,  temple, 


DISEASES  OF  ORBIT,  LACRYMAL  At'PAHATVS,  AXJ>  LIDS.     215 

clicck  or  nose— l)y  iiicaiis  of  flaps  witli  ix-diclcs  or  from  other  regioiu 
l)y  Ha|)!<  witluiiit  pcdiclfs  or  hy  skiii-prafts. 

Flaps  with  twistcil  pedicles  are  often  used  after  Fricive's  method, 
ill  which  the  base  aluits  one  end  of  the  raw  surface.  The  ftaj)  left  l>y 
the  flaj)  may  l)e  covered  by  Thiersch  or  Wolfe  jjrafts,  or,  if  not  t(Ki 
larp'.  h_;  undermininj;  the  limitin>t  skin  and  suturiii .  the  edges  to- 
gether. In  the  em])loyment  of  slidinj;  fla|  by  Dieffenbach's  method, 
which  has  been  much  jjractised,  a  more  or  le.><s  vertical  and  (|uadran- 
gular  flaj),  at  the  side  of  the  pap — which  is  made  fairly  trianpular — 
is  slid  into  |)lace  and  stitched.  Its  bed  is  covered  by  Thiersch  or 
Wolfe  grafts  either  at  once  or  after  a  day  or  twf),  or  later  by  smaller 
dermic  grafts.  Knapp's  method'  of  stretching  horizontal  flaps 
(Fig.  12())  is  a  distinct  addition  to  blepharojjiasty.     Hy  it  (me  may 

Km  ir'. 


&JS 


Arlt'a  method  of  tcmoTiog  ■  growth  from  the  ctntbui.     a  i 
Fiu.  123. 


Frifku'a  method  of  hl('i>har(>i>lttsty.    (Aki.t.) 

remove  a  neoplasm  re(|uiring  the  sacrifice  of  most,  if  tiot  all,  of  the 
lower  lid,  and  then  cut  a  flaf),  going  beyond  the  bridge  t.f  the  nose, 
:ui<l  a  longer ''••  vvith  broad  base  on  the  temple,  and  unite  them  in 
vertical  line.  s  to  restore  a  useful  eyeliil,  tarsorrhapliy  being  also 
done.  The  writer,  following  the  suggestion  of  C.  S.  Bull,  has  found 
systematic  ma.-sage  of  cicatricial  keloid  and  other  .scar-ti.ssue  a  valu- 
able adjunct  to  blei)haroplasty. 

The  Le  f-ort-Wolfe  transplantation  of  flap  without  pedicle  and 
the  ThiiTsch  skin-srafting  liave  [)r!>ved  a  great  g:iin  to  blepharoplasty 
and  a  boon  to  op  -ra tors,  who  need  not  now  run  the  risk  that  they  mar 
more  than  they  mend.     \\olfo"s  method  was  tiesigned  sjK'cially  for 


'  Archives  of  Ophthalmology,  vol.  xlU. 


n» 


TUE  EYE. 


ra-i-  in  wlm-h  fkin  is  iiffdcil  tn  rc|ilact'  oicfilricial  tissue,  n'  'lie  iaftcr 
mr<  iiiiul-^  "ii;iMiapc(lii.  i-andisiiisulficii'iit  to  supply  flaps.  Thicrscji 
sl^ ill-drafts  lie  -niiu-tiiiiis  iiuirf  suitable.  In  tlv  peri'drniaiKc  of 
the  Wolfe  o|ieia!ion,  wliieli  is  especially  well  ailajited  !■  'a.ses  \\ !  -  v 
as  a  result  f  liuros  or  injuiy,  the  free  ed;;!'  of  one  lid  has  iMvi.nn 
attached  tothi'l)n  vor  tliicheek,  tli  lid  is  freed  hy  careful  dis,Mrtioii. 
The  lid  '■  rre<>('  1  y  careful  di.s.seetion  until  liofii  lids  (  n  («■  cti.sily 
nj»pr<ixii  .■,,!.   uh<ri   thi-y  -ire    sii'ured    at    three    or  f   .sr  appoj^l 

points  w'K !(■  'i    margins  have  l*e«>n  pared.     Th'  raw  sui  laces  -tre 

triniined  uh;  !  tin  \  ire  smooth  and  vascular.  "Il.ivinp  taken  the 
shaix'  o  •!!■  Way  r^  inired  with  a  piece  ,,f  lint.  I  carefully  di.^s.  ,t  ,, 
piece  of  kin  irofi  tl.:-  forearm,  cutting  it  larjii-r  tl  m  neces.sary  .11 
around,  .s<  -, ,  m  .d'.  nv  1  t  sli'inkinK.  I  then  turn  u  ts  deep  surfac  •  . 
and  wit,  a  ,-,';  '  ;i  shai  scissors  pare  off  evi-rv  vestige  of  suh- 
cutaneoiife  ti.>sue,        .s  to  lej.  ve  the  surface  of  a  jiut    white      lor.     It 


Ki...  las. 


Fio  124.— Arlt's  method  when  u  jiortioii  of  i  he  cyeli 
Fw   l-'.'i.— liielTeul)ach'!i  meilim!  of  hlopharopl,i.-iy. 


IS  til  tip  facrlHcetl. 


eyelid,   to  wiiVh   it    !■- 

■iud  mouldin;L'  it  ini  > 

~urface  for  ..liout  ti 


is  tiien  .ipplieil  to  tlu'  gap  m  ■  h- 
fine  silk  ligatures.     After  pressinsi 
soaked  in  hot  water  is  ;ippl!e<l  to  its 
It  is  finally  dressed  with  lint  wrung  out  of  hot  water      ( »\ 
folds  of  dry  lint  arc  placed,  and  the  whole  covered  witli 
jiercha  tissue,  and  secuM  I  l>y  aii  imniovahle  handage 
day  the  dressing  is  reim.'.cd,  and  it  i-  found  that  ailhesioi 
place,  the  H'lj.  looking  clean  and  dry  and  ^i.irnia!:  hiui.-l 


visible  here  anil  'here.     Tl 

In  Thiersch      mettio( 
superficial  layers  of  the 
the  arm,  .ire  tran-ferr-d  tw  tin-   ra-. 
method,  ti"'  lids  being  stitcheij  tog 
While  makuig  the  shaving,  the  part 
logical  salt  solution,  and  the  fonnr 


lAHLT.) 

:led  1< 
cc.  lint 
linui' 

ills   In 

■  g  .It. 

:  ne  third 

iiail  taken 

limv  are 


an, e  dressing  is  repeated  daily. 

t_>f  skin-gra'ing.   strips  of  epide      -^   and 

kin.  cut  gc;    r.ally  from  the  hairles-     art  of 

;rfar.     [.rejiared  i,-  in     .\.ll'i-V 

T  or  the  upper  t<.  the  chec!  . 

kep!    vet  with  war-ii  nhysi,.- 

lid  (ii!  the  ra     r   .ne  .icross 


i>jsi:.iska  of  ntijiir  :  mhymal  avi.\r   /(a.  axd  irm.  247 

till  raw  8urf;n(  hy  its  n  .  all  cliils  having  first  Uvn  i^  iiiovt^ !.  Drt-ss- 
ijijt  '>  <'«>ii''  'I--  iti  til  VVulf'i-  tiH'fluMl.  It  is  \v<ll  to  Imii. !iig('  Ixitl,  cyos, 
Ifi  forty-fipJit  i>r  t^evpi sty-two  liours  tlif  \>ti  arc  rari'iiilly  cxpowHl 
iiiiil  I■>■llrt•H^■•  I  utl  then  from  time  to  tiin  Tin  iipaturc-i  ciii  l>c 
fft'ii-    (I  ill  k.     Mon-  or  k'.s>  shriiikiiijj  <     thefUh    25  to  30  |x'r 

<i  't..  mtn      ' 

ill  (-icatiifuii  cfrropiofi  f()ll«)wiig  hurii>.  iu\,  in  uhirh  at  iea-t  a 
jMirtion  of  thf  pyi  tirow  has  Ih-o  (i(>stroyi'(l.  Hotz'  has  olniatod  the 
iiiK-"  iwity  of  t  If  ^\|'lf«■  iiM'tho"!  the  (l;i!  j;«>r    t  r(-<vfrsion  of  the 

liil  trom  shri  kag  of  a  Tran.«(iuuit('i  flap  ir  :icnoii  of  tissupn. 
Frori.    '  <•  atlj;.  I'l.         itri  ,    m  itself  he  tak('s     a  fi;ij>  large  eiiouieh 

to  Cf!  •  the  li'^  stirf.H'-f  oi:  .  1*4. <  fixes  the  np|H'r  iiiarjrin  of  this  llap 
to  tt^  ii  'IT  t"''  '  '  the  i  »r-tis."  The  ra>^  surfae<  >l)ove  the  lids 
is  coM'ii      l»>  1     l'-         1  fiiersch  grafl^.     The      cisioii  begins 

Klo.  126. 


r 

? 

I 

\  ■ 

u-;^ 

h 

- 

Knapp'i  method  of  t  .epharoplutjr.    (K^ 

ne  inn      oanthus  and  ends  about  (S  tnni.  i^<  iter,  and 

kui    a  larp        in  flap,  wiiieh  is  then  carefully  disse-  'roni  the 

idriving  -     i-tissue,   l;)ut   is  left   connected  witli  border. 

ilic  lid  ;    relciised  from  ihe  deei)er  scar  tisstie  ut  m  he  re- 

pi  '  d  in  its  iiorniai  pasition.  The  contracted  flap,  still,  howi  ver, 
in!  'I'  eiioiidh  to  cover  the  whole  surface  of  the  lid,  is  spread  out 
s:  .othly  over  this  surface,  and  its  margin  is  fixed  to  the  upper 
b. ndt'r  of  the  tarsus  by  four  silk  sutures.  Into  tb"  wound  upon  tlie 
lid  :i  skin  Hap,  which  may  also  contain  a  good  ileal  of  scar-tissue,  is 
ti;!     I'lanted. 

1  I'leiiliaroplasty — apart  from  a.sppsis  and  great  care — thei'  .ire 
sf  '  [loiiits  that  conduce  to  success.  The  flap  shotild  be  a  third 
'  than  the  gap,  should  have  a  broad,  thick  base,  with  as  good 

iM-ular  supply  as  possible,  anil  be  noatly  adjusted  with  the  least 
uv  -ting,  and  the  least  strain  upon  the  sutures.  The  latter  should 
not  be  ])iif  in  until  al!  bleeding  !i.i.°.  r-o.'ised  ?.r\'\  clots  :'.re  removed. 
The  thread  should  be  fine  and  of  twisted  (not  braided)  silk,  because 
leaving  less  mark,  and  the  stitches,  which  should  be  closely  placed, 

'  Archives  of  Opblhalmoloii.v,  vol.  xxv..  No.  3. 


248 


THE  EYE. 


shoii'd  be  rcninv(>(l  rarly.  Tho  flai)  for  tlic  lower  lid  should  ho  tiikoii, 
when  it  is  feasible,  froin  a  hiniier  level  to  |)revent  sapjiiiif; "reversion 
from  after-traction,  whieh  is  |)artly  met  by  tarsorrliai)hy.  For  the 
nplH-r  lid  tli(>  flap  is  often  taken  freni  the  mid-frontal  region.  After 
restoration  of  the  liils  the  parts  should  be  kept  warm  and  (|uiet,  and 
free  from  special  tension,  by  means  of  compresses,  |)laster,  and  baiid- 
aj;e,  .so  adjusted  as  to  avoid  undue  direct  jiressure.  The  natural 
fohis  and  creases  of  the  adnexa  .should  be  kept  in  mind.  Tissue, 
especially  conjunctiva,  should  not  be  wa.sted,  thouph  neoplasms 
should  have  wide  berth.  Hence,  in  this  das.-i  the  importance  of  early 
correct  iliajinosis  and  i)rompt  excision. 

Flai>s  with  pedicles  have  not  been  discarded  because  of  th(>  Wolfe 
and  Thiersch  methods,  for  these  have  their  drawbacks.     Flaps  with- 
out  pedicle  shrink  from  :}:{  to    ")()  jx-r  cent.,  and  sometimes  more. 
le  original  (defect  mav  recur.     Not  .seldom  they  slough  in  part 


,d  tl 


or  whollv.  aiic 


lib 


id  tlu 


y  re(|uire  mon 


after-care  than  twisted  or  sliding 


flaps.     They  have  the  advantage  over  the  latter  that  one  may  u.se  the 
skin  of  hidden  i)arts,  the  loss  of  which  is  not  felt. 

Trichiasis  and  Distichiai>^d.  The  former  refers  to  an  inversion  of 
one  or  more  cilia,  as  a  consequence  of  which  the  (>veball  is  rubbed 
and  irritated:  the  latter  indicates  a  double  row  of  cilia,  the  inner- 
m>st  of  whieh  is  inverted  and  irritates  the  eyeball.  As  a  result 
of  the  irritation  i)ro%-oked  by  the  lashes  in  both  of  these  conditions, 
theeveball  becr)me.s  inHamed,  and  corneal  ulceration  and  oi»acity  are 
favored.  The  chief  cau.se  of  the  distortion  of  the  cilia  is  trachoma, 
the  faulty  |>osition  being  given  them  by  the  cicatrization  of  the  tarsus 
and  the  "conjunctiva  wrought  by  this  diseas<'.  It  may  also  be  (u-ca- 
sioneil  by  injuries  and  blepharitis.  Treatment  i (insists  either  in  the 
removalof  the  cilia  or  operative  measures  to  correct  their  faulty 
position. 

Trichia.-:!^.  When  malposition  is  limited  to  only  a  few  of  the  cilia, 
it  may  be  corrected  by  excising  an  oval  ]>iece  of  the  tissues  near  the 
free  edge  into  the  tarsus  and  stitching  the  skin  wound  ( Wolfe) :  also  by 
splitting  the  (<(lge  of  the  lids  behind  the  row  and  juitting  in  a  tiny  piece 
of  ski;;  :.r  nuicoiis  membrane.  In  so-called  scalping,  the  li<l-margin 
is  s|ilit  xeitieally  behind  the  stunted  and  incurved  l;isiies.  and  the 
aiiti'rior  lip.  just  wide  enough  to  hold  the  hair  bull>s.  is  absci.^ed.  This 
is  now  very  lav  ly  done,  being  replaced  by  the  Hurow  incision,  (Ireen 
or  van  Miiiiiigeii  operation,  etc.  i which  see).  Kleetrolysis  is  now 
used  to  destroy  misplaced  cilia  wlirn  they  are  few.  .\  fine  needle 
viiegative  pole)  is  passed  into  the  follicle  with  the  ciliuiii  as  guide. 
A  few  seconds  closure  of  the  circuit  suflices  il  (here  is  frothing  (Mitch- 
ell, Hensoii). 

Sim;\(KH  W.M'son's  .Mktiiod.  An  incision  is  made  in  the  inter- 
marginal  space,  and  a  second  one  ]>a!:illel  to  the  boidi'r  of  the  lids 
and  above  the  row  of  cilia,  as  is  done  for  their  aiiiatioii.  'I'liis  strip, 
ront.aining  the  eili.a  and  follicles,  is  cut  across  at  one  end  only.  Then 
a  .second  Hap  similar  in  shajie  is  made  abt.ve  the  .irst,  its  free  end 


DISEASES  OF  ORBIT,  LAVHi'MAL  AI'PAHATCS,  ASD  LWS.    249 

liciiifl  at  tlic  saiiK'  cantlias  as  tlif  base  of  the  other;  tlio  flaps  arc  then 
iiitcrchanpcil  ami  sutured.  Tliis  operation  is  now  rarely  (lone,  except 
for  trichiasis  near  one  or  other  canthus.  In  these  |)()sitions  Fudis 
considers  it  the  most  suitable  procedure,  hut  the  Haps  are  made  much 
shorter  than  in  the  original  operation,  which  was,  indeed,  the  jnonecr 
in  intermarginal  work.  .... 

Thk  .I.\KsrnK-Aui.T  ()i'KU.\Ti()N  for  trichia.sis,  which  is  done  under 
an  aiuesthetic.  is  as  foUows:  A  Snellen  or  Knapp  lid  clamj)  is  applieil, 
and  the  lid-margin  is  spl'*  from  end  to  end  by  an  incision  two  lines 
in  ilepth.  which  Is  met  at  '  le  bottom  by  a  horizontal  cut  through  the 
skin  at  right  angles,  made  about  4  mm.  above  the  ciliary  border. 
The  anterior  flaj),  lioliling  the  skin,  orbicularis,  cilia,  and  bulbs,  is 
then  cut  awav.     A  small  semilunar  piece  of  skin  is  now  dissected 


rv.  127. 


Jaeache-Arlt  operation  on  tlie  upiwr  eyelid.    (  Arlt.) 


oir  higher  up,  and  the  marginal  flap  is  then  stitched  to  the  upper  raw 
v<V'v  The  effect  is  to  roll  out  the  .'dge  of  the  lid  and  the  eyelashes. 
TiTmake  tlx'  result  more  lasting.  Waldhauer  trims  the  excised  skin 
and  tits  it  in  the  wound,  and  supports  by  bandage  to  ensure  union 
with  tiie  raw  surface.  This  operation  has  largely  b<-en  replaced 
l,y  reconstruction  or  restoration  of  the  lid-margm  (after  van  Millin- 
f:('li.  (ireell.  Hot/,).  .  .    , 

Entropion  and  ectropion  refer  to  an  inversion  and  eversion  ot  the 
margin  of  the  lid,  respectivelv.  Entropion  may  be  occasioned  by  a 
detVct  in  the  normal  contour  of  the  lid  as  the  result  ot  a  disease  or 
JMiurv  of  th.  conjunctiva  or  tarsus  (nra/nnVi/ cn^rf>/«"n),  or  it  may 
|.;  (,.,\wed  hv  ii  "pa-^m  of  the  orbicularis  muscle  acting  n-flexly  from 
a  conjunctivitis  or  keratitis,  or  from  ban.lagingof  the  eyes,  esijecmlly 
in  tiie  aged,  with  lax  .skin  and  conjunctiva  {siKismodicentropwn). 


Tilt:  KYE. 


i 


On  ai't'ou 


lit  (if  ilu'  irritation  w 


liicli  the  inturninf:  of  tin'  iaslics  iipuii 


the  ill 


(ilic  proviikt 


lacrvin 


junctivitis  an 


1  kcratitis'arc  tlic  rule 


ition,  jiliotophobia,  aii.l  the  sifiiis  c.f  con- 


Treatment  consists  in  n 


storiiiL'  the  niarpii  of  the  liil  to  its  pro] 


.<T 


p.isitioii 


If  the  entropion  is  due  merely  to  spasm,  it  niav 


iften  1> 


licve.l  by  liaiiitiiifl  t 


Id  ill  liaiulafiinn  liy  applying  :i  strip  of  adliesive  plast. 


n 

avoi( 

lids. 

OPKIiATIONS    F()l{ 

troiiioii  tends  to  jiei 


hf  skin  below  the  lid  with  collodion.    It  may  k 


L'r  th 


Kntuoimon.     When  spasmodic  or  nmscular  en- 
■Ct  in  spite  of  the  use  of  plaster  or  collodion,  etc.. 
fa    horizontal  strip  of  skin 


<oiue  operation  is  rcMiuired.     Kxcision  ol    a  -i,,,,,.,.!, 

often  s  ifHc's  in  senile  cases,  or  of  a  narrow  strip  o  ,sk.n  and  luuscl. 
1  vn  to  the  tarsus  close  t..  the  free  edp.  of  the  lid  ((.reen).  Many 
S-slave  b,H.n  cured  by  means  <,f  .leep  vertical  sutures  M  trans- 
iix  the  septum  orbita.  n..ar  the  infra-orbital  nu.rfrin  '--■"'f  .^  ""/'"' 

ri.cipleoftliellotz..peration((lrueninfr..     'Ihe  (ia.llard-.\r  t  sutu 
I  als  .  efiectiv...     Four  threa.ls  in   two  sets,   by   n.eans  ot   d.m  1 
threa.led  needles,  are  enteird  under  the  skin  o    the    lower)  hd  cios.- 
its  edpe  and  at  rifjht  angles  to  it.  and  an-  brought  out  at  2  cm 
traidit  below.     Kach  set  forms  a  short  loop  o-M-.d,-  the  .skm  n.-a. 
the  .-ilia  and  traction  on  the  f  ee  ends  when  lyinp  (over  a  muiH)  everts 
.'  d.'sin-d      The  sutures  are  l.-ft  a  f.-w  days,  so  as  to  cans.'  vertical 
subcutan.M.us  cicatrices  which  ensure  permanent  tension 

In  entropion   with   narrowing  of  the   hssure   (blepharophiniosis), 
,  jr„ud  result  mav  be  had  by  canthotomy  combined  with  the  insertion 
;/deep  v-rtical -sutures  passing  from  the  chary  niarp.i  ch.se  t..  the 
outer  surface  of  the  tarsus  and  emerpufi  high  u].  m  the  hd.        lu 
tinnlv  tied  lifiatun's  are  allowed  to  ~  ii.puraK-  out:  ui  s.mie  cases  they 
1,...  (ak.-n   out   .arlv  ( I'ajienst.-ch...).     For   the  correction  o    s.-.i  h- 
!  ,„,,pion  of  the  lower  lid.  Theobald  uses  caustic  potash.  att.T  the 
n  u„  er  of  the  late  I'rof.-ssor  X.  H.  Smith.     Tlu-  cravon  is  sharpene.l 
':  '  'oi,,,.  ,„.l  is  moved  back  and  forth  across  the  lid  at  ab.nit  4  mm. 
froii   it  >  marpn,     .\  spreading  of  the  caustic  action  of  perhaps  _'  mm. 
om  ti.e  h.;  of  applieation  is  to  be  allov  ed  tor  by  simp  y  causing 
,1„.  potash  to  act  upon  this  narrow  strip  of  tissue  l.aralle   to  the  hd- 
margin.  and  moving  it  back  and  forth  gentl;.  ,  perhaps  a  doicen  tunes 
one  secun-s  a  very  marked  caustic  action  ,.,.on  the  tissue.  ;vlno  >  '  '• 
I,..  ..l„.,.k..d  If  -lesin-d  by  diluted  acetic  acid.     As  a  rule    the  hd  n    1 
in.inediatelv  stav  <.ut  in  goo.l  position;  a  slotigh  takes  place,  and  tl.. 
cases  in  wliich  a"  com,.lete  cure  is  not  ,.fT....ted  m  senile  eiitrop.-'n  are 
verv  unu-unl      The  method  is  not  appro|.riate  for  the  uj.i.er  lid. 
Trichiasis  and  Cicatricial  Entropion.    To  <-orre<t  t.ie  incutAinfr- 
-    of  the  lid-margin,  bevelling  of  the  inner  hp  and  malposition  of  tlie 
,ilia,  eaused  bv  shrinking  of  the  conjt.nctiva  an,   the  <M.nst.-int  trac  lo  . 
inwu'<l  in  theVi-t  "tag<-  of  trachoma,  three  metiiods  may  be  adopted, 
that  of  c.unter-tension.  release  from  tension,  and  restoration  (recn- 
.tructiont  of  the  lid-margin.     The  first  is  the  pnncipl.'  ot  the  .\nag- 
noslakis  and  ih.tz  operation,  which  has  stoo.l  t.ie  tc-^  of  years,     la 


DISEASES  OF  ORBIT,  LACKYMAL  AlTAUArVS,  AM>  Ul>.s.    251 

it  counter-tension  is  kept  up  by  usiuR  us  a  fixed  iH.int  ti.e  ti«-sn-url.ital 
l^.i     at  the  orbital  n>arpin  of  the  tarsus.     Ihe  r-;'"'    .;: "^       , 
„l,j..cts  are  pained  by  the-  Green  operation,  very  wuiel>  u.e.lh 
■s    he  ina.rve,l  h.l  edp<'  and  n-stores  its  u.ner  hp,  and  also  b>  the 
.  ,  Mi  linpen  op..ration.  a.ui  in  a  different  way,  nanu'ly    l.y  u.ter- 
sin,     b' rior  between  the  skin  of  tlie  lid  an.l  .ts  -"J""<-''-'-   ..     .. 

'      )     GUKKN'S  OPKK.VrU.N  K..H  (•..ATUICIAI.  l-.NrUOlMuN.      A  luURltudl- 

.nl'ineision  is  nuule  through  the  e..n,iunetiva  and  tarsus    Iron,  one 
;  I        the  tarsus  to  the  ..ther  (after  Bun.w).  and  para  lei  to  and 
dl;  o  ;'  line  or  one  an.l  a  quarter  line  distant  Iron,  the   ree  bone 
the  lid      \  strip  of  skin,  a  little  .nor.'  than  a  hae   i.  \Mdth,  an. 
„       a  ine  listan   fr.„n  th.-  r..w  .,f  .'yelashes,  is  exe.se.l.  the  l.u.sene.l 
;  .  -S.        th.-  li.l  turne.l  f.-rwar.l  an.l  s.-cure.l  n>  its  n..w  p..s.t.on 
.Mhree  to  live  sutures.     The  n.-e.Ue  carry n.g  the  sutu.-.;  is  .na.le 
."  te   a   t  e  e.lge  of  tlte  li.l.  in  ..r  near  the  r..w  ..f  c.l.a,  an.l  .s  carn.-.l 
,w    .       s^  u.n.^th  the  skin  u-.til  it  appears  i.,  the  ...taneous  wound, 
s  then  Plung.'.l  .l.vi-lv  thr.>uph  an.l  behnul  tlu;  hbres  of   he  ,  rbu- 
:   is  nmslle.  an.l  is  b'r.iupht  .n.t  through  the  sk.n  f-"' »     »-,/;; . 
■df  of  an  inch  almve  the  upper  hp  of  th."  wound.     The  effect  of     » 
'.w      s    ures  applie.l  in  this  way  is  t..  tilt  f..rwar.  th.-  .nargin  of     e 
:^^;^h  the  hnplUte.!    cilia,  leaving  the  l..,.pdvu  uu    wotnu    on  ^k- 

;t:  hi  r  n^^rrow  strip'of  skin.     An.l  -1"-  no  sk.n  ..n  be  s.njred 

.ranuhUi..       n     is  s.,on  c.!ver.-.l  by  sn,o,.th  onjunct.va.     The  u- 
gianul.    .1.  .  ^^.^  f„r,„atu.n  of  n.'W  t,.s.,ue  is 

crea.se  in  the  in  igUi  .)i  im    ''"•",.    •.       „      i    h,,,.  ^trii>  of  ivucous 

=£,;;;;a:x'S.::;v;;ir;::r:.o..i:;L:2,. m. 

it,..  '  .;      Thr(>e  sutures  are  then  put  in  the  (iiiar\  x.ii..u    .■  i 

i'irri.;;;'  .1;;  t^X^  .i-  .iiv»i"i .««« u,.>i  ..k-  e.,x-".  .*- 

of  the  orbicularis. 


252 


77/ i'  KYE. 


■i 


\NU-.vo=^T\Kis   AM)   HoTZ   ( )i'KH.\Ti()\.     Thp  operation    is    per- 
form,,! ,M  tl>e  .ipi.er  li.l  as  follows:     Wiiile  an  assistant  fixes  tlie  skui 
•It  th'    sufra  ..i!)ital  niarpn.  the  operator,  seiznig  th<'  centre  ot  the 
ii,l-l)<'nl"r  will,  iinfiers  or  foreeps,  draws  the  lid  downward  to  put 
its  skin  well  on  a  streteli,  and  makes  a  transverse  ineision  through 
^kin  and  orlneularis  nniseie  from  a  point  2  or  ;}  nun.  above  the  punc- 
tmn  la<-rvina!e  to  a  point  2  or  ;{  nnn.  aln.ve  the  external  eaiithus. 
T\n<  incision  divides  tlu  lid-skin  in  a  line  i)arall(  1  to  an<l  a  little  below 
the  ui)per  border  of  the  tarsal  eartilage.  and  is  therefore  from  4  to  X 
mm  distant  from  the  free  border  in  the  centre  ot  the  hd.    The  skin 
and  muscular  laver  are  now  dissected  from  the  incision  down  to  the 
roots  of  the  evelashes,  and.  wiiile  an  assistant  is  holding  the  edges  of 
the  wouikI  well    sejjarated    the  operator  seizes  the  forceps  aiul  ex- 
ci-;es  witii  curved  scissors  the  muscular  fibres  running  transversely 
across  the  upper  bonier  of  the  tarsus.     Next  tl-e  sutures  are  in.serted. 
Three  sutures  are  usuallv  sufficient— one  in  the  centre  of  the  wouiu 
and  one  at  each  side  of  the  central  suture.     The  curved  needle,  arine.l 
with  black  silk.  No.:?,  is  firs"  i>assed  through  the  wound-border  of  the 
lid-<kiii,  then  it  is  thrust  through  the  upper  border  of  the  tarsus  aiK 
returned  through  the  tarso-orliital  fascia  just  above  this  border,  and 
linally  it  is  carried  through  the  upper  wound-l)order.     "When  these 
sutures  are  tied  the  skin  is  drawn  upward  ami  fixed  to  the  upper  tar- 
sal bcrder,  an<l  tliis  slight  traction  is  sufficient  to  turn  the  inverted 
lid-bonier  and  evela.-^hes  to  their  normal  position,  and  as  the  skin 
becomes  firmlv  imited  with  the  tarsal  bonier  the  tension  thus  pro- 
,luc(>d   upon   the   lid-honler  is   i)erinanently   secured.     The  sutures 
^lio"!d,  of  course,  not  be  tied  until  all  bleeding  has  ceased  and  the 
wound  is  thonnighlv  cleansed;  they  may  be  removed  on  the  thin! 
<lay.     liidcr  asejjtic  dressings  tlie  wound  he.als  by  first  union,  even 
if. "as  sometimes  occurs,  secondary  hemorrhage  or  (edema  causes  con- 
siderabli'  swelling  for  several  days. 

Tin;  v\\  .Mii.i.iNOFN-  OpKUATioN-  FOR  Tiiu'iiiAsis.'  "The  inter- 
maigiiiMl  space  is  split  fnmi  end  to  end.  as  in  .\rlt's  operation,  and 
sullicimtlv  to  iiroduce  a  ga])  '.i  mm.  in  bnwlth  at  the  ci'iitral  part 
of  the  liil.  and  gnidually  becoming  narn)wer  towanl  the  canthii. 
The  gap  is  kept  n\)on  bv  sutun's  pas,><ed  thniugh  folds  of  skin  on  the 
ui)per  lid  and  by  me.'iiis  of  which  the  lid  is  prevented  fn)m  closing 
for  twciitv-four  hours  at  li'ast.  .\s  soon  as  the  bleeiling  has  ceased, 
a  strip  of  mucous  membrane  of  the  same  length  as  that  of  tii(>  lid, 
and  2  or  2\  mm.  in  breadth,  is  cut  out  with  two  or  three  dips  of  a 
pair  of  curved  scissors,  fnitn  the  inner  surface  of  the  under  lid.  and 
placeil  :it  once  into  the  g;ip  at  the  intermarginal  space.  It  should 
then  be  pn-ssed  into  situ  with  a  iileilget  of  cotton-wool  stee])eil  in 
sublimate  solution.  Sutun's  are  sui)erfiuous,  and  do  more  harm  than 
good.  The  operated  lid  i>  tl.-ii  covered  over  with  a  flap  of  linen 
containing  a  thick  layer  of  iodoform  va.seline,  and  this  is  covered  over 

'  Ophtlialmlc  Review,  November,  1SS7,  vol.  vt,.  No.  73. 


*wapTBP^"?F»a 


Pl^EASKS  OF  ORRIT,  LACHYMAL  APPAltATUS,  ASD  LIDS. 


253 


hv  .utton-wocl.     Botli  eyes  sh..ul.l  bo  baiulaKo.l.     I  invariably  us«> 
sublimate  lotion  (I: 'Am))  f<«r  disinfecting  the  eye  an.l  li.l  .luring 
before,  an.l  after  the  operation.     The  baiulape  shouM  b..  r.-newn 
once  in  twentv-four  hours,  ami  tiie  sutun>s  on  the  upiier  lul  shouh 
not  be  removed  l-fore  the  second  day.'"     Some   preter  a   strip  of 
^kin  (from  behind  the  ear.  llotz).  without  suturing'.     Others  witii 
sutures.     Some,  like  van  MilUnjten.  are  partial  to  mucous  m<-mbrane 
( from  tiie  lip.  We<'l<s),usinfi  sutures  or  not.  ,        •,   • 

Thk  Stkkatfkiu.  oi-i;uati()N  of  pr.K.vmg  the  tarsus  vvhen  it  is 
thick  and  misshapen  has  been  modified  by  Snell.'...     In  the  Str.'at- 
fcild-Snellen  operation  an  incision  is  nuule  tlirouph  the  skm  ot  th( 
upper  lid  about  ;{  mm.  from  the   marpiii   and  para  h'l  to  it  an.l  ex- 
tending ah.ng  its  whole  length.     A  strip  of  the  orbicularis  about  J  n.in. 
in  wi.lth  is  excis.".!,  and  next  a  triangular  w<-.lge-shap<-d  pi.<-e  of  the 
tarsus  along  th.-  whole  length  of  the  ii.l.     Three  sutures  are  then  m-. 
verted  in  the  following  manner:  A  suture  arine<l  at  each  end  witli 
'.,  „,,,lle  is  to  be  passed  through  the  upper  edge  of  the  mcisiun  m  the 
t.,r.i'.    an.l  both  needles  are  then  to  be  carru.l  thv.,ugh  the  lower 
..'.argii'i  of  this  groove  and  brought  out  through  tin-  skin  J "^J  above 
the  line  of  lashes,  the  points  of  exit  lying  4  nnn.  apart      Thv  Um 
other  sutures  ar-  to  be  inserted  in  the  ,^ame  way,  care  '•»'>''>Jj"';'' ' 
that  the  points  of  exit  are  about  4  mm.  from  each  other.     A  be.ul  is 
e.  pasLl  over  each  end  of  the  sutures  (to  prevent  their  cutting 
,hc  skin),  an.1  the  latter  carefully  tied,  so  that  the  two  opposit.'  ^.des 
„f  the  incisi..n  in  the  t.rsus  are  accurately  approximated.    The  upi  er 
edsre  of  the  skin  wound  is  left  open.  r   :  i    i   •> 

I'vnvUnkiikn  Opkuat.c.x.    The  skin  of  the  li.l  is  divi.led  2 
or  ?  mm   ■ib.'.ve'the  free  border  of  the  li.l  an.l  parallel  t..  .!..•  latter, 
tuii^sior  inning  the  whole  length  of  the  li.l      Then  from  the  c.  ge 
;:  t  Js  incision  thc^kin  is  fi.e.l  as  far  ur-  as  the  I'l'l-'^-j'-^f;^ 
fn-«us  and  a>=  far  down  as  the  free  bord.'r  of  the  li.  .     Next,  the  n  u 
;„  ,e  pe  being  insert e.l  beneath  the  lid,  an  incision  is  ina.le  whid, 
;        n      e  same  wav  as  in  the  skin.     In  this  way  th.'  lower  half  ,. 
f  r-.  1    with  the  free  bonier  of  th.>  li.l  is  ma.le   reely  m.^yabl...  an.l 
V  ■  e   otaml  f..rwanl  bv  means  of  sutures,  so  that  the  c.ha  assunu- 
,h,- ,    o,  er   lirecti..n.     The  sutures  an-  fonne.l  int..  loops  an.l  pass,, 
d  , V     hrough  the  clge  of  the  tarsus  an.l  th..  tars.M.rb,  a  hisc.a.  an. 
;t  free  3  of  the  loop  are  br.,ugi4  out  Ik  hin.l  the  skm  o    th..  lul 
a  „,„  the  intermarginal  line,  an.l  h.^e  are  tie.l  over  -^P^^-  -J'  '^^j^j^^. 
Th..  (ireen  an.l  the  Hotz  ..perations  yieh!.  as  a  ml."  yix  satisiac 
torv  n  ^u  ts    nls.    the  van  Millingen.  especially  in  trichiasis  of    he 
wer     f  ombincfwith  canthoplasty  an.l    .he  ^t-;;;^;;''  ;^-J;:; 
,e,    in.licate.l.    In  ca-ses  of  misshap..i  j-''^^-'^'}'  JJT         ^^^^ 
few     it  m-iv  be  necessarv  to  combine  th.>  features  of  two.  it  n..t  three 
of Ve  e    ;  e  iuri    ucce  s.  and  this  is  the  rule  with  operators^  W  .-eks 
;  ;  r"  favor  dSv  of  a  number  of  ca-ses  in  which  he  tne.l  a  e..mibmat.on 
of  the  f..ur-canth.)pla.stv,  the  van  Millingen.  the  Strrath- M-Sm-ht-n. 
^ndHoU-thesutu'ring  differing  from  that  of  the  latter  in  that  the 


THE  EYE. 


„,.e.llo  is  iMM.lc  to  i,ass  through  tli.>  upixT  Vu\  an.l  to  omorRO  S  mm. 
al,„v..  th.'  .narpn  ..I  lh.>  mi-I-.t  Hai..  Th.>  writer  who  can  t.'stity  to  the 
vihic  of  the  Hotz  an.l  (in-.-n  o|.crations,  early  lound  it  advisable 
(hefore  the  van  Milliiifien  operation  was  in  vopie)  to  eoiubiiie  the 
lii-st  at  times  with  the  Hiirow  tarsal  ineision. 

I  ike  entropion,  vctrnpin,,  may  either  U-  cicatrieial  or  spasmo.lir. 
,  iMir  \>S.  1  ( •icotric  ' '/,  or.  as  it  is  sometimes  callt'd,  onjnnw  niropwn, 
..   ...u. ",-.'. ..■,>■„.. i<   ..Lscess  of  the   lid  and  orbit,  ami  disease   ol 


1LS 


l)oubl>:  rii-Htriciul  c-nrciiiion. 


Arlt's  opcraiion  for  ectropion.    ( AR1.T.) 


Treatment.  The  Adams  operation  was  dev'  ,d  to  oorre.-lclongation 
a,„l  partial  evrsion  and  moderate  ectropion.  It  con.sist.s  in  the 
n-moval  of  a  trianpular  V-shaped,  piece,  inch.dinp  the  whole  thiek- 
,„..s„f  the  lid.  the  base  of  the  triaiifth'  being  turned  tow.-.rd  the 
„u.r"in  of  the  latter  and  the  apex  toward  the  cheek.  lh.|  .Mges  ot 
the  \v.,un<l  are  carefullv  brought  togeth.-r  by  sutures,  one  ot  which  is 
inssed  clos..  to  the  free"  edge,  so  as  to  prevent  a  groove.  Nmietunes 
:,  harelip  pin  and  sutnn-  is  used  This  operation  is  now  i.referably 
,,,„„.  „„l„.  ,1„-  outer  canthus  in  conjunction  with  tarsorrhai)hy.  It  is 
.ueciallv  udai.ted.  for  senile  ectn-i.ion  or  that  due  t..  chronic  con- 
j'mctivitis.  for  which  also  the  Snellen  and  the  Argyll-Robert.son  suture 
oiierations  have  been  designeil.  „       ,         ,    ■  i 

In  the  Vr.'vll-Robertson  operation'  two  needles  thnvided  on  a  long 
w.xe.1  silk  ligature  are  passed  through  the  skin  an.l  h.!  (me  line  from 
its  cil'-arv  margin,  and  each  one-.|uarter  of  an  inch  from  the  mesial, 
nasse.!  on  through  the  fornix  aiul  brought  out  tiiroiigh  the  .skin  one- 
In.arfr  of  an  iiirh  apart  at  one  to  one  and  one-quart.-r  inches  from 
the  ciliary  border.     A  bunch  of  fine  rubber  tubing  is  i)laced  vertically 

■  Eillnburgli  Clinical  ftiid  IMlliologlcal  Journal,  I)«-«iiiber.  1««3. 


.,vj;i:--.-v'._L, 


VISLA6ES  OF  ORBIT..  LACRYMAL  APPARATUS,  AXD  LWS.     255 

within  tho  I....1.  on  tho  (.utsi.h-  ..f  the  li.l.     A  pioc;  of  thin  sheet-l.-atl 

n      r    inoH,  mrter  inch,  rounded  off  an.l  n.ouKl.-.l,  is  Mipi..-.    mto 

onl  .rsTun  or  the    hr.-a-ls,  and  tho  hpaturo  is  thon  t.od  ovor 

;;:  t:^  7l;:. Img.  -xho  0.^,0  of  th..  ^^^^^ 

r  volvo  imvanl  <.vor  tho  upjH'r  od^.-  ..f  tho  pi.-oo  of  loa  ,   \hi .   t 
.,    ■    r   tilage  is  oausod  to  nioul.l  itsolf  to  tho  ourv.M.^  tho  oad,  and 
,;;.  ;lv;STt^.,,,•..  oooupios  its  ..omud  po-sltion.-      Thos.turos  aro 
not  roniovodfor  from  tivo  to  ton(h\ys.  .    .:  . 

,     i     S.Ul<'n-stiture  operation  f..r  sonilo  ornmscu  ar    octr<.,..o„ 
,h     li^duros  aro  pas«ed  througl,  tho  conjunctiva  and  suhadjaoont 
isuosud). ought  out  and  tio,l  ovor  a  roll  2  cm.  bo^nv    ho  fr.-o 
J    iC  o^Toct  may  bo  increased  by  tarsorrhaphy  as  d<>s,rod.     _  . 
In'par  a  o  tn.,.ion  with  hypertn.phy  of  conjunctiva,  the  oxcsum 
,'",'     .       ,,V.,,in  „f  the  latter  and  closure  1)V  sutures  may  suthce, 

.  f  Arl  uhirh  is  Dorforniod  as  follows:  The  cicatrix  and  tho  skin 
that  of  ^.rlt.;;'  •'^ '  "J  ™  riangular  area  boundo.l  by  the  points 
surrounding  it  are  ^'\«'"':/ "  /^"'iV!^^^^  .^  the  edges  of  the  denuded 
"'^t:;^!:^^^^^^^  ^  isl.proximate  to  d. 
:;;;;? rSdJ" "ho  1;:^  L  is  m  contact  with  cd.    Harehp  pms  may 

'-^^:r^^:Sr^^^^^^^^      it  bocomos  n^essary  to  Wl 

•„,  ui  iaiX  a  fl  p.    This  may  bo  accomplished  by  either  the  Pricko 

t  Sm-nJach  method.     Both  of  those  consist  in  excision  < vf  t he 

oW„„.  »n.  n»,lo  in  ll,r«.  "'f  ■"™' ''JJ  f„*;,  ^iC  thr«:  suluro. 

tlu.  pifitriK  has  been  iissected  out  tho  nds  an  unmu  y>i  ni 

3  -;r;;.r'L:i;ls'Lf«"S'^s=wrf  '^^ 


^mf 


!o6 


Tut:  KYt:. 


iiiti)  raw  surfaces,  citlicr  fri>m  hums  or  (lis«\is<'s  of  tlif  coiijunrtiva, 
causing  loss  of  tissue,  sucli  as  traclioina  and  tlipiitiifritic  conjunc- 
tivitis. 

Treatment.  Ankylohicpharon  is  remedied  hy  dividing  tlii'  adliesions 
het\ve<'u  the  lids  and  between  the  lids  and  tiie  globe,  and  by  covering 
the  denuded  areas  by  iransi)lanted  portions  of  conjunctiva  or  strii.s 
of  mucous  membrane  taken  from  the  lii)s.  In  m.any  cases  it  is  of 
ailvantage  to  perform  a  canlhoplasty  at  the  .same  time.  The  ste|is  i:i 
the  operation  for  the  cure  of  .symbIei)haron  consist  in  separating  the 
adhesions  between  the  lid  and  the  globe,  and  in  preventing  readhe- 
-ion.-  bdween  the  denuded  areas  by  placing  a  conjunctival  surface 
in  apposition  with  a  raw  one.  A  number  of  procedures  are  available, 
but  that  of  Himly  or  Harlan  is  to  be  |)referred.  The  former  perforated 
the  b.ise  of  the"  attachment  of  the  adhesion  in  the  cul-de-sac  and 
placed  a  .strip  of  lead  wire  in  that  position,  the  wire  being  i)orniitted 
to  remain  until  it  had  worn  a  groove  covered  with  i-pithelium. 

Flo.  191. 


Ecchymosis  (Black  Eye),  .\fter  a  contusion  of  the  lid  there  is 
often  a  great  amount  of  swelling  and  discoloration  of  the  skin  of  the 
lid  and  its  loose  connection  with  the  sublying  tissues.  Ice-packs 
.should  be  applieil  for  tl-e  first  few  days  after  the  accident,  hut  these 
should  be  replaced  by  .:  >'.  comi)resses,  *.  promote  absorjjtion  of  the 
e\tra\:isated  l)lood. 

Emphysema  indicates  that  there  ha.s  been  a  fracture  of  the  walls 
of  the  orbit  establishing  a  connection  with  the  nose.  .\s  the  >  is 
forced  into  the  lid  by  blowing  the  nose,  the  patient  should  \>  w- 
tioned  against  this  act  until  th<'  wound  is  heal(Ml,  and  a  firm  com.,  -ss 
banihige  shon!  '  !)e  applied  over  the  eye. 

Injuries  of  the  Eyelids.  Th(>se  may  be  a  mere  incident  of  a  more 
serious  traumatism,  and  hence,  if  fciusible,  the  features  of  tlie  accident 
should  be  learned.  Wound.^  should  be  explored  for  possible  foreign 
bodies  in  the  eye,  orbit,  and  adnexa,  and  one  will  sometimes  be  sur- 


/,mu.>£5  OF  ORBIT,  LACRYMAL  APPAHATVS.  ASD  UI>S.     257 
•     1     .  t»«.  fin.liiiirx      Forcien  i)articl«'s  should  Ix-  n-inovcd,  aiitl 

w       L    wist.-.l  silk      The  lips  of  vvouiHls  .livuhng  tlu-  .-Ig.-s  of  th.- 

r  1     r    .1.1  h..  .-infuUv  coautfd  to  av.ml  .listortioii  ..r  a  uroovc.     A 

•  ;  sS'  i^  t ,;    i  -1;^  it-lf  is  of-  us.'ful.     If  thoipator  pa  - 

J^.    U-t.  Jn    t  should  Ik-  stitch.'.l  with  finr  c-atKut.     W  h.-n  skm  is 

ict«(l  dressings  are  helpful. 


17 


CHAPTER    VI. 

DISEASES  OF  THE  CONJUNCTIVA,  CORNEA,  AND 

SCLEHA. 

By  JOHN  E.  WEEKS,  M.D. 


CONJUNCTIVA. 

Anatomy.  The  conjunctiva  is  si  (iciicatc  mucous  membrane  wiiicli 
cov<T<  tl>c  posterior  surface  of  tiie  eyeiiiis  and  is  reflected  onto  tiu- 
anterior  half  of  the  eyehail.  At  tiie  marpin  of  the  lids  the  conjunc- 
tiva joins  the  intejiument :  it  iloes  not  pass  Ix'vond  eithiTcanthus.  At 
the  inner  canthus  tiie  conjunctiva  exteti.is  ovit  the  fleshy  glandular 
mass  iinown  as  tlie  caruncle.  It  is  thrown  into  a  crescent i<-  fold  just 
beneath  and  to  the  temporal  side  of  the  caruncle.  This  told,  which  is 
drawn  outward  on  movements  of  the  cornea  to  the  temixiral  side,  is 
termed  the  i>liai  sfrtiilunnri.-:.  \W  its  n'flection  from  tlu'  li<ls  to  the 
eveball  the  conjunctiva  forms  pouches  above  and  Iwlow,  which  are 
termcl  conjunctival  sacs  (cul-de-sac).  T\u'  depth  of  the  upiM-r  sai- 
at  the  mi.liih'  of  the  lids  is  approximately  19  mm.,  of  the  lower  sac 

S  nun.  The  conjunctiva  is  divided 
into  various  parts,  as  follows:  jxtl- 
jHhml,  that  coveriiifi  the  posterior 
portion  of  the  litis:  jurnix.  the 
transition  fol<l;  ocular,  that  cover- 
inc  the  clobe.  The  ))art  of  the 
palpebral  portion  that  covers  the 
tarsus  is  known  as  the  tursal  cdh- 
JKHcliro.  M  about  three  millime- 
tres from  the  marfiin  of  the  cornea 
the  conjunctiva  becomes  closely 
united  with  the  anterior  reflection 
of  Tenon's  cai)sule.  Tlu  epithelial 
layer  is  stratified.  (Fiji.  l."Jl.> 
The  tunica  propria  is  very  thin. 
The  coniuiictiva  ixissesses  no  lar^e  vessels,  but  it  has  a  very  rich 
network  of  small  vessels,  which  become  prominent  on  irritation  ot 
the  conjunctiva.  In  the  retrotarsal  and  ocular  i)ortions  of  tlie  c(.n- 
jiiiictiva  ili(  vrrri.  are  frwly  m--.vab!e  over  the  luulerlyms  tissue, 

\  rich  plexus  of  Ivmphatic  v(wels  exists  in  the  conjunctiva,  those 
of  the  upptT  onjuiictiva  near  the  outer  canthus  beinj:  in  connection 
with  the  chain  of  lymph.itic  vessels  which  pass  to  the  preauricular 

(  2.-.S  ) 


KpithiUciiianf  itie  ImlljRr conjuiieliv*.    iiiRiH 


rrrsr^i^^S^fir^. 


DISEASES  OF  VOXJLXCriVA,  COH.SEA,  AXJ)  SCLERA.       2r»» 

rr^ion;  tlms.' of  the  l.mcr  lid  niv  (M.nnoctcd  ni.in-  .lircetly  with  th.- 

Th-  n.Tvr  supply  is  from  tl..-  larryn.al  aiul  from  the  supratroch- 
lear aii.l  infratr.x'hlrar  hraiifhcs  of  the  fifth. 

CoMenital  AbnormaUties.  Th.'  most  fr.'.,u.-nt  coi.K.nital  growths 
n.H  with  are  .lerinoul  tumors,  which  visually  cxt.'U.I  onto  tlu-  .•ornca; 
thev  ar.'  usually  pair  i»  color,  hut  may  Ih'  pi-mciit.-.l:  they  arc.  us  a 
rule  supplie,!  witha  numher of  hairs,  glands,  ..tc.  pn.s.M.tm>j  the  c har- 
aeteVistics  of  the  skin.  Small  fattv  mass<-s  an-  also  m.-t  with:  these 
are  situate.!  appareiitlv  Ix-neath  the  conjunctiva. 

.\n>:ioma,  cavernoma.  and  telauKic'tatic  ^^rowths.  conpenitul  in 
oriuiii,  sometimes  are  found  in  the  conjunctiva, 

\„  usseuus  irrowth  <.cca.sionally  is  found  l.eneath  the  conjunctiva, 
situat.-d  hetween  th-  out.T  margin  of  the  corn.-a  an.l  the  .•ommissure. 
■  Mules  or  pigmented  patches  .sometim.'s  ar.«  observed  ..n  the  con- 
junctiva;  then,  occur  n,..st  fre.,uentlymmdivi.h.al>  who  present 
'similar  spots  on  tlie  skin. 

Kil.rous  Lrrowths.  sometimes  ern.u.M.usly  spoken  of  as  lii.omata. 
..ccur  rarely  just  l.eiu-ath  the  n.eml.rane  in  the  upix-r  outer  portion 
of  the  ocular  conjunctiva.  .        rn  i     »„,i 

Hypersmia  of  the  Conjunctiva  (Dry  Catarrh).  The  palpebral 
..Sctiva  is  the  part  usually  affected.  The  mucot.s  nu-inhrane  is 
n-       1 1  verv  slightly  roughened,  hut  is  not  apprc-iahly  thickeno.1. 

Etiology.  •  The  con.lition  is  .lue  to  irritat.on  lr.,m  inanv  caus.-s- 
explrfto  heat,  bright  light,  glare  from  water,  -'''  -  ;'^;;-  ^I'^^f 
wii.l  .old,  St.  rms  of  rain  or  snow,  cnstant  use  .,f  h.  .■>.■>  %Mth 
hci.M  ■  iUuu.ination,  eyestrain,  in.ligestmn,  alcoh..hsm.  gou  . 
i;"I„H.tor  .listurl)ances,  lacrymal  .liseas.^  acute  exan.hemat.ms 
fevers,  and  blepharitis  marjruialis.  . 

Symptoms.  The  lids  iM  stiff  ami  dry,  an.l  are  m..ve.l  with  .l.fh- 
cuUnV  burning  sensati.-n   is  experi...-.!    an.l   then-  is   mcn-as.-.l 

c  vn,  tion.     Ti;e  su.H.rtW.ial   epithdial   '-";='"'';''*"?:.; 
nip^llv  than  in  h.-alth,  an.l  are  f..un.l  "' ^;'"'  .^''-^tteZ  s  ^ 

,,;„l,i  an.l  s.,metimes  at  the  margin  of  th.'  I  .Is.      J    '"'I"^  <"  "^•' 
the  eves  with  artihcial  light  an-  ;.  romi.am.Ml  b%  .listnss. 

Treatment.  The  caus.>  <houl.l  U-  s..ught  t..r  and  n-move.l.  In 
a.lSrtt  eves  shouM  b.'  hathe.l  twice  .laily  with  a  :5  p.-r  cent. 
«>hiti<)ii  ..f  boric  aci.l;     (   t her  measures  atv  unnecessar>  . 

C^^^m^tl^l^^^^^^^^'^^-  Tl'istormis  applie.l  .-  a  .mmber  o 
.li^aS^f  tl.  coi^ictiva.  all  of  which  are  acc.,mpam.j.i   J-  ujer..^d 
•nul  alt.'re.l  s..cn-tion.  by  .listivss.ng  symptoms,  an.l  In    transit nt 
uriH-rmamMitpathoh-gicalohiinges  in  th.- membrane. 

Classiilcation       Sine-  the  disc..very  of   th.-  g.>n..c..c(-vis  ot    .s.-isser. 
in  is"     h   s°  ecihc  micro-.>rganisms  of  a  numb.T ..f   ..rms  ot  .•..njum^ 
i^-  ti    lave  tl-eii  .lescriln-.l,  which  makes  it  a.lvisab  e  to  '"...h      th 

I  r    !      iKr>li„i>  >.f  li-e.w-  of  thi.s  nionihrane.     .\11  of  th.-  forms  .f 
;;::j    .S;S:';rit^^".le<lun;lort..hea.lings:a^ 
a  spe,-iHc  cause  has  not  k^on  detenmned.  and  (-')  those  forms  in 


c?wi 


••«£  WWE.  "K  »!&?..<¥: 'ii»«i£«.'TSKi&3 


2tin 


Tllk'  KYK. 


isf  lii.<*  1m  .'I.  .!*'t<Tiirm<-.l.    Tn  til.-  first  cla^.*  U'hnr. 


.i.upl.MM,!  lui.clivitis  iM.Tviual  .■..njunrtivitis,  h.-rprtUMMmjuiM-tivitiH, 
xvn  lil  nrnjuuHivitis,  l.lli.  =,lar  ••.mjunclivitis  trarlnMua,  |h-,m,.  np.>. 
l..rin;u..l-s  .■onju.Htiv.M-,  „.uty  .-...i.-Mivms.    T-  ll.r  s..ron.^  rhiss 

l,il„p:    .,„,..    .-.nau......    nrnj-. -.    -^i.lKU'ut.-    .■nnju.u-tm Us, 

srunnrrl.u  ,1  n.njnn.iiN  nis.  .lii.l.tl.criti.- .■o,,|.m.;..v,t...  n.tus.s  ..j-.t  u- 
r,.,lis   pl.lvctoi.ular  or  oi-zfiiiaH-us  .•••njunctivitis,  uiUTralosis,  lupus, 


Non-specific  Forms  of  Conjunctivitis. 

Simple  Conjunctivitis  (Catanhal  Conjunctivitis,  or  Ophthalmia). 

Tl.is  ,.:„uliti..i.  is  cl.aracl.Tiz.Ml  hy  i,.j..-ti.m  an.l  sM.t  t h.ck.M.n,« 
„,■  tlu-  (■n„j.m.-tiva  (•..nfmo.l  ali:...st  .-ntin-ly  t..  tl..-  i.t.l|«l.rM'  port  inn. 
l.,ss..f  transparciu-v.sliKl.t  r<M.stu■..i^^^  a.i.l  tl.-'  prosoi.r.M.f  a  v.Ty  littU> 
„n„.us,  wl.icli  fauscs  tlir  li.ls  tu  a.lh.-r>'  tojiKluT  u.  tlu"  monnng. 

Causes.     Th.'sc  arc  i.uiucrnus  an.l  |H-nnit  <.t   (•lassihcati..ii: 

1  Mk.  MWi.M  lrritati..n.)f  the  (•..njuiictiva.  .luc  to  tlic  cntranc-c 
„f  partirlcs.'.f  tn.-lai.  .lust,  p..tl(M»,  oxposun'  t.)  win.l.  plar.M.t  l.plU. 

•>  Vhhoci  \  iKi).  .\ir.)nipanvinj;  tlu-  cxiinth.-uiatous  fevers ,  rli<;u- 
luatisni,  nasal  cntarrli.  I.n.iicliitis,  ecwMua,  facial  .'rysi|K>las,  iiupeliK.. 
c.intapiosa,  in.iliuscuin  cmtani  '^uni. 

i   Symptom \ric.     Forms  a.TMmpanyinn  eyestrain,  otr. 

Symptoms.  S.iuk.tivk.  l.ia^  li.-avy.  hurninR  s.-nsation;*  m  tlie 
oyo.  irritation  oi'  niovi.  i:  the  ey.'s,  p!i.)t()pliol)ia,  ann.iyanee  in  use 

of  the  e\vs.  ,•  .  .     .•  ■  •        .       ,i    . 

Ohif.tivk.  Lacrvii.ation  m..re  profuse,  slight  sti.-knig  t.-petlier 
of  the  li.ls  in  the  nmrninf:,  s!ij:ht  thiekeiiin;;  of  the  h.ls,  liyp.  nenna 
of  the  tarsal  conjunetiva  an.l  .)f  th.-  r.-trotarsal  fol.ls. 

Simple  cnjunctivitis,  as  is  apparent  hy  a  ^lanee  at  the  list  ot  pauses, 
is  m.)st  e..mmon  in  ehil.lr.Mi,  tnit  no  sta<;e  ..'.  life  is  exempt. 

Prognosis.  The  .lurati..n  .lepen.ls  ..:>  the  eontmuation  .)f  the  cause; 
wh.-n  this  is  reni.iv.-.l  (mechanical  an.l  sympt..matic  f..rnw)  .)r  siib- 
si.l.-s  (associate.1  f..rms),  rec.)very  occurs  spontaneously.     No  lasting 

iniurv  results.  _  ,        i-  r 

Treatment.  In  a.l.lition  to  removms  the  cause,  much  relief  m:i> 
1,,.  ohtaiiuMl  hv  Dathinj;  the  eve  two  t..  four  times  .laily  with  a  s.)  u- 
ti„n  ..f  iM.ii.-  aci.l,  ;}  per  c.-nt.  .\  mil.l  astrin^'.'Ut  solution  may  .also 
lM-empl.>ve.l-ziMc(fir.  j  t.>.',j)  is.'xcellent.  ...      ,  ,     , 

Lacrymal  Conjunctivitis.  \  form  ..f  onjunctivitis  dependent 
„n  th<-  i)resence  of  irritatiiif;  secr.>tion  fr..;n  the  c.n.lucttnir  portion  of 
the  la.Tvnial  apparatus.  .\lm..st  a'l  of  the  cases  mifiht  projier  y  he 
eh.ssed  witli  the  simpU-  coajunctiviti.les,  hut  a  few  cases  develop  a 
mirulent  tvp.'  whidi  tnav  result  in  much  .lamage  to  the  eye. 

Diagnosis.  The  .^xu:\,trm.  jHTulia:  tn  nhsfru.'tinn  uf  the  lacrymal 
P'lssapes  an.l,  fre.|ueiitlv,  a  .lacryocystitis  are  present. 

Treatment.  This  consists  in  renderinjr  th.  lacrymal  canals  patul.)u.s 
■uvl  in  c..rrecting  the  condition  ..f  th.-  lacrymal  conducting  apparatus; 


rm 


hist:.ist:s  of  co.sji  mtiva,  corsea,  .isn  sclera.     2i;i 


ihc-"'  lucuMin's  innv  !«•  suppli-tiK'nt.-.l  l.y  clrtin-mK  th.-  cMnijitictn  i 
with    niii..  I)l:iii(l  artfptic  sulutioii  lUi.l  iIk-  iis«-  of  a  mil<l  a-'tniip'nl. 
Litliiasis  Conjunctivitis.    A  form  of  irrititiii.n  of  tli-  <-oiijiihii' 
,liic  \"  ill"'  pre-  iicc  of  <'alfar.M>us  deposits  in  the  (isHur  of  the  | 
I„.|,r;,l   coMJuMctiva:    ilifv  ocftir  most  cummonly  it.  th.    tarsal  c  u- 
I,n,ctiva.   hut    are   lu.'t    ^^itll   also    i,,    tlir   paliM-l.rJ   p-rtioi.  of   t  .0 
ivirotiMsil    f-'l'l''.      Til*'   small    ma,-:<<-s    apiK'ar    a^    vfllowisl.-wlii  •• 
l,o.li<-r.   alfinst    imm.-.liat.'Iv   lK-ii.-atl»   tli.-  cpitlHliiim.      Thy   ton.l 
t,,    pctirtrat.     tiu-    cpitliclial    lav.-r   and    to   procure    irritation    .rf 
il„.  cwl.all    aii.l    li<ls.      Tin-   conditicm    i-    m<'t    \Mtl    •■ommoiily   m 
tb.M-'ol  a.lvaiicMl  v.-ar..  an.l  is  a.^suciat.".!  usually  with  rhcumatisn. 
ur  trout.     Tli<-  (IqK;    •    i-onsist  principally  of  calcium  carbonate  an.l 
cliolotcrin. 

Treatment.     Hcmoval.  .     ,  ,       if 

Herpes  Conjunctiva.  1  ^^  condition  is  characterize.!  l>y  the  lor- 
,„ation  ..f  .lusters  of  v.-sicles  on  a  hyiK-nemic  base  The  vesicles  col- 
laps.-.  formiiiK  a  .suivrticial  ulcr  which  heals  rapully.  leaving :iv.-ry 
.sliitht  sui-erhcial  cicatrix.  The  afTecIion  accompanies  herj»s  orbitiilis, 
and  -.vill  he  .lescrihe.l  un.ler  that  head. 

Vnnal  Conjunctivitis  (Conjunctivitis  CatarrhaUs  «sUva;  ^myc- 

tena  PaUida  ( HirschLergi :  Spring  Catarrh).    A  .lisease  characteriz.-.! 

hv  roudienini!  and  thickening  of  the  p:ilpebral  coni-inctiva.  ac.-om- 

,,a„H"d  hv  hvpertrophv  of  the  conjunctiva  at  the  marKin  ..f  th.worn.-a. 

Gauge.  ■   \Vhil.>  this  iliseas..  is  in  all  im.hahility  .lue  t..  a  s,H.citic  germ, 

tl enn  is  n..t  known.     The  exac-rhHi-ns  occur  when  the  weather 

h  .".nnes  warm,  wh:  •    .<-r  th.>  season;  hu.  .he  ,m.cu  lar  apjM.irar.c..  ..f 
the  tarsal  c.mjunctiva  is  n..t  -Mitireiy  ahsem  m  th.-  wmt-T  months. 
•■  ■    ■  flftcm  vears  are  aiiacke.1  mo.st  fre- 

•  :  '-  apiH'iirs  in  adults,    often  two 


''hililren  from  the  age  of  ti: 
piently,  hut  the  condition  .'•■ 


or  more  in  a  family  an>  :;tta' 

<|uality.     In  .dmost  all  cases 

Symptoms.     Irritation,  jis  . 

on  use  of  eyes,  hurniiiR  and 


which  point.s  to  a  contagi.-us 
,.    1  e  affected. 
,iu'.  iMxly.  phot.»phohia.  di.4re:  ^ 
,',ur(>  is  excessive  lacrvteition. 


a  scantv  nuicoi.l  (stringy)  .lischarge,  which  is  evidence.l  m  t,.  ■ 

hv  a  v.'ll. .wish-white  mass  along  th.'  lashes  an.l  at  the  inner 

.  in  ..verting  th.'  upjx-r  li.i.  the  tarsal  cotijunctiva  is  foun.l  "•  t"'^  »^      > 

,hi..kon,.d    and  th. 'surfac."  is  roughen,-.l  hy  the  pres..nc..of  t.um.^^^^^^^^^^^^ 

,,„,,  pMuillitonn  elevations.    The  surfac'  .f  the  pall«-hral  '■""  ""<-^'  ' 

hoth  ah.,v,.  aiul  Ivlow  presents  a  f:un..  i^'arly  hu.>.  as  th'-^l;  «  U.  .p  ^ 

skinniUMl  niilkhadlnH-n  pass.Hlover; :.  ;insapiH.arance..ohM^^^^^^^^^^^^^^^ 

th,  ..arlv  as  well  as  in  the  later  stages  of  the  -hsease.  .rh'"'  ^^^^  : 
j  m-tiva.  except  at  the  margin  of  the  cor.,ea  is  hut  ;l'.Pj»  '  f  •''l'  .; 
at  ti...  hmhus  th.  epith..!ial  layer  becomes  much  <h'<-kene.l.  This 
liuckening  is  usualU  greatest  in  the  horiz.  1  '':''l}'^'^''-.JX^Zh 
vatioiLs  have  a  pearly,  translucent  apin^aranr  ■-'  the  "P^;-  ^  ;" 
is.-haraci..:-i.c'  The  hypertrophic!  t>-^e  -  .  enc  oach-  mUo 
the  cornea  .-t  a  distance  of  one  ..r  two  milhn.  res,  and  a  narrow 
grayish  zone  separates  the  hyiK-rtrophied  tissue  from  clear  cornea. 


262 


THE  EYE. 


'  »i     i 


Pi 


In  the  later  stages  in  severe  eases  Hattene.l  fun^oi.  elevati.jns  apiK'ar 
on      e     alpel,n>l  e.n.junetiva  ..f  the  upiH-r  and  Unver  h.  s      These 
o  te    re  eni.le  traeh..,Ma  granul.-s.     They  n.a>  Ik-  l";.'"'"'"  'f'"';,,  ., 
Pathology.    Theehanp..sinthenmjun('tnae..ns,st.nseant>  s  n a  1- 
oell  inhltnttion  an.l  the  .level..,Hnent  -f  pap.!  a.,  i.art.eularly  .me 
up  «:    tarsal  eonjunetiva.     Thes<.  papilla"  eons.st  ot  a  <:;;»-•='•'' 
v.!k,.N  -.M.l  s.,n.-  n.nneetive-tissue  stn.n.a  eovere.    w.  h  a  la>er  .< 
h  rk  n<'     «^tratitie.l   epitheliu.n.     It    is   un.l.mhte.lly   the   tuekene.l 
eni  hel iu  n  th  t  jjives    he  whitish  shin.n.er  to  thesv.rtaee      In  severe 
elv^.  S'i .1  ix'n-seenees  fcnn,  eonsisting  of  a  tibrous  pap.Ua  eovere.l 

bv  thiekened  stratiHed  epitheluun.  ,...,;..bl,.  n.'rio.l 

•  Prognosis.     The  .li.«*ease  reeurs  every  summer  for  a    %  ai  lalle  pi  ri  d 

(t"T>  twenty  years),  when  it  subsi.les,  usually  leavmp  but  httle 

'''i;eatoent.  I'roteetivn  glasses,  a  bla...l  wash  (borie  aei.l  solution) 
and  the  use  of  an  ointment  of  the  yellow  ox.de  of  mereury  .1  to  i 
wr  cent  )  usuallv  give  the  best  results  so  far  as  rem.-. I.e.  an-  .-o.,- 
^erned  ral  mtr,  in  i.npalpable  powder,  .luste.l  o..to  th.'  pal,H-bral 
crimetiv  i,.  vrv  thin  laver  every  see.,...l  day  ,s  a.lvantageous 
?Satie  eJaliges  .lo  .....st  g..o.l:  the  sufferer  sh..nld  go  to  a  eo..l 
pliiinte  duri.iit  the  h.)t  .iDiiths.  .      ■     x    ■ 

FoWar  conjunctivitis   (conjunctivitis  folliculosis  sunplex)  .s 

ehSeriz..!  by\he  app.-ara..ee  ..f  small,  I'-'-'^h  ,»-''';';^'';'  .^ . 
.lovations  arra..g(Ml  ..ffn  in  rows  wh.ch  oceupy  th.-  m.U .   i    rt  .m 
„f  the  fornix  ..f   the   low.-r  li.l.  oeeas....ui  ly  be.ng   pr.  sent   at 
oufr   an.l    i.m..r    porti..ns  of    th.-    paliH-bral    e...,ju..etiva    of    th.' 

"''cai8e"'Ther..  is  ....  know.,  speeific  ea.ise.  b,.t  the  .liseas.-  ..eeurs 
n.o^t  fre..u.'..tlv  i..  ehildren  wl...  liv.-  in  m.hygi.'ni.;  surr..u...h..gs.  an.l 
Z  ev-uU''...'.'  is  i..  fav..r  of  tilth  as  a  cav.se.     The  .l.s.'us.-  .s  ...fe.-t.ous. 

'^'tZ^'^r.  is  oft....  e..nsi.lerable  irritati.m:  ,h.>  li.ls  ^ 
.lichtlv  thiek.-n.'d.  Th.T.'  is  so....'  n.uc.i.l  seor.'t..m  ....  th.'  h.ls  ...  the 
n' oSp.  l-se  ..f  the  .'V.'s  <.aus..s  s.-nsations  .>f  l....-.....g  a...  s,nart..,g. 
The  oeular  e....jnnetiva  a...l  .•..r..."a  are  s<.l<l.m.  ...volv.'d.  (  M.  .i.spe«'- 
.il!,,  ,h,.  palp.'l..-al  e..njunetiva  is    fonn.l   t..  be   e....g.'st,..l.  a.ul  the 

folli.'le-s  an>  nroiiiine.it.  ,  ,  ., 

Treatment'    Th.'  .'V.'s  sho..l.l  be  bathe.l  three  ..r  fo.,r  t...>..s  .la.ly 
with  a  .i  p.'r  .'.'..t.  si.hitio..  of  borie  aei.l,  a...l  a  sohit.....  of  me.rur..- 

ehl.iri.le    lum  to  \:Mm.  sh....l.l  be  .In.j.pe.l  ...t..  the  .......iimet.val 

s,.  afte'r  .'aeh  batl.h.g.     Aris.ol,   i...lof..r...,  bWn...tl..  a..d  .■alo...el. 
,.„ual  parts,  or  eal.....el  al.....'  ...ay  b.'  en.ploye.l.     In  i.e.-s.stent  eas..> 

X  ,.ssio..  ,.f  th.'  eont,'..ts  of  th..  follieh's  ...av  be  resort...!  t..^  Km-  -s 
of'n.f.-aeti..n  sl,..ul.l  be  e..rr...'t.'.l.  T..  I'r<-ve..t  spn.a.l...g  -.f  t  |e  d.s- 
,.as..,  isolation  sh..ul.l  b.'  res..rt...l   t...  esp-eially  when  .t  oeeurs  m 

'"xiachoma  (Granular  Conjunctivitis;  Egyptian  Ophthalmia;  Mili- 
tary Ophthalmiat.     This  .lis..ase  is  el.araet<.nze,l  by  the  presence  <.f 


DISEASES  OF  COSJUNCTIVA,  CORSEA,  ASD  SCLERA. 


263 


,n„nrr..us    small    oval    n.assrs   in    tho   paliK-hral    .•..njun.-tiva     by 
n  -U V  ami  l.v  fjrav,-  suhs,.MUont  c-hauges  in  the  cnjunctjva  1 .1. 
,        ten    n  th.-  RlolM..     It  oc-curs  most  fr<-.,uently  m  ';l»l'l"'»- ^'^ 
;;;;'.  aff'.I-t  in.liviauals  at  any  ag.  .'X.rpt  ,..Tha,.s  .lunng  the  hr^t 

•■'De^rii^n.    Tradu.n.a   .nay  Ik-  eonveniently  .livi.le.l    into  three 

''  nr;i,  the  stage  of  Im^erirophy,  «.  whieh  the  P"-^""!;;; T 'l' -^S 
.„  1  the  -irc'i  <.f  the  conjunctiva  is  as  great  or  greater  than  m  the 
;;;:;.',;';.  -;:,  eieatrh-ial  tiiue  having  fonne,l.     This  stag.-  present. 

*';:;  The'S"iui-"-e;up  without  .!iscon.fort  to  the  patierU,  veij 

lit  le  mm-.fus.HT.tion  Ix'.ng  pr..s.M.t-n.,t  sutticu-nt  to  «-al  the    . Is 

•  ^-  tiw>ro  i«  •!  ^lidit  excess  .)f    acrvmati.Mi,  and  the  U.ls 

'.;;,;:'.;:;'"i'SX  u,x;:,i;'S"i.  „„  r,Hi,„»  ot  ,>,. ,«-.,,» c™,. 

Sh-  .-a  Iv  ^irt  ..f  this  st.ge  th.-  c.rner.  n.ay  give  .-vulence  of 

thev  l)econi.-    visible   only  aftor   the 

«w.>lling  of  the  conjunctiva  lias  sub- 
sided.  The  pn-auricular  glands  an-  en- 

iarg.-.l.    Wh.-n  .u-curring  in  residential 

schools,  asylums,  reformatories,  an.   n> 

famili.'s,  the  disease  spn-ads  rapidly, 

and,  unl.'ss  isolati.m  is  jmictised,  many 

of  the  imnat.-s  become  aff.-cted. 
U-)  This  phase  is  f.)rtunat.-ly  rare: 

it  is  the  most  stnere,  usually  aff.-ctmg 

vmnig  and  inid.ll.Mige.l  adults.     The 

onset  is  rapid.  Hurnuig  and  scratch- 
ing of  th.'  lids  are  .-omplani.-.l  of. 
Th.-  lids  b(-.-)me  mo.ler:  t(-ly  s\v.)llen. 

Tlu-re  is  lacrvmation.  and  in  a  .lay  ...    ■ .         ■  „„.>».i,t 

a  ptinolent  discharge.     Hyp.rtro,^,y  of  the  -"^V""^  ^  .  '  .^-1 
aft.r  a  few  .lavs:  at  theen.L.f  ten  .lays or  tw..  we.-ks  '  ■•'.  "^^^^^^^ 

is  gn-atlv  thick.-ned,  the  en, ire  f.,rnix  pres.-ntn>g  a  p    - ,  u"        >    'f 
tissue.   Th.-  ocular  conjunctiva  b...-.>n,es  .U-ep  v  '"l^';;    V  "  ^\;;,,j;4 
unusual  to  observe  evi.lence  of  corneal  irntatu.n  earl>  m  the  course 


Fio.  132. 


ConJ>.nr.iv»of  upper  li.llu  chronic  Kn.ii- 
ul«r  conjanctlTllii.    (Arlt.i 

or  two  a  nuiwpurul.-nt  and 


264 


THE  EYE. 


of  tlio  (lisoaso.     The  preauridilar  lyinp*>  glands  are  pwoIIpii,  and  in 
some  cases  the  siibniaxillary  glands  are  similarly  affected. 

The  first  stage  of  trachotiia  may  last  six  weeks  to  a  year:  it  grad- 
ually ijasses  into  the  scmnd  stmje,  which  may  be  termed  the  "toge  «/ 
coalescrncc  or  bef/inniw/  itj  cicotrizntum.  This  stage  is  common  to  the 
thre«>  phases  of  onset,  appearing  later  in  the  first  phase  than  in  cither 
of  the  others.  The  granules,  which  before  were  di.screte  in  the  first 
Iwo  pha.ses(,f  onset,  coalesce,  and  cicatricial  tissue  apjx-ars  in  the  form 
of  narrow  bands  throughout  jMirtions  of  the  paliM>bral  conjunctiva. 
The  area  of  the  conjunctival  surface  diminishes,  and  the  cul-de-sacs 
decrea.se  in  depth:  with  this  change  the  tarsus  tvcomes  narrower  and 
shorter  and  abnormally  acutely  curved.  The  rough  surface  of  the 
lids  rubs  again.st  the  cornea  and  destroys  its  ejiithelium.  \'ascular 
pannus  forms,  suix'-'ticial  ulcerations  of  the  cornea  follow,  and  if 
{)athogenic  gcruis  fii'il  entrance  to  the  corneal  tissue,  dw])  ulcers,  with 
more  or  less  deatru  -tion  of  'he  coniea,  ensue.  The  margins  of  the 
lids  l)ecome  inveited  fentro|)ion),  and  the  la.shes  rub  again.st  the 
cornea.     The  palp«'bral  fissure  is  narrowed. 

Trachomatous  tis,sue  may  appear  on  the  ocular  conjunctiva,  the 
caruncle,  or  even  on  the  cornea.  Years  may  elaps(>  befon-  the  second 
stage  piv.'^ses  into  the  third  statje,  which  is  known  as  the  dwic  of  atrophy 
or  cicatrization.  The  cornea  now  presents  an  opacjue  ap|)earance. 
The  conjunctiva  is  nmch  reduced  in  area,  and  presents  none  of  the 
appe.irances  of  the  normal  nnicous  men\brane:  the  .surfaces  are  dry. 
except  i)erhai)s  fo--  the  presence  of  a  few  islets  of  approximately 
norma!  tissue.  Vision  is  reduced  to  i)erception  of  light:  the  con- 
junctival surface  as  well  .is  the  cornea  is  dry  (xerosis  cicatricialis) 
and  pale  in  color. 

Trachoma  -leed  iiol  neces-sarily  pa.s.s  through  all  of  these  stages,  but 
may  Ih"  arrested,  with  the  preservation  of  what  normal  tissue  remains 
at  any  i)art  of  the  first  or  second  stage.  The  dis«>ase  ceases  spon- 
taneously in  rare  ca.ses,  l>iit  too  fre(iuently  p-rsists  throughout  the 
life  of  the  patient  if  tr<-atment  is  not  resorted  to. 

Causes.  While  trachoma  is  not  confined  to  the  poor,  it  is  much  more 
freiiuently  met  with  aii'ongthem,  filth,  overcrowding,  vitiated  .atinos- 
phere,  and  improiM-r  aii('.  insufficient  food  contributing  to  its  produc- 
tion. It  is  pos-'ible  that  a  cnntagium  mu.st  \w  added  to  produce  the 
.lisease.  .Many  researches  have  In-en  undertaken  to  discover  tiie 
siH'citic  cause,  and  a  micro-organism  has  IxM'n  isolated  which  In'ars  a 
close  relation  to  the  disease:  this  micro-organism,  which  is  a  small 
double  coccus,  has  Imvu  des(Tii)ed  by  Sattler  and  Michel.  Mutler- 
milch  has  .Irscnlx'd  a  funsrus  which  he  terms  Microsporosa  tr.ichoma- 
toruni.  I'feifer  and  Hidley  have  described  i)arasitic  protozoa. 
.Mthxugh  it  is  iM'lieved  to  Ih'  a  microphj'tic  disea.se,  sufhcient  evi<lence 
is  not  yet  at  hand  to  establish  the  identity  oi  any  known  germ  as  the 
sjM'cific  cause. 

It  cannot  be  demonstrateil  that  any  condition  of  the  system  pre- 
dis|>oses  to  traciioma.     It  is  found  in  the  robust  a.*  well  a.s  in  the 


< 

a. 


'Hi 

5 


it) 


i 


DISEASES  OF  COSJUSCTIVA,  CORSEA,  AXD  SCLERA. 


26.) 


,,„„rlv  nourisluMl.  Lymphatic  in.livi.luals  do  not  appear  to  c.n- 
i-ict  "the  (liscasc  more  mulily  than  others. 

pltlology.  The  trachon.a  folliele,  wlm-h  is  suhstant.ally  a  nnn.a- 
,un   lvn.,!h  Klan.l,  is  the  essontit.l  elen.ent;  these  folhelc-s  consist  of  a 

■  icate   in.ietinite   connective-tissue  capsule  cmtainniR  a   n.ass  of 

V  m    oi.    c«.lls.  this  collection  of  cells  In-ing  traverse,    by  very  hne 

ne  vcMissue  tralK-cuhe.  (Plate  V.)  ^>-' V'^tr t  [l^!!;:  i' 
„•  co.ni.-ctivc-tissue  stroma  that  surrounds  the  f.,  hcle  an.lcap  1- 
"ri  '  an  nud  in  the  mas«  ..f  cells  that  form  the  foUu-le.  As  the 
i^-as.  passes  into  the  second  stage,  the  septa  between  mdn.dual 
f  Hides  lisappear  an.l  the  lymphoid  nuisses  beco.ne  <'.«'"t>m>""N /  """ 
1  ,  aqu,>s  of  various  sizes,  and  the  substantia  propria  o  the  c.njm.c- 
,i\'a  pnlduallv  gives  place  to  cicatricial  tissue.  The  epithelium  cover- 
imr  the  irraiuiles  varies  in  thickness  and  IS  irregular.  ,    ,      u 

'"ioli     Trachoma  in  its  first  stage  may  »-  -^^fl^'^j^;;'^^ 
venvd  c-itarrh  tulwrculos  s  of  the  conjunctiva,  and  I  arinaud  s  (Usease. 

VI  "h  i  r       "the  case  will  suffice  to  distinguish  it  from  the  first,  or 
if    1.    hi^Jorv  is  not  .suffici..nt,  microscopical  examination  of  a  nodule 

i      ufl  (  n  vernal  catarrh  the  nodule  is  a  fibroma.     The  m.cro- 

scniclal  examination  with  the  history  of  the  ca^  will  suffice  t..  .  ^- 
tiiS  t  fn.in  tuberculosis,  and  in  Parinaud's  .hsease  the  excessive 

S  e  un^  cer^•ical  an.l  preauricular  glandsw.th the aiTect.on 

...nfincl  to  one  side  (as  it  usually  occurs)  wi    \w  sufficient. 

iro-^osis  This  is  favorable  when  the  .hsease  is  seen  m  the  first 
or^nrh  mrt  of  the  secon.l  stage.  When  the  cornea  has  become 
lohl;i.'furlher  da  nage  may  be  obviate.l:  but  the  tissues  .lestroye.l 

••='i;;ati:r  tSs  is  prophylactic  medicinal,  and    -^^;^J- 

n-r    k     it;       .'.ia  ion  ^vith  indivi.lual  tow<>ls  sh.mld  Ije  .-nforced. 
M  •m.-iNU  ■    The  evesshoul.l  be  thoroughly  cleansed  as  often  as   s 
n..e  .  ■     V  to  keep  then,  free  from  .iischarge.  by  bathing  with  a  solu- 

•  ; n,!:;'  liid  or  mercuric  chloride  (1  ^^^^L^^'^ 
„„.rc„ri,.  chloride  (I  :  o(KX.  to  1  .  :«KX  )  formalin  (1  .  •  KM)  cl  lor.  e 
w.,.er  (  ->()  ner  cent     V.  S.  P.).  or  chlor.de  of  zinc  (gr.  J  to  .^O   n.a\  iie 

::;;;;;-;;;,';;;':!yMhn>e  or  fourtimes  daily:  thec^nju.^^ 
nnv  he  MM-n-e.!  ,nce  dailv  with  tannic  acid  and  ghee  in  (gr  \\x 

V    o  ^i  '      IV  -oglvceride  CM)  to  .50  iK-r  cent.)  may  b.-  applied   to 

V:J...  onh.tniunctiva,  and  is  of  value  in  the  bU.  s  age.w^ien 

tl«Te  i-  more  or  less  xerosis.     Io<lide  of  l)eiizosinal,  i  ptr  unt.  (.  <a 

,  k  V  I     o    ser^•iee.     Je<,uirity  bean  in  infusion  and  m  powde 

lr:;I;;,iu;ed  to  "Idt^a  counteUnHammation  to  cause  absorption  ..t 

'':;S'1;,//.,.....     TI.  ren.edy  that  finds  ^^\;^^^^^'^ 
tra.'homa  where  t!ie  discharge  is  not  profuse  is  tlie  crystal 


2()<i 


THE  EYE. 


"■"■'7  tsK;;'i.'^,s:a'  ^JSSirttZ^f;'^ 

smooth  irystal  over  vv   amio  '  \  .,       |  ,i„,  ^n-k  of  luiti- 

FIO.  133. 


Knapp'i  exprei«ion  forcep*. 


i,  „„on„,...,l  \"l'f '-^^r^rjii  XS    ..y  1.^  cnp'oyoa/   Fig. 

w,  cocL ;» y  iJ  -'■  T""  li'i'  -■  '""^  """"'■  *'■  ""'""■ 


Fi«.  i;M 


Wocks'  scarlfiCRlnr. 


r  •  n,.  ......nfiod     -10(1   the  shallow   incisions  (lirocto.l  parallel 

suiio.hc.ally   !*^"''7  •    •'"      "If,,,.   f„,,,,   „f   o„„j..nctiva    arc   s<..z,m1 

•^'•u^l"irS,S^  IK.^^  aSl    or  ;.onnal  .ali,.o  ;oh,tion.  an.l 

In     ,  1  rtoM      .np^^^^^^^    witho.,t  ba,ulasi..K,  or  a  l.a.ulapc  ..my 

nli    I     o     t    Xfour   Ixmrs;    th.-   intnuluclio..    ..f   n,.    o.nt- 


VISEAHES  OF  COyJUyCTIVA.  COBSEA,  ASD  SCLERA. 


267 


,l„.«o  iulhcsions  aro  attacko.l.  In  ras^-s  whore  the  pallH.l.ral  ti«.ure 
Is  nTrrmve-l  a.ul  the  c.nH.a  is  sufforiuR  fn.n,  u.ulu,>  prrssur.  fr...n  the 
li.U   (•anth()J)lastv  inav  lie  resorted  ti).  . 

Pariiaud'8    conjunrtivitis    is    a    ...ueopurulent    affectum    of   the 
..onSva  rharacterize.1  by  the  f<.nnation  of  rather  larpe  pranuies 

'      va   ..ns  on  the  eonjunctiva.  whieh^.net.n.es  "H"  ,"■•  u-ulat.. 

(Jiffonl)      The  condition  is  aceon.pame.l  by  ,.ron..uneed  suelhng  of 

ihr,,reaurieular.  retrou.axillary,  an.l  cer^■ical  glands,  wh.ch  son.e- 

^' '^"1;!;"!;' l'annau.l-s  .Usease,  s.,  far  as  the  eye  is  eoncenved  is 

JX  like  that  of  acute  trachoma.     Lacrynuit.on  .s  fo ll.Aved  ,n  fort.  - 

^ito  seventy-two  hours  by  a  n.ucopurulent  --;•'"; -*--^'^ 

iii  of  the  li.ls   which  in  si-vere  cases  is  pn.nounce.l.     On  evcrtinp 

£•    nner    i.    on  the  third  or  fourth  day,  elevatmns  are  observed 

S^id'T^i-n  1  lo  the  granules  in  acute  trachoma:  these  nodules  gen- 

nllvl^^  ».L.n.ewhat  l.xrger  than  in  trachoma,  and  soon  superficud 

uJers  aro  obscTved  in  the  sulci  between  the  small  ""'l"'^^-    7"; 

i  s'eem  to  In-ar  some  relation  to  the  degree  of  mvolvement  of    he 

r  lur  cu  •  r  an.l  cer^•ical  glan.ls:  when  the  ulcen>  are  numerous  the 

KnT-i  '   no"    severelv  affecte,!.     Ulceration  of  the  cornea   wh.ch 

f;  u  occ  si     d  is  also  more  apt  to  occur  when  the  con- 

;;;;ct!"l  ui:^;';a;i..n'is  nK>st  .narked.    Chills  and  fever  accon.pany 

""ca^'^'The  .lisease  is  supposed  to  Ik-  ,lue  to  an  infection  of  animal 
ori'trit  at  tcks  in.lividuall  of  all  agc^s.  is  "u.nolateral .  »md  dr.s  no 
;  .;  to  U>  contagious.     No  specific  nucrc-organism  has  l>een  <Ils- 
^llliidlalthoigh  ihe  nature  of  th^e  disease  ,K.ints  strongly  to  a  spec.hc 

''Station.    The  .lisease  nmy  temnnate  in  three  weeks   or  it  .nay 
•  H-S^t  for  six  or  eight  months.     Relapses  are  very  apt  to  occur,  but 

sarv.     Fre.,uent  clix..si..g  with  a  sdut.on  ^'':;^^Xt^^\ 
sufficient.     A  solutio.,  of  mercuric  chloride  (1:  .«KM)    n  a>  1h>  in.  tuu 
,  v"rv  four  hours  or  calomel  mav  1«>  dusted  onto  th<-  lids 

Gout  of  Sie  Ooniunctiva.  An  intense  .edematous  swel  uig  .-f  the 
.M^-^"  71.  SSaiKl  of  the  eyeball,,  accupanie.!  by  pr.^use 
nSation,  with  little  mucus,  and  ,>ccasion.ng  grea  ^^^^^^ 
,,„ient,  is  sometimes  met  with  m  in.  ivi.  uals  « »^  ,;"^"  Vf,' "  1 
Tl,w  form  .if  oiiiunctival  irritation  cl.)sely  n'sembles  the  nianiie.  la 
^  ;';^.u  asa;::.S-e.l  in  thesw..lling  of  the  great  t-^^the  .e.Ujnu, 
f    lu.  ankles  .an.l  .,ther  .listal  articulatu.ns  ^PP^'';  J'    c   le^ 

reaching  its  height  in  twenty-four  to  f'>'^y-''!S'^\  .*^?"^;; ,X  h  •  T.n - 
i„  five  to  ten  .lays.     Thenu-sis  may  Ih'  marke.l.     is  "J^j"    '';;  "!^^ 
na.ue.l  bv  gout:  manifestations  in  ..ther  parts  ..f  the  sjstnn.  ami 
tli.>  occasional  manifestation  of  a  gtuity  crisis. 

Treatment.     Locallv.  cleansing  "♦    the    conjunct  val  ^J^^^}^^^  "J 
four  times  daily  with  a  solution  of  boric  aci.l  an.l  the  application  of 


"""wgjf -'Tr!tiriwr  'Biai .  .irr-sgtHHtet  ji  1'jih!i  ,  vrwi^ ' 


2(M 


niE  KYE. 


u 


Hiii 


.....l  loa.l-.M.l-o,mnn  wash  .■..n.,>n.ss.-s  t.,  tlu-  W^^,    Intornally,  troat- 

Horner.     It   i>  ( liar.uu  n«  i     •         •  ,,       ,.„i.,r  c.iiiunctiva, 

whi<-h  fnnn  on  tlu-  i-alin-hral  an.l  "«■"<:"  ]^^^^^ ^  Ho.,r  sliphtly 
pal,.r  than  th.  surroun^mp  nn.jjmHn   j   th     m  ^^^^^ 

Langinp  to  its  hor.l.-rs:  tho  .l.-nu.l.Ml  -"^f'"" ";: ^    '^',       i,,,  .u-nu-lo.! 
fornuMl  .'pitliHiirn.  an.l  tho  ,.roc.>ss  is  sho  t  >  .  t <    •       ' 

.urfaros  !..•<•..,»•  aRplutinat.-.l   t^"I'i;:»^'"«.;','\t  o.uh    an.l  pal- 
.:onn.ri..ian....u..Uof~>;^;^^ 

.....nphiRUs  foliacc.is,  an.l  .Iq.omls  on  a  (hscr.isia  ..I 
attacks  in.livi.luals  at  all  ap-s 
Treatment.    Tn'atnu«nt  is  of  httle  value. 

Forms  of  Coniunctivitis  in  which  the  Etiological  Factor  has  been 

Determined. 

,,  „  ,™,ll  l.»"ll-J<';'»  '  -        ,    J,^   ■;;;  K..,.|,  i„  IN«.  a,„l  ,r,.v,.,l 
his  (Flat.'  \  1.,  I'ljr-  II-  n^^^'  '": '"  ,  ..  ,x-.:..i...  ;.,  \-,.v,.i..h<T.  ISSH. 
to  he  th.' 

SusceptibUity.     AH  .'onjnnC 
this  niicro-orsanisni. 

""»"""tL,      For  thirtv-ix  to  fortv-oipht    lumrs  a 

l,„rning  s-M.^.t.-m  n.  tho  h.K  .•'.;['•,,,,.,,,  an.l  th."  iJ.'n.'ral 
Towar.l..v..nin,th..nu.e..,n.rul<  t  -  «  ';^'<;  ^  „„.  ,,,,,,,„  ,.as 
.hscmfort   is  n.on-  n.ark.-.l.     B>    th     >"""'''    .        ,5.,,,^  „f  „„. 

ihsl^^o  is  t^sually  roaoho.l  ..n  th.-  ;'''••;  ^  j^jt-'  -on.  >i."ai;v 
sfi.'.>  lasts  fniin  throo  t..  s.>von  .lays,  an.    ina>  d.    a      . 

"•- i:;:;r;;^;™;:iL,s';;'i:;'rr,;;™;i;  fr-"^' 


„.enh.  ,nior.,-..rganisn»  by  ^^.-ks  in  N..v.>.nU-r     >M, 
'  \11  .-onjunctiva'  aro  suscoptihl.'  t.    th.'  nitlu.  n.     -  ' 

Olio     **•■"'■  "'  '*■"  ''•'*•■•■"''■  ''<'*'^  '■       •"■'"'"" 


attack  of  tho  .lisoaso  .I.h-: 

alter  ti 


■  uicoption 
tho  i'\<'  is 


.•XI 
li.l^ 


FLATK   V 


Ki 


l)-W<oUs  Bncillu>. 


M.  .1 


,,x-Ax.-lU.-l>l    tJii'l>''''"  '""" 


In 


h  1 


DISEASES  OF  COSJISCTIVA,  COHXKA,  AS1>  SCl.riiA. 


•JtSH 


tw-'     Tlic  f..i.irrr'ti..i.  of  tl..- .M-uhir  (•onjunctiva  in  tin-  acut.-  Mat;.- 
Jivrs  t  ..  ..v..  avivi.!  r...l  i.,.|H-aran.--.  wl.irl.  has  .-aus...!  tins  f..nn  ..f 

.f.tf.'  slll.si.lcs.  the  s..<Trti..|.  l,cc.mu-s  Irss  copuuis  l.ut  tluk.r.  A 
|,;iht-vrllow  mass  of  s,.m.tio„  is  ,,r..s<.nt  at  ihr  mn.T  .■antl.us  n.  t  ..• 
inurni..'^,  a  si^Mi  ti.at  is  almost  |.atlu.(ji,oni..n.r  „f  ll..- disoas.-.  \M  h 
!  !."•.■  of  tlH.  s,..T..tiu„  ana  of  tl...  sw.llmK  of  tlH>  h-is  an.l  .-on- 
;  ,  iva.  II...  ,.ainful  svn,,.ton,s  .iisap,H-ar:  howv-r  a  M-ns^.twrn  of 
;;;.';„'!;;  ;,f  ,1..' .•onju..Hiva  ,....-sists  for  w...-ks,  ,,art.rularly  notin-abl.. 
,,„"vis<-of  ll.ci'Vi's  withartiti.'ial  lijllit. 

Duration.  If'si.n,-!.-  .•Iranli.u'ss  is  ol-s.-fv..,!,  tlu-  .l.s<.asj.  nsuall> 
,,.""  ..ours,,  in  two  or  ti.r..,.  w.vks.  all  of  tlu-  syn>,.ton,s ,  .sa,.,..-a  - 
Z  It  n.av  last  for  six  months  if  no  tr.'at.nrnt  is  n.stitut...l.  \  rxl.T 
snital.ic  treatment  the  averape  .luration  is  e.pht  f;  twelve  .lays 

Con1»gio«.  QuaUtie..     Mueopun.lent     eonjunet.v.t.s    ,s    extremely 

nSS.    Z  .vsulential  sehools.  asylmns   l.arraeks,  penal  u.st.tu- 

'  o  n  nunities.  an.l  fan.ilies.  it  fre.pu>ntly  lH.,-.Mn..s  epul..m.r 

,av  lM-on,e    en.lemie.     ('onmmnirat.on    fr.m.    one    in.ln..  lal    to 

..theris  prol.al.lv.  hv  means  of  towels.  romn...n  l.athn.K  wat.r.etc. 

,      el  as    V  .lin-et'  e..ntact.     There  is  littl.-  .l<.ul.t  that  the  e..ntaK.o  us 

;.lemen;  nluy  L  rarri.-l  by  .Irauphts  of  air  an.l  by  the  water  .n  pubhe 

'"'liiimoBiB      In  a  tvpieal  rase  the  .liapnosis  is  comparatively  oa.sy. 

U^^T'iJ^  the  ■i.n.lition  ,nay  be  .nistaken  for  p.norrh.ea   eon- 

„;3  s  or  even  for  dii.htheria  in  eases  wh.-re  a  pseu-lona-mbrane 

;;;,;:;,'^.    Th,   ;nicr,.scope  is  necessary  to  clear  up  the  .hap.os.s  m 

"'SnSa^ons.      Phlyctenula-,     ,«*eudome,nbrane,     corneal     v.lcer 
''Stis^rX-l^^ianH^.    oonsi.s    in  strict  quarantine 

""iLiii;^^  (3';;;;i;:Sr;ie  ii..s  ..r  one ....  at  a  tim.. 

tlmrf"!es  .lailv  .lu  inp  the  acute  stage.     Fre.,u.-nt  cleansmg  w   h 
^e   "hc    d!i  soluti. '  (3  ,..r  cnt. )  shoul.l  1.-  "-y-,  ^;'- ,„^   j^ 

-p^SocS''isSc;i^sr^Acuto  c.^ 

,,,  ,.  the  pres..nce  "f  th.-  p..e.u;..occus     r^  ^r^x a  j^ 

;;irr  siinn.^.?';!::^  ::i  r...;,- n  ^^^^-^-;,:-z 

ConUgious  Qualities.     Pneun^ococcus  '"''J^'L'-  '  '  '^  ""^;'*;,' J^j    ,  • 
•m.l  adults   an.l  it  mav  become  epi.lemic.     It  has  l)een  pr^^f"'  ''> 

I.on.m;.;wrthe  conjunctiva  mu.t  exist  before  the  disease  m.,uest,on 


MICROCOPY   RESOIUTION   TEST   CHART 

iANSI  and  ISO  TEST  CHART  No    2! 


1.0 


I.I 


i-IM 

f~     136 


1.25  IIIIII.4 


m 

2.2 
ZO 

iJ= 
1.6 


^     APPLIED  IIVHGE     Inc 

^^  '^^i    tJil    M'lr    :,lre** 

"^=         i"e)   *8^       C300  -    Phorv 


270 


THE  EYE. 


can  hf  produced.     It  is  well  known  that  tho  Wcichsolhauni  pnonnio- 
eoccus  may  exist  in  the  normal  conjunctival  sac  witlu  ut  protlucinp; 

intlammation.  .        .  .  .    , 

Diagnosis.  It  is  difficult  to  differentiate  it  from  conjunctivitis  due 
to  the  small  bacillus.  The  microscope  will  serve  to  establish  the 
diagnosis. 

Duration.     Tiuie,  three  days  to  two  wwks. 
Prognosis,     (iood  in  all  cases. 

Subacute  Conjunctivitis  (Diplobacillus  Conjunctivitis^.  This 
form  of  conjunctivitis  is  insidious  in  its  onset,  iiroducing  redness 
and  slight  thickening  of  tht!  conjunctiva,  largely  conhned  to  the  con- 
junctiva of  the  lids  and  fcniices.  There  are  slight  increase  in  lacry- 
mation,  a  scantv  secretion  of  mucus,  with  some  i)us  corjRisdes,  irri- 
tation as  of  a  fo'reign  hodv  in  the  eye,  and  burning  sensations  on  use 
of  the  eves.  The  annoyance  is  relatively  slight,  but  jiersistent.  The 
eyelids  liiav  become  somewhat  congested,  but  they  are  not  apjm-ciably 
thickened."  In  rare  cases  the  cornea  becomes  involved,  a  superficial 
nnrginal  keratitis  being  produced,  followed  by  cloudiness  of  the 
affected  area.  This  may  advance  and  narrow  the  transparent  area 
of  the  cornea  to  verv  small  limits. 

Cause.  Morax,  and  later  .\xenfeld,  have  described  a  bacillus  as 
the  cause  of  this  disease,  and  their  studies  have  been  confirmed  by 
(Jifford  and  others.  Tne  bacillus  measures  2  to  S ,«  in  length,  and 
I  to  1.5,«  in  brei;dth.     (Plate  VI.,  Fig.  2.) 

Duration.    The  disease  may  last  for  six  weeks  or  as  many  months. 

ConUgiousness.     \erv  slight. 

Treatment.  The  eve  should  be  clean.^^ed  with  a  boric  acid  solution, 
and  zinc  chloride  (gr.  j  to  .^j)  shouhl    be   instilled    twice   or  three 

time-;  a  day.  ...       »     ^    m 

Gonorrhoea!  Conjunctivitis  (Purulent  Conjunctivitis;  Acute  Blen- 
norrhOBal.  This  disease  is  d(>scribed  under  two  titles,  namely, 
goiiorrlueal  ophthalmia  and  ojjhthalmia  neonatorum,  the  latter  tenii 
l)eing  ai)plied  to  the  disease  as  it  occurs  in  infants  less  than  one  year 

of  age. 

Cause.  This  affection  is  due  to  the  iiresence  iii  the  conjunctival  sac 
of  the  goiiococcus  of  Xeisser,  descril)ed  by  him  in  1S7!).  (Plate  VII.) 
The  contagium  is  most  fre.|uently  conve.ved  by  the  finger  from  an 
Mctive  gonorilKcal  urethritis  or  from  a  gleet ;  towels,  washing  utensils, 
-oiled  linen,  etc.,  may  be  the  means  of  carrying  it.  In  all  proba- 
bility the  micro-orgaiiism  is  not  carried  by  currents  of  air  This 
micro-organism  attacks  all  human  conjunctiva' with  which  il  comes 
in  contact,  regardless  of  the  condition  of  the  individual. 

Description  of  the  Disease,  Acute  Stage.  A  ])erii)<l  of  twelve  to  thirty- 
six  hours  is  reciiiired  after  the  entrance  of  the  contagium  to  j.roduce 
marked  disturbances,  then  the  lacrymation  is  increased,  the  conjunc- 
tiva soon  becomes  injected,  and  swelling  rajiidly  advances.  Twenty- 
four  hnnr^  inter  the  liils  have  become  much  swollen,  the  conjunc- 
tiva thickr'iied  and  deeply  injected,  and  the  secretion  mucopurulent. 


PLATE   VII 


Gonococcus. 


DISEASES  OF  COyJUyCTIVA,  CORXEA,  AND  SCLERA.       271 

MUiiPtiiiics  sanguiiiolont  an<l  mixed  with  the  lacrymal  fluid.     Buni- 

inp   and    jrrittv  sensations   are  ex])erienred ;    dull    jjain    in  the   eye 

is  occasioned   i)v   pressure  of   the   lids.     In   two  or  three  (hiys  the 

heifilU  of  the  acute  stape  is  reached.    The  swelling  of  the  lids  now  is 

(jften  enormous.     The  eyelids  cannot  be  ojiened  by  the  jiatient,  and 

are  oitened  with  difficulty  by  the  surgeon.    The  ])alpebral  conjunctiva 

is  much  thickened  and  velvety,  due  to  a  cellular  infiltration :  the  ocular 

conjunctiva  is  swollen  and  often  glistc-ning:  small  ecchyinotic  spots 

are  sonietunes  present:  chemo.sis  is  marked.    The  secretion,  which  is 

yellow,  not  verv  thick,  and  almost  entirely  free  from  nuicin,  flows 

from  beneath  the  upper  lid  onto  the  dieek,  matting  the  "ilia.     The 

acute  stage  continues  five  to  eight  days,  when  it  gradually  pass(>s 

into  the  subacute  stage.     The  tense  sv.elling  of  the  lids  subsides  and 

the   venous  stasis  is  relieved.     The  .secretion,  which  is  copious,   is 

creamy,  the  conjunctiva  is  thickened  and  thrown  into  folds   and 

nodules,  and  the  cheniosis  is  less  marked.     With  diminution  in  the 

weight  and  tension  of  the  lids  the  pain  becomes  less  severe.      This 

stage  may  last  two  or  three  weeks,  and  recovery  then  be  established; 

or  the  disease  may  i)ass  into  a  chronic  stage,  which  may  continue 

for  weeks  or  even  months. 

Severity.  The  description  just  given  applies  to  the  ordinary  cases 
met  with.  Cases  occur  in  which  the  affection  is  exceedingly  light, 
the  discharge  scantv  and  not  free  from  nuicus.  Some  ca.«es  aie  ex- 
tremely severe,  and  the  swelling  of  the  lids  and  conjunctiva  great. 
The  c(injunctiva  is  pale  in  hue,  from  the  jjressure  of  the  infiltration. 
I'seudoinembranes  form  on  the  surface  of  the  palpebral  conjunctiva, 
nften  closely  resembling  diphtheria.  The  severe  ca.ses  occur  most 
fre<|ucntlv  in  adults. 

Complications.  The  cornea  is  involved  in  about  .33  per  cent,  ot  the 
cases  occurring  in  adults:  the  ultimate  imi;airment  of  vision  varies 
much ;  complete  destruction  of  vision  may  occur.  I'lcer  of  the  cornea 
.Iocs  not  occur  ordinarily  until  the  second  week  of  the  disease,  (jonor- 
rlKcal  iritis  ami  iridochoroiditis  may  complicate  the  attack,  (ionor- 
ihoal  rheumatism  mav  also  result.  This  complin  tion  occurs  only 
in  the  late  stage  of  the  disea.se.  I'seudomembrane  forms  on  the 
paliM-bial  conjunctiva  in  perhaps  20  i)cr  cent,  of  the  cases  that  occur 

in  adults.  i    i      vu 

Diagnosis.  Light  forms  of  the  disease  may  be  confounded  with 
acute  contagious  conjunctivitis:  severe  cases  may  be  mistaken  for 
diiihthciia.  Microscoi)ical  ex.'Uiiination  of  the  secretion  will  serve 
to  make  the  diagnosis  clear  ii-  the  -rr;  atcr  number  of  cases.  In  cases 
that  have  been  under  treat M.eiit  for  some  time  .and  in  the  very 
mild  cases  it  is  difficult  to  tiud  the  gonococcus,  but  patient  search 
is  usuallv  rewanlcd. 

Prophylaxis.  One  who  has  goiiorrluval  urethritis  .should  be  cau- 
tioned regarding  the  danger  of  infecting  the  conjunctiva.  Alter  a 
-..norili.eal  conjunctivitis  is  established  in  one  eye,  care  should  be 
■liM'rved  not  to  convey  the  contagion  to  the  other  eye.     In  adult.- 


272 


TlIK  EYE. 


it  i«  wiso  to  protect  tho  eve  citlior  by  a  carefully  ai)i>lKMl  aseijtic 
haii.laiie  sealed  at  the  nasal  half  with  collodion,  or,  better,  a  Hiiller 
.hield  inav  be  eiiiploved.  This  consists  of  a  watch-plass  which  is 
.ecure.l  over  the  ev."-  i>v  means  of  rubber  adh<"siv.'  plaster  AH 
.h-essings  that  come  from  the  eve  should  be  destroyed,  and  the 
iin-itest  care  should  be  observed  in  the  .lisinfection  of  api)liaiices 
used  The  nurse  and  others  in  attendance  shouM  Ix'  nistructed  re- 
frarding  thr  danger  and  the  precautions  necessary.  The  hands  shoul' 
b(>  washed     'ter  touching  the  eye. 

Treatment.     In  cases  that  are  seen  in  twenty-four  or  tliirty-six  hours 
after  the  eve  has  b(-en  infected,  it   is  i)ossible  to  abort  the  disease, 
i„  a  number  of  cases  at  least.     This  is  done  by  thoroufihly  cleansm- 
the  eve    freeing  it  from  all  secretion,  thoroughly  ai)plyin>I  a  s<.lutiou 
.,f    nitrate  ..f  silver  (1  to  1  per  cent.)  to  the  entire  surlace  of  the 
conjunctiva  twice  in  twentv-four  hours,  and  makmg  cold  ai)plications 
to     he  lids,     .\fter  three  applications  the  silver  may  be  stopped. 
The  use  of  boric  aci.l  for  cleansing  the  conjunctiva  should  be  mn- 
tinued  for  a  f(>w  davs,  as  shoul.l  also  the  cold  applications       1  he 
greater  number  of  cases  have  i)r()gressed  too  far  when  seen  l,y  the 
surgeon  to  ix'rmit  of  abortive  treatment.     Careful  vigorous  treat- 
ment should  be  commenced  at  once.     If  the  lids  are  much  swollen, 
cold  applications  should  Ix-  made  constantly.     If  the  h.ls  are  not 
creatlv  swollen,  the  applications  may  be  made  for  three  hours  at  a 
time  an  int(>rval  of  one  hour  permitted,  and  the  cold  applications 
resumeil      This  should  be  continued  until  the  acute  stage  has  i)asse(l. 
and  the  f-ciuencv  and  length  of  time  gradually  dmnmshed. 

Mkthod  of  M.vKixr.  ("old  Ai'I'I.u-.vtions.    Pledgets  of  Imen  one  and 
uno-half  bv  two  inches  s.,uare,  of  thr(H>  or  four  thicknesses,  or  s<iuares 
of  t)atent"lint  or  absorbent  cotton,  shouhl  be  prepared,  and,  alter 
being  moistiMied,  jilaced  on  a  cake  of  ice  to  the  number  of  a  dozen  <)r 
,„„re      (  \  thin  piece  of  linen  mav  l>e  spread  on  the  ice  and  the  i)ads 
laid  <'.n  tile  lin<>n.)     The  pledgets  should  be  change.l  from,  ice  to  eye 
cverv  one  to  two  minutes,  or  sufficiently  often  to  ke(>p  cool  the  pledget 
that"  rests  on  the  eve.      To  carry  out  this  treatment  re.iuires  the 
constant  atten.lance"  of  two  nurses-one  for  .lay  and  one  for  mgh 
,h,tv      It   mav  hapi)en  that  the  eye  is  kept  too  cold  and  tiie  cornea 
tissue   lo.ses   its   vitalitv.      This   calamity  may  easily   l)e   avoided 
bv  inspecting  the  coriiea  from   time  to  time.     In  such  ca.ses  the 
,.;.rnea  becomes  uniformlv  hazy,  taking  on  the  ai.p<-arance  of  grouiu 
trMss      If  the  cornea  shows  the  effect  of  cold,  the  applications  should 
be  made  for  a  few  liours  at   a  time,  and   the   intervals  lengthened. 
Heat  is  not  desirable  until  the  gonococci  have  disappeared:   m  the 
later  stage  of  the  disease  it  may  be  of  service. 

The  eve  shoul.l  be  k.>i.t  as  cU-an  as  possible  by  fre-iuent  "it  "'f.^^J*' 
;,  solution  of  boric  acid  Ci  per  cent.),  nr  mercuric  .hloride,  1 :  .).(MX) 
In  ..leaning  liie  eve.  the  lids  shc.uld  be  separate.}  very  g.-ntly  an. 
the  solution  b.'  p.>rimtted  to  enter  th.^  eye  by  .Inppmg  ironi  a  pl.dg.v 
of  cotton,  bv  pouring  from  an  undine,  or  by  a  gentle  stream  fr.nn 


DISEASES  OF  COSJIWCTIVA,  COHXEA,  AND  SCLERA.       273 

a  i)i|)('tt('.  For  washiiip  the  oyc,  boric  acid,  trikrosol,  potassium  jx-r- 
niaiifiaiiate,  mercuric  chloride  or  cyaiiitle,  formaldehyile  1  :  1(),()(K) 
to  1 :  ")()(K),  or  hydrogen  dioxide  (one-third,  l'.  S.  P.)  may  1)«>  eini)loyed. 
Tiie  ])eroxide  of  iiydropen  m:iy  he  employed  four  or  five  times  daily 
for  this  purpose,  rotassium  [KTmanpanate,  1  :  2000,  to  irrigate  the 
coiijiiiictiva,  is  efficient. 

It  has  heen  found  advantageous  to  stutT  the  conjunctival  .sac  with 
boric  acid  ointment  (5  (kt  cent,  of  l)oric  aci<l  vaseline.  Wilson)  each 
time  after  bathing  the  eye.  Applications  of  a  solution  of  nitrate  of 
silver  10.5  to  2  per  cent.)  mw  Im'  made  once  in  twenty-four  hours. 
Solutions  stronger  than  five  or  ten  grains  to  the  ounce  are  .seldom 
necessarv. 

I'rotai-gol,  20  to  40  per  cent.,  may  be  api)lied  to  the  conjunctiva 
once  or  twice  daily.  The  continued  use  of  this  drug  ])roduces  a 
thickening  of  the  conjunctiva  that  is  recovered  from  but  slowly.  It 
may  be  employed  with  advantage  for  a  few  days  during  and  innne- 
(liateiv  following  the  vt'ry  acut"  stage. 

When  ulcer  of  the  cornea  is  threatened,  borated  vaseline  should 
be  aiiplieil  at  least  every  two  hours  to  the  corneal  surface  after  thor- 
ough cleansing  of  the  "cornea  and  conjunctiva.  To  the  va.seline, 
atmphie  may  be  added  in  the  proportion  of  one  grain  to  the  oimce, 
or  atrophie  ni  solution.  1  per  cent.,  may  l)e  instilled  twice  daily.  If 
perforation  is  innninent.  i)aracentesis  may  be  (hme  through  the  floor 
of  the  ulcer.  If  there  is  no  evidence  of  congestion  or  inflammation 
of  the  iris,  and  the  ulcer  progres.ses,  eserine  (0.5  per  cent.)  may  be 
in>lilled  twice  (hiily.  The  leucomata  and  staphylomata  and  the 
shiimkeu  globes  that  follow  in  some  cases  should  be  treated  as 
thought  most  expedient. 

Dkim.ktion.  If  the  lids  are  greatly  swollen  and  the  cornea  likely  to 
suffer  from  iiressure,  a  fre(>  caiithotomy  may  be  ix-rformed,  which  af- 
fords depletion  as  well  as  rel<-ase  of  tension.  Critchetfs  oi)eration, 
which  consists  in  splitting  the  upjx'r  lid  vertically  through  its  entire 
thickness  and  stitching  the  fla])s  to  the  iin.w,  restoring  the  lid  by  a 
plasiic  operation  after  the  disease  has  subsided,  may  l)e  resorted  to. 
Scarilication  of  the  chemotic  tissue  may  be  done  in  .some  cases. 

('i)\snTiTi()\Ai..  The  general  condition  of  the  i)atient  should  be 
studied,  and  .■<uch  measures  as  are  re(|uin'd  to  maintain  the  normal 
vital  processes  in  full  vigor  should  be  instituted. 

Ophthalmia  Neonatorum.  Liberally  construed,  this  term  may  be 
made  to  include  the  purulent  or  mucoi)urulent  inflammations  ol  the 
conjiinctivM  that  occur  during  the  first  year  after  birth.  Ordinarily 
the'term  is  api)lied  to  those  forms  of  conjunctivitis  that  ajij-ear  before 
the  end  of  tiie  first  month  after  birth. 

Cause.  .Ml  who  hav  ■  made  careful  bacteriological  examinations  of 
the  secretion  in  cases  of  oi)hthalmia  neonatorum  -re  convinced  that 
the  cases  that  occur  before  the  end  of  the  third  day  after  birth  are 
due  :ilmost  without  excejition  to  the  presence  of  the  gonococcus. 
Cases  that  occur  later  may  be  due  to  the  gonococcus,  but  not  a  few- 
is 


THE  EYE. 

..rr  ,luo  to  tlu-  Koch-Weeks  haciHus.tlK-  l.tieinnococous.  the    Klehs- 
Ln..iHcr  Imcillus,  or  some  other  form  of  i-iith.-penic  pern,  or  irritating 

'"Metiolof  Infection.     We  are  m^  .<  luen.e.l  witli  the  .-lass  ..f  eases 
that  ..ceur  h.  the  first  few  .lays  after  birth,  an.l  nee.l  not  n.ent.on  the 
,a.„les  of  infeeti....  that  pro.kiee  .'onjunetivitis  later  than  this  ,K>no.l. 
In  almost  all  of  the  eases  infeetion  undouhte.lly  oeeurs  .hirinp  th( 
passage  of  the  ehil.l  along  the  genital  tract  of  the  mother  a.ul  J.ist  at 
h.'  thiie  of  (leliverv,  due  to  the  entrance  of  th.>  vaginal  secretion 
i„t„  the  conjunctival  sacs.     In  rare  cases  infection  takes  place  ante- 
r  ,1.    the  disease  being  well  a.lvancd  at  birth.     In  some  cases 
is    u  iio    of      e  cornea  has  already  taken  place.     Infection  !.>•  the 
uri's  han.'  loan  wa.shes,  and  soiled  linen  may  occur  after  Inrth. 

Descriptic  the  Disease.     A  slight  re.ln...ss  of  the   conjunctiva  is 

usually  ob.s..n-e.l  on  the  second  day,  an.l  .m  the  thinl  morimig  the 
li,ls  are  glued  together  by  a  small  .|uant,ty  ot  mucopus.    The  1  ds 
iK^gin  to  swell,  and  soon  the  upper  lids  lK>come  •'"">•""•»'*  y^''''^: 
ened,  .luskv  re.l.  and  very  tense.     They  overlap    lie  lo^--    '<    .  a 
in  the  earlVpart  of  the  acut.-  stage  sen.nuic<.pus  tinge.  1..  ten  xu 
11,.  pignu-nt  ..ozes  from  the  palpebral  fissure.     Tlu-  height  ..f  the 
acute  stage  is  reache.l  on  the  thinl  ..r  fourth  .lay  atfr  the  cminence- 
ne      of  ?he  .lisease.     Soon  the  character  ..f  the  .lischarge  changes 
t.,  a  creamv  pus,  large  quantities  of  which  escap:  the  co.ijunctna 
be,'..nies   gfeatlv  thickene.1,   the    palpebral    portu.n   suffering   n...  e 
tlrui  the  ocular.    The  acute  stage  gra.lually  pa.sses  into  a  subacute 
con.lition,  in  wliich  the  swelling  of  the  lids  subsi.les:  the  conjunctn-a 
although  rough,  becomes  pale  an.l  at..n.c,  the  .lischarge  a   ittle  less 
creamy  an.l  less  in  c,uantity.   This  condition  may  continue^  fnr  weeks 

'"^aiverity!    The  above  is  a  description  of  a  ease  of  mediur    seventy. 
Ca.ses  of  much  greater  severity  are  occasionally  observe-  "t 

is  more  rapid,  the  secretion  serosangumolent  at  hrsf  ..  ^  -i- 

brane  forms  on  the  palpebral  conjunctiva,  and  the  diseu.  -oles 

.liphtheria  of  the  conjunctiva.     A  numlier  of  cases  are  .  ..reuieU 
mihl:  the  onset  verv  slow,  an.l  recovery  rapid. 

Diagnosis.  The  age  of  the  patient  determines  the  term  to  be  applied 
to  the  disease;  but  it  is  not  always  easy  to  determine  the  variety  of 
inflammation  without  a  microscopical  examination  of  the  secretion. 
Thi-  will  serve  to  relegate  each  ease  to  its  projier  category. 

CompUcations.  Corneal  ulcer,  .lestniction  of  the  cornea,  pan- 
ophthalmitis,  iritis,   and   gonorrheal   rheumatism   may  complicate 

"Ctil^^'lfKaXen  fully  demonstrate.!  that  efficient  meas- 
ures taken  to  prevent  the  .levelopment  of  ophthalmia  neonatorum 
serve  to  reduce  the  percentage  from  between  9  and  10  F'"  cent,  to 

0  5  per  cent,  or  less.  ,        ,      ?j  u 

■  Just  before  and  during  labor  the  genitals  of  the  inother  should  bi- 
rendered  as  aseptic  as  possible  by  the  use  of  suitable  douches  and 


of 


n- 
,te 


ini 
to 


bi- 
nd 


PLATE   VIII, 

I  Hi     1 


Diphihot  la    Baiilliis 


'«*:s    v^ 


^         <;        V 


•Si   -      --^  « 


Dipluhi  rjn   Bncilliis. 


'I  IK 
I 


i 


ii 


PLA'l  K    IX 


Sliiphvlc"  i>i<i.l>    Pvo()>'iifs   Auicl-l'- 


Si  ri'|>ti  >i<  n<Hi--    Pyoqciu'S. 


DISEASES  OF  royjrscriy.i,  initsEA.   i  v/'  sci  i:i:\ 


wiislics.     Wry  shortly  iiftcr  tlw  hirtli  "f 
frcrd  from  sccnMioii  tiy  wipiiij:  willi  :lll^■■l 


,h«'  cbild  ilir  liils  slioilM  1«' 
,1  nt  cottMii:  ilic  fvo  >lioulil 


till'  ;icut»' 
-.  <-ii.  than 
iKnisly 
I  for  two 
.lild  caM's, 


1  liru  mini  ^<  '■>•■■•■•■■.■•■  -I  •■•'-  .       ;  i 

llicii  lie  hathcil  wit'  i  weak  solution  ot  mircuri  ciilorKlf,  l)oric  tu  -I. 
,,r  i.oni.al  salhic  solution:  thr  li.ls  part.'.!,  mi..!  mUc  .Iroi.  -.f  a  2  i«t 
.•.■ut  solution  of  nitrate  of  silver  iiistill.Ml  from  the  en.l  oi  a  class 
ro.1  If  more  than  one  drop  enter-  the  eye,  the  solution  sliouid 
Ix'  neutralized  hv  washin):  with  normal  sali.i.'  solution.  It  th.;  ivae- 
tion  is  eonsideral.le,  .-old  al.l.li<'ati..ns  should  !«■  made  to  the  hds  lor 
an  hour  after  the  applieation.  This  is  th<«  method  of  ('rede  mtro- 
dured  l.v  him  at  the  Lyi-e  in  Hospital  in  I.eipzip  in  ISSO.  Memine 
ehloiiile!  1  :  2(KH),  may  h     uhstduted  for  the  silver. 

Treatment,     ("old    aj.p      •uons  are   most    desirable   m 
stap'.     Thev  should   1       niade    more   e.  Mtimiously   ••' 
in  mild  ea.se"  ,  but  need  not  in  any  ease  he  employed 
•,-•  in  adults.     In  some  ea.-es  applieations  should  i 
"hours  at  a  time,  with  inter\als  of  one  or  tw<.  hours. 
.,ne  hour  three  tim.s  daily  will  sutliee.     Irripitioii   .m»1i  l^.'ie  aeid 
Uiti-n  should  he  .lone  fre.|u.ntly.  every  hall-hour  in  an  onlmary 
..:.;,.,  to  keep  the  eve  free  from  secretion.     Fotas^ium  permanganate 
-olution,  1:  2(KH),  or  m.-irurie  chloride.  1:  V,m)  may  he  substituted 
from  tune  to  time  for  the  borie  .■id  sohuion.     As  7"'  l';";'."^:^;:; 
brawn V  condition  of  the  lid  has  ,  ,itly  si.bsi.le.l.  applications  oi  sih .  r 
„i„,,t.    0..^  to  1  l.er  .rnt..  should  be  made  once  m  twenty-four  hou  s^ 
.  otai-ol,  20  IK.r  cut.,  may  be  substitut.-d  for  t^je  s.lv,.r:  but  the 
.01     p.     ilse  of  protarpol  Should  be  avoided.     The  a,;plwat ions  o 
The  nitnite  ot  silver  ano  the  b.thiiiK  with  bone  acid  solution  should  be 
eontinued  until  the  secretion  ceases.  wi    1,   ;„  „nd  Ihnt  of 

Pathology.  Tli<-  pathology  of  pee.orrhn-al  ophthalmia  and  t  at  ot 
oilthalnJ!  neonatlmim  are  very  similar.  The  t.ssiie  <^  -  j  ^  - 
i,  Hltrated  by  serum,  plastic  eM  '•.tion.  and  ^"'a  l*^'' "-  J^^^^Z. 
tion  is  undoubtclly  excite.l  b.        .maines  prn-lucd  «    "^       '^I 

ment  of  the  conococcr-  in  tli.      'ix'rfi.'ial  layer  of  the  ..njuiHtna 

iS";;i.il;:f'^he  conju..ctiva «...  nds  '-•••-;'-'-^';;  -;::;!;;;;?;; ; 

.,,,,1  a  certain  decree       venous  stasis  is  produced.      1  he      "J""",  j 

chronic  cases,  in  which  ne.lular  masses  remain  ir  the  conjunctna 
,1  tie  p,■l,.illar^•  body  remains  jK-rmaneiitly  hypertropu     . 


of  conjunct 
notably  the 


\  the  staphvlococcus,  which  mo.hfy  the 
acillus,  often  increasing  the  seventy  of 


,.ffrct  of  tlie  K!t-bs-L'>effl 

the  disease.     (Plate?  VIII.  and  IX.) 


•i7(i 


THE  EYE. 


Description.  The  jxTioil  (if  iiiciiliatioii  is  I'rotii  twelve  t"  tliirty-six 
hours.  Intense  swellinjr  of  tlie  upper  li<l,  wliieli  lieconies  brawny, 
dusky  red.  and  very  tense,  develops  rajndly.  the  tinn  condition 
heinjx  due  to  a  jjlastie  exudation  into  the  tissue  of  the  lids,  venous 
stasis  from  jircssure  imparl inft  the  eyanotie  ap])e:iranee.  The  seere- 
tioii  from  the  lids  is  scant  at  hrst,  heinjt  compo.sed  of  laerynial  fluid, 
serum,  and  hlood.  Very  little  pus  or  mucus  is  seen  earlier  than  the 
second  day  after  the  onset.  Craduaily  the  secretion  becomes  flaky 
and  mucop\irulent,  containing  blood  and  shreds  of  hbrin,  which  char- 
.•icter  it  assumes  in  the  subacute  stage,  becoming  purulent  at  the  end 
of  this  stage.  The  tense  .swelling  of  the  lids  lasts  from  two  to  five 
days,  after  which  the  lids  become  flai)by,  but  remain  thickened  for 
oiii'  to  three  weeks.  l{estorali  to  tiie  normal  condition  progresses 
verv  slowly. 

Pseudomembrane.  At  the  end  of  twenty-four  hours  after  tlie 
congestion  of  the  conjunctiva  begins  the  paljiebral  conjunctiva  is 
covered  with  a  thin  i)seudonieml)raiie,  which  rapidly  increa.ses  in 
thickness  and  extends  to  the  ocular  conjimctiva.  The  i)seudomein- 
brane  persists  until  the  subacute  stage  is  well  est.-iblished.  It  rarely 
attains  the  thickness  of  more  than  one  millimetre,  and  when  detached 
it  often  presents  a  perfect  cast  of  the  fornix. 

Severity.  Diphtheritic  conjimctivitis  may  exist  without  the  intense 
thickening  of  th(>  lids  that  has  been  described,  but  a  i)seudomeinbrane 
forms  and  is  persistent.  The  pseudomembrane  may  be  scarcely 
notice;d)le  and  the  affection  extremely  mild.  Some  cases  may  be 
termed  ■fulminating."  >o  rapid  is  the  onset,  so  intense  the  swelling, 
and  so  disastrous  the  result  to  the  cornea. 

Pathology.  ThedeveloiHuent  of  the  micro-organism  in  the  conjunc- 
tiva ajipears  to  cause  destruction  of  the  superficial  epithelial  cells,  and 
so  to  affect  the  bloodvessels  that  a  portion  of  the  jilasma  of  th.e  blood 
escapes  into  the  tissue  of  the  conjunctiva  and  lids,  there  coagulating, 
;ind  producing  the  tense,  firm  thickening.  The  ]ilasma  of  the  blood 
also  escapes  onto  t!ie  conjimctival  surl:ice,  there  coagulatimr  and  forin- 
inir  the  p~eudomenibrane.  In  mild  cases  where  the  lid  <loes  not 
become  hard  coagulation  of  i>lastic  lymph  in  the  tissues  of  the  lids 
does  not  occur.  While  the  formation  of  pseudoniembranr  i-^  ii'it 
pathognomonic  of  diphtheria,  it  almost  always  occurs  in  iliphth'  la 
of  the  <Minjunetiva.  The  greater  mnnber  of  cases  known  -  crou])ous 
conjunctivitis  are  in  reality  diiihtheria:  they  bear  the  siuiu^  relati(in 
to  the  more  severe  forms  that  membranous  crou|.  does  to  diphtheria 
of  the  nose  ;md  pharynx. 

Diagnosis.  When  di|)htheria  of  the  conjunctiva  is  associated  with 
diphtheria  of  the  nose  or  pharynx,  the  diagnosis  is  easily  made.  How- 
ever, jirimarv  diphtheria  of  the  conjunctiva  may  occur,  and  the  diag- 
nosis is  then  not  so  readily  made.  The  condition  may  be  confounded 
with  ironorrhd'a  of  lh(>  conjunctiva,  or  even  with  nmcopurulent  con- 
junctivitis in  rare  ca.ses.  liacteriological  examination  will  serve  to 
establish  the  diagnosis. 


DISEASES  OF  COXfrSCriVA,  CUItM:A,  AXD  .SCLERA. 


Zi  I 


Treatment.  As  soon  as  it  is  i<no\vii  tiiat  diphtlioria  of  tlic  coii- 
jiuictiva  exists,  tlic  i>aticiit  should  he  given  a  liypoderniic  injection 
of  l.")(M)  to  l'(HK)  units  of  (liplitheria  antitoxin,  inai<infi  the  injections 
either  in  the  loose  tissue  in  the  sides  of  the  abdomen  or  in  the  loose 
tissues  of  the  hack.  If  the  pseudoineinlirane  does  not  hogin  to  soften 
at  the  end  of  twenty-four  hours,  a  second  injection  of  1500  to  2'M) 
units  of  the  antitoxin  may  he  fiiven. 

If  the  circulation  of  the  lid  is  not  too  nuich  interfered  with  tiy  the 
swellinjr,  cold  applications  should  he  made,  as  in  fjonorrhceal  conjunc- 
tivitis, and  as  soon  as  the  pseudomemhrane  is  removed  nitrate  of 
silver  may  he  ap|)licd  once  daily  in  ihe  streiiftth  of  0.5  to  1  i«'t|  cent. 
riie  eye  should  he  cleansed  every  hour  with  a  saturated  solution  ()f 
hoiic  iicid,  a  weak  solution  of  ))otassium  jiermanfranate,  salicylic  acid, 
or  mercuric  chloride.  Peroxide  of  hydrogen  is  of  service  in  the  re- 
moval of  the  membrane,  if  for  any  reason  this  is  thoiiglit  advisable, 
it  does  no  good  to  remove  the  pseudomemhrane  forcibly,  unless  for 
the  purpose  of  applying  remedies  directly  to  the  surface  of  the  con- 
junctiva (even  then"  it  is  of  doubtful  expediency),  as  the  membrane 
ri'forms,  and  the  traumatism  occasioned  opens  up  new  avemies  for 
the  entrance  of  the  micro-organisms. 

If  sloughing  of  portions  of  the  conjunctiva  occur,  the  endeavor 
must  be  made  to  prevent  adhesions  Ix'fween  op])osing  surfaces. 

CompUcations.  I'lcer  of  the  cornea,  total  destruction  of  the  cor- 
nea, i)ani'i)htlialniitis.  and  sloughing  of  parts  of  the  conjunctiva  and 
lids  are  the  complications  met  with. 

Membranous  Conjunctivitis.  This  is  a  class  of  cases  in  which  at 
the  beginning  the  lids  are  only  slightly  swollen  and  red;  there  are 
excessive  l.'icrymation  and  some  nuicopumlent  .secretion:  the  con- 
junctiva is  slightlv  thickened.  On  everting  the  upper  lid,  a  pseudo- 
membrane  is  fomid  which  extends  into  the  fornix.  It  is  usually  not 
very  thick.  It  mav  be  removed  without  much  force,  and  on  removal 
discloses  a  nnicous  meml>rane  that  bleeds  only  very  slightly,  but  is 
not  deepiv  injected,  nor  does  it  exhibit  the  characteristics  of  active 
inllammation.  The  p<eudomembrane  promptly  reforms  after  re- 
moval, and  may  continue  to  reform  indefinitely,  .\lthough  commonly 
affecting  both  eves,  it  is  sometimes  confined  to  one  eye.  The  indi- 
vidual sutTers  hilt  little  pain:  there  is  but  slight  photophobia.  In 
UKxuv  of  the  cases  recovery  occurs  in  from  three  to  five  weeks,  but  in 
somr  cases  the  pseudomeuibrane  persists  for  as  many  numths  m  sj.ite 
of  treatment. 

Cause.  In  a  number  of  cases  the  Klebs-Loeffler  bacillus  is  lound. 
These  cases  res]ionil  readilv  to  treatment.  In  a  few  cases  the  streji- 
lococcus  is  found,  and  the'affection  is  associated  with  dacryocystitis. 
(  H'ciMring  as  ;m  accompaniment  of  measles,  scarlet  fever,  and  iiiHuenza 
(dc  Schweinitz),  the  prognosis  is  not  only  imfavo-.able  as  to  vision,  but 
unlavorable  to  life.  Membranous  conjunclivitis  may  accompany 
iiiiiictign  ;M(inixi.  The  sl;ip!iy!orncpus  aiid  'he  p.neumocnccus  have 
ai>o  been  found  in  the  secretion  in  the.se  ca.ses. 


•'7.S 


TIIK  EYE. 


Diagnosis.  Wlioii  pscMiiloincinlinmc  occurs  in  tin-  conjunctiva,  it  is 
not  always  possible  to  <|ctiTniinc  tlic  cause.  The  hacteriolojtical 
examination  will  suffice  in  a  number  of  cases,  ami  tiie  history  of  the 
case  will  (letermini'  others. 

Treatment.  Meinliranous  conjunctivitis  due  to  di.seases  which  have 
been  discus.sed,  viz.:  diphtheria,  gonorrlKea,  mucoimrulent  conjunc- 
tivitis, etc.,  also  acconi|)anyinfr  the  eru])tive  fevers,  and  that  due  to 
Imrns  and  injurv,  (lisai)pea  s  when  the  local  or  constitutional  disea.'^e 
is  recovi-red  from,  or  when  the  effect  of  the  b-irn  or  injury  has  [tassed 

awav. 

Ill  some  of  the  indeterminate  forms,  which  are  rare,  treatniont 
seems  to  have  littl(>  influence.  However,  cleansing  solutions,  such 
as  saturated  solution  of  boric  acid,  salicylic  aci.l  in  saturated  aciueous 
solution,  mercuric  chloride  (1  :  (KM)  to  1  :  lo,(K)0),  pota.ssiuni  pennan- 
jianate  (1  :  "JOtMl).  and  hydrogen  j)eroxide,  may  be  employed  to  kee]) 
the  conjunctiva  free  from  secretion.  Cold  ai)plications  in  the  more 
acute  stage  may  be  u.sed  intermittently  with  benefit. 

Neighboring  disease  proce.s.ses.  as  dacryocystitis,  abscess  of  the  lids, 
eczema,  etc.,  should  be  properly  treated,  and  the  general  system 
should  be  put  in  a  healthy  condition, 

Xerosis  epithelialis  (xerosia  triangularis;   xerosis  infantilis)  is 
characterized  by  a  lustreless,  grayisli-white,  foamy,  greasy  deposit 
on.tiie  conjunctiva,  wtii.  1    i<  not  moistened  by  the  tears  and  is  very 
persistent.      The  disease  aitacks  all  individuals  except  the  very  old. 
Cause.     .\  six'cific  bacillus  in   this  disease  was  described    first  by 
Cohniatti,'   and   carefully  studied   by  Leber'  three  years  later,  and 
termed  by  him  the  diplol)acillus  of  xerosis.     The  bacillus  is  short, 
and  often  apjiears  in  pairs  joined  end  to  end.     One  of  the  members 
is  often  broader  at  one  end  than   the  other  fclubbed);    the  cheesy 
secretion  cont;iins  multitudes  of  the  ba"illi  almost  in  pure  culture. 
Description  and  Symptoms.     .\  recejitive   conilition   of   the  system 
a|ipears  to  be  neces.sary  to  permit  the  development  of  the  disease. 
When  infants  are  attacked,  it  is  always  the  marasmic   infant:   the 
robust  never  contract  the  disease.     Children  and  adults  always  give 
a   historv  of  malnutrition,  most  often  because  of  scanty  food,  with 
scarcity    (if    fresh  vegetal)les  and  fresh  meats— those  who  are  con- 
fined ill  barracks,  ])risons,  or  who  work  reni'  •"  from  a  base  of  plen- 
tiful food  supplies,  as  in  mines,  or  railroads         on  plantations.     In 
infants  the  lids  become  slightly  swollen,  and  a  thin  flaky  secretion 
escapes:   the  infant  is  but  little  disturbcl  by  the  condition  present. 
On    everting   the    lids,  the  conjunctiva  in  the   fornices   is  more  or 
less    covered    bv   thi'  characteristic    secretion.     The   secretion    may 
extend    over    the    whole   conjunctiva    and    cornea.     Koth   eyes  are 
affected.     In  chililren  more  tlian  one  year  of  age  the  secretion  may 
show  itself  first  either  on  the  palpebral  or  ocular  conjunctiva:    in 
adults  ahnwst  a!w:iys  on  t!i'-  ■-■iiliir  cMnjunctiva,  the  patch  occupy- 

1  Ci)u«.  iMTl(Mii.iue  inter.  'Ic  (>i>liili,  Atuiuxi's.  Mtiy  'JH,  lK,s(). 
■  i.mefi'n  Arch.,  Itn;!,  llmul  xxU.,  iv,.  S.  iH. 


i)isi:A^£ii  OF  coyjiwvrnA,  cohska,  asd  sclera.     27!t 

iiijr  the   ( juiictiva    in    tlic   liorizoiital   nii-riiliaii   nii    Ixdh  sides  of 

thr  (MinicM.  iisimllv  triaufiular  in  sliapc,  the  i)as<'  ix-iiifi  next  to  the 
iiiaririii  "f  tlic  coriica.  Tiic  sensation  to  tlie  adult  is  that  of  a(lry 
sui)stancc  on  tiic  conjunctiva.  One  i)ati(Mit  sjjokc  of  it  as  liis  "dry 
patcii.  "  Slight  irritation  of  the  conjunctiva  is  notic('ai)I('  about 
the  iiiarttin  of  tl:e  patcli.  In  ciiil(h-en  ami  in  adults  a  condition  of 
henicraloi)ia  obtains.  The  disease  is  not  a  local  one.  In  a  number 
iif  autopsies  that  have  been  made,  the  bacillus  was  found  ni  the 
parenchvma  of  the  liver,  spleen,  kidneys,  and  pimcreas. 

duration.  In  infants  this  disease  la.sts  until  death.  In  adults  the 
secretion  jiersists  for  n.onths,  and  in  many  cases  for  years. 

CompUcations.  In  infants  the  cornea  is  <le])rived  of  mitrition  and 
.sloufrhs.  All  infants  under  one  year of  age  (He.  In  children  and 
adults  the  cornea  may  become  involved,  the  patches  of  exudation 
jiraduallv  advancing  from  the  margin  of  the  cornea,  or  ai)pearinp  m 
Muail  islets  slowlv  encroaching  on  the  pupillary  area.  Years  may 
pass  befon>  the  pupillarv  area  is  completely  covered.  Fortunately, 
in  the  greater  number  of  adults  and  cliildren  the  cornea  iloes  not 
iM'conie  involved,  jirovided  suitable  treatment  is  instituted. 

Diagnosis.  The  condition  camiot  be  mistaken  for  anythmg  else 
alter  the  clinical  picture  is  recognized  by  the  surgeon. 

Pathology.  Aside  from  the  presence  of  the  bacilli,  the  superhcial 
epithelial  lavers  undergo  fattv  degeneration  and  death,  and  are-ca.st 
otf  The  oi'l  globules  in  the  cells  are  very  minute.  The  secretion 
consists  of  these  degenerated  ei)ithelial  cells,  some  leucocytes,  and 
the  bacilli.  On  examining  the  conjunctival  tissue  little  change  is 
found  ex''ei)t  a  .slight  increase  in  size  of  the  blood ve.s.sels,  some  small- 
c,  11   infiltration,   and   the   thickened   and  superficially  degenerated 

epithelial  laver.  ,1,1  . 

Treatment.  In  infants  it  is  of  no  avail.  In  adults  the  local  treat- 
ment consists  in  the  use  of  antiseirtie  lotions  and  washes,  and  of 
ointments,  such  as  bicliloride  vaseline  (1  :  50(K)),  the  u.se  of  powders 
-calomel,  iodoform,  aristol-the  powders  t  )  be  du.sted  on  theaffectec 
area  after  the  secretion  has  been  gently  wiped  off.  I'nless  the  local 
treatment  is  supplemented  bv  a  nutritious  and  varied  diet,  a  cure 
cannot  be  exjx'cted.  Suitable  tonic  remedies  should  supplement  the 
diet.  .  X        ^   •        I 

Phlyctenular  conjunctivitis  (conjunctivitis  eczematosa)  is  ciiar- 
acterized  bv  the  ai)pearance  on  ihe  'hulbar  conjunctiva  of  one  or 
more  small  "nodular  elevations,  which  are  situated  at  the  ajM'X  01 
a  triangular  leash  of  vessels,  the  base  of  the  leash  being  directed 
toward  the  fornix  coiijunctiv;r. 

Cause.  The  writer  has  feU  justified  in  including  this  affection 
among  those  that  are  cause.l  by  a  specific  micio-orgamsm,  because 
of  the  res,>arches  of  others  as  w.-ll  as  of  himself.  If  an  mibroken 
lihlvctenule  be  carefullv  rendered  asei)tic  externally  and  the  con- 
tents of  tile  |,hlvctenule  conveved  to  a  tube  of  nuf>-tit  agar,  a 
culture  of  tlie  stai)hvlococcus  will  invarial)ly  be  obtamed     Ihe  same 


280 


Tin:  EYE. 


*  I 


1 


^iii 


i.  tn...  of  the  n...U.l.'  "f  <-<-^nim.  Sin.ilur  n..,lulos  may  ho  im.dun'a 
hv  i.itn«lucinfi  th.'  stai.''yI..c.KTi  hcncatli  the  .-imh.-liuni  m  su.tahl.' 
sul.iccts.  Pustular  l.l.'i'I'aritis  inarjiinalis  an-l  n...ist  <><-zrMna  are  iv- 
nu.-ntlv  a.Tu,ni.a..i..l  l-v  plilyclenular  c.njunct.vit.s  ..r  k.-ratitis;  th.-> 
an-  und-uhtcUv  s.iuroos  ..f  inlV.-tion.  Phlyctenular  '•"•"J""*:^';'^^  '^ 
,n..st  frciuont  in  ohihlron  <.f  th.-  poorer  classes  who  have  n.hen  • 
taints  or  are  tubercular,  or  who  suflV-r  fron.  n.alnutr.tu.n  aee.mM.a.  e.l 
I.v  Ivn.pluul.-nitis,  l.y  moist  eczema  ..n  son>e  P'^^. "f  ?•"■«"'>,•.  f!'': 
j.irlv  oil  the  hea.l.  face,  and  ears;  eczematous  rhmitis,etc.    (1  ig.  1.5.>.) 


Fiv..  1S5. 


I'hlyctennlur  conjiinctlvittB  in  a  scroliilous  subject.    (Dalrympi.e.) 


V.lults  are  not  exen.pt.  hut  they  are  rarely  attacked.  Occas.onallN 
:  parentlv  robust  individual  is  affecte.l.  but  n.  tlu^se  cases  bl.-phar- 
i  iV  anrinalis  or  a  ,>atch  of  moist  .■czenu.  is  pn;s...t  or  has  pre,.eded 
,.  ;,  H.k  of  phlvctenula.  Acute  c.njunct.v.t.s.  the  exanthen.at:  , 
,„,l  ,le,,ilitatinfi  illness  of  any  kind  predispose  to  eczematous  con- 

^"DeSion  and  Course.    In  the  early  stages  small  tnjnslucent  nodule, 
ai.p  ar     t    the    limbus  conjunctiva-  or  on  the   bulbar  conjunctiva 
;   •!:   ;.n.,     The  bloodvessels  of  the  conjunctiva  ra.lmtn^  f rom  1 1 
,„„,„,,.  ,„,,,„„,   i,,i,.,.ted.     The   nodules   n.av  be    smgle  <"■  "■"    ''o 
S.on  the  apex  of   the  nodule  softens  and  ''.sappears.  a  d    Icon^ 
Wn\<  of  the  vesicle  take  on  a  yellowish  api-earance.     The  softemnR 


■i..  a-  .mi ..  i^aiHi  i^WL^iJ..- 


DIHEASJCS  OF  COyjUyCTIV.l,  COliyEA,  AMJ  SVLEUA.       2H1 

I >n ijrrcssos  until  th"  ihmIuIc  Iims  iciicIkmI  tin  level  (if  tli'.-  conjiHictivii, 
wiicii  the  ul'-cr  hccdii  cs  clean:  ei)itlieliiini  is  developed  on  its  surface, 
ami  recovery  occurs  without  leaving  a  scar.  l{ecurrences  are  the 
rule.  Tii(>  process  from  the  first  stajje,  the  stafje  of  efflorescence 
iFuclis),  to  coinjilete  recovery  retjuires  eipht  to  fourteen  days. 

When  hut  one  or  two  nodule;^  a  .■  present,  the  redness  of  the  con- 
junctiva is  hut  partial,  and  is  confineil  to  the  vicinity  of  the  nodule. 
'Hiere  is  liut  slijiht  incre  -^e  in  lacryniation  and  little  irritation;  no 
photojihohia.  When  niaii>  nodules  exist,  the  rediies-'  may  extend  to 
the  ])alpei)ral  conjmictiva,  the  lacryniation  and  secretion  may  be 
nuich  increased,  and  .some  ]ihotoi)h()l)ia  may  be  experienced. 

Fig.  13fi. 


I'hlyotenular  conjunctlvUis.    (Dalkymple.) 

Diagnosis,  riilvcteinilar  conjunct ivitis  may  be  confounded  with 
herpes  of  the  coi'ijui.ctivii.  i)iiiguecula.  lymphanpectasis,  and  vernal 
catar.li,  but  the  hWovy  I'f  the  ca  -e  will  serve  to  make  the  difTerential 
diiifrnosis. 

Pathology.  The  elevation  or  nodule  is  composed  of  an  accumu- 
lation of  small  cells  restinj;  on  the  basement  membrane  and  causin;, 
an  elevation  of  the  epithelium.  The  bloodvessel  +he  base  of  th( 
nodules  are  eiifrorRed  and  enlarged,  and  there  i  cant  small-cell 

infil.ration  in  the  surroimdins  tissues. 

Treatment  should  be  local  and  constitutional. 

I.(i(  Ai..  A  cleansing  aseptic  wjish  should  be  used  to  bathe  the  eye 
three  or  fotw  times  dailv.  An  ointment  of  the  yellow  oxide  of  mercury 
1 1  per  cent.)  should  be" put.  into  the  eye  twice  daily.  After  the  nodule 
has  been  coiiverteil  into  an  ulcer,  calomel  may  be  dusted  over  the 
afiected  area  once  dailv,  if  the  patient  is  not  taking  io.linc. 


2H2 


Ti/A'  EYE. 


Intkunai..     Hiiitahlf  tonic  rciii(>( 


lies  sliuiild  l)c  jlivcn.     Small  uihI 


f 


itly  rci)i':it<'il  (loser 


f  caloiiicl  (fir. 


.'    to  ,i„.  tlircc  times 


lailv) 


:;rri;':7m^rS;:-^^^^^ 

^"^iel^XS'oi  E^iunctiva  may  '^;.pH-ry  or  .-conaary: 

■"i;:";;;;:X'i;:U';"::f^ho  conjm.tiva.  whi.;h  is  t..  n..^. 

•K-ut  •  £  the  tuheicle  bacilli  ontrr  the  conjun  -val  tissue  through 
'  uml  t  e  conjunctiva,  sonu-tin.es  due  to  o,K.rat>ve  procedure 
X^!^n^  to  Valuile,  tubercle  bacilli  canm.t  penetrate  the  mtact 
^'"cli'i^n^ptcs.  Withina  .eekorten,l.^^^ftc.  tl.en 
trance  of  the  bacilli  the  con  uiict.va  m  the  vicm  ty  of  the  plac.  ot 
n  ;;:;.^  l'con.es  injecte.1,  and  numerous  ^-^^^^^'^^^ 
tub.Tcles  resembling  trachoma  granules,  appear.  This  nui\  "C  ."r  '  " 
ouaro     palpebral    conjunctiva.     The    li.ls   become   shgh 

e  •  n  a  verv  protracte.l  cours,s  an.l  .nay  mvolve  the.ornea 
I;:i' n.s>;it  in  loss  ot  Vision.  Son.e  rise  of  temperature  accompan.es 
the  earlv  stages  of  this  for...  of  tubercular  ..ifectio.i. 

Dainosis  This  for...  of  tuberculosis  ...ay  be  ....stake.,  for  acute 
trSu  and  for  I'arh.aud's  co,.ju..ctivitis.  It.<  '"<»"»;»>=^V<'  >;  " 
, ;    '  .        the  ...arked  i..volv.>...ent  of  the  ly...phat,cs  o,.  the  aff..cted 

,  . \v  e  suffici.-t  to  exchule  trachonia.  Kxannnat.un  of  a 
sKti.;;.  .'f  theS.le  will  disclose  the  bacilli,  .lifTere..t.at...g  .t  fro.,. 

'''Tl;^::^ni;"^A5de  fro...  earlv  excision  of  the  affecte.l  tissue  little 

,  J  beTne.     Appropriate  constit..ti<...al  .treat...e,.t  a..d  attc.t.o.. 

to  the  <v..ilitoms  as  thev  arise  are  all  that  .s  pnss.ble 

T 1,.  i     Irv  lorn,  oj  tuberculosis  is  ch.-o..ic  fron.  the  onset.     It  .s 

th.    1  se       for..-.Vrly  kn.nv..  as  lup,.s  vulgaris,  a..d  .s  "'-t  freq.uj.. 
e  to  exte.isi,..,  fro...  the  ..asal  ...ueous  ...e...brane  by  ^^a^   of  th( 
crv  .  al,  a'  ages.     It  is  characterise.  1  by  the  appea.-a.ue  of  .rregu  ar 

Sr;,lcers  .m  the  palpebral  ..ro.a.lar  co..junct.va  <  mon- fre-ju^^ 

n    the  .v.lnebral  co.ijunctiva).  with  raised  edges  an.l  g.-a>  .sh.  u...  ^. .. 

H  ,  r     .   'te       re  enti,  g  gra.mlation  tiss.ie.    The  s.jrroun.  ...R  conju..c- 

f  vai       u     i"htlv  i"ieei-J.  the  lids  are  slightly  th.cke..ed,  a.ul  a 

.■  11  an    ,..t;i  rather  thi...  flaky  ...ucopus  is  p.vsent.  there  ,s  l.ttle 

in   a.".     1  ;Mlist,.rba..ce  to  the  patie..t.  except  fro,.,  the  p^^^^^^^^ 

In    cus    is  slight.    The  p,'eauricular  glands  on  the  affecte.l  s..le 


DISEASES  or  COXJIWCTIVA,  COllSKA,  AXD  tiCLEllA.       -JS-'l 

arc  ciilarficil.  I)iit  tlicr*'  is  little  tcniiciicy  to  siipimratiitti.  An  alTcctcd 
aiva  iiiav  cvfiitiiaiiy  l>t'  ncciipiiMl  iti  whole  or  in  i>ait  hy  cicatricial 
tissue.  Ill  old  cases  the  conjunctival  sacs  may  he  entirely  obliterated 
hy  the  cicatricial  process,  the  cornea  may  become  involved,  anil  vision 
Ik-  lost.  Years  may  pass  with  but  little  chanpe.  but  the  tendency  is 
to  slow  and  stea<ly  progress. 

Diagnoivs.  Tuberculosis  of  this  form  may  be  mistaken  for  ei)i- 
thelioma,  or  chalazia  which  ojM'n  on  the  coi.junctival  surface.  Study 
of  a  section  of  the  tis.sue  with  the  microscope  will  suffice  to  make 
a  diapiosis. 

Pathology.  The  change  in  the  tissue  in  the  first  form  is  such  as 
is  found  in  miliary  tuberculosis.  In  the  second  form  the  margins  of 
the  ilcers  are  made  up  of  a  small-cell  infiltration  of  the  conjunctival 
ti.ssue,  with  increa.se  in  vascularity.  In  the  tissue  of  the  wall  of  the 
ulcer  the  tubercle  bacillus  is  found. 

Treatment.  Excision  of  the  diseased  parts,  thorough  scrapmg  of 
the  ba.se,  and  freciueiit  inspersion  of  iodoform  will  produce  good 
results.    The  ulcerated  areas  may  also  be  d  -^troyed  by  means  of 

the  cautery.  .  •   ,      ■        i 

Leprosy  of  the  conjunctiva  may  occur  as  a  pnmary  infection,  but 
it  is  secondare  to  leprosy  in  other  part?  <.i  the  boily  in  by  far  the 
greater  muiil)"er  of  cases"  Morrow'  cites  a  case  in  which  a  lejjrous 
tubercli'  appeared  on  the  eve  and  was  mistaken  for  .sarcoma.  Cu- 
taneous tubercles  followed.  A  sclerosed,  aiuesthetic  condition  of  the 
conjimctiva  follows  the  api)earance  of  leprous  nodules  on  the  coii- 
imictiva.  This  i)rocess  mav  invade  the  cornea.  Irregular  pterygia 
are  sometimes  produced.  Ai.  infiltration  of  the  cornea  unattended 
bv  pain  is  (.•served  in  the  later  stages  of  this  aflection.  A  mih 
i>erslstent  irritation  of  the  conjunctiva,  with  slight  redness  and 
increased  lacrvmation,  has  been  observe.l  by  the  wnter  m  cases  of 
le])rosy.  Fuciis  mentions  iritis  and  cyclitis  as  accomi)anying  leprosy 
of  theOcular  conjunctiva  and  cornea. 

Syphilis  of  the  cor.junctiva  manifests  itself  in  a  numlM>r  of  forms 
corresponding  with  the  s'age  of  the  disease.  Chancre,  papillary 
syi)hilide,  copper-colo.od  si)ots,  mucous  jnitches,  gummata,  nodular 
svphilides.  and  svphilitic  ulcer  may  ai)i)ear  in  the  conjunctiva. 
■  Chancre  appears  most  frecjuentlv  on  the  tar.-al  conjunctiva,  extend- 
ing to  the  margin  of  the  lid,  but  may  occur  on  the  retrotarsal  folds  or 
ocular  conjunctiva.  It  possesses  an  indurated  base  much  reseml)ling 
ii  piece  of  parchment.  Considerable  irritation  is  produced  by  the 
chancre  and  a  rather  jirofuse  mucoiiuruleiit  secretion  accompanies 
it  The  elevated  mass  sometimes  disappears  without  ulceration:  but 
usuallv  the  apex  of  the  chancre  softens  and  disappears,  and  a  shallow 
ulcer  with  indurated  sides  and  base  is  present.  The  ].ai)illary  syph- 
ilide  is  not  common.  It  accompanies  papillary  syiihilides  on  tne 
face  and  lids.     Cnpi)cr-col()red  spots  nre  not  of  common  occurrence. 


n  of  DlseiweB  of  the  Skin,  Dermatology,  vol.  ill.  p.  5S7 


2H4 


TUK  EYt:- 


A 


,.„,  i,.,v.-  lu..-n  ..h^orv.Ml  to  uc(....Mim..y  tli-  sanu-  (•...uUti.-ns  on  tl.(^ 

l;™::™, '",;.;':  .IS,; ;;"'■■;!, ;;:;;-t;r';;™;:  iii^ 

flu.   l.iillvir  conuin'tiva   near  tlic   liiunu!-.      iiii\   .ii>i"ai         '     .   . 

;;:lTXiiviii"r,,ivL,iK.un,i..,iyn 

"'^;^:;'  'i;  ;:*sJ;:,si'!'ri,r.,«„».  w,.,,  .una,,,,.  .^. 

curie  chlorulo  (1  ;  5(MX)  in  vasc'lni.')  may  be  plaml  m  tlu  o>o  alter 
,.Mch  cleansing.  «)r  at  least  three  times  a  day. 

/^vio  d  disease  of  the  conjnn.tiva  is  a  very  rare  aff..ct.on.     It    s 
Amyi0iaai8e»  .,„,„..,rance   of   waxv.   translucent,    polypoul 

i^;:rS   winliiv'slru.,  fron.   th.:.l.nver   forni.   In.t   n.y 
'^;ive    1  e  entire  conim.ctiva.  converting  .t  ,n to  large  f<.Ms  winch 
.n      P  .Mn-nc-,  'uu    greatlv  obstruct  vision.     The  tissue  is  alnu.st 
;E;l::r.' hi::;i^;:^ls  and  is  ^ery  fniible.     A-IuUs  onW  are  attacked. 
The  diseas(>  is  apparentlv  a  purely  local  one.  ,        ,       f  ,..„, 

Pahoogy.     The  masses  are  found  to  l,e  made  iip  largely  of  l,n- 
,J.idcd?  which  in  parts  near  the  surface  un.lerg..  a  change,  con- 
ic Ung  them  into  a  ho\nogeneous  ma.ss.  which,  in  the  greater  numlK^r 
f  ,..wn«  irivc  the  starch  reaction  to  the  iodine  test. 
SS»S        xci^on  of  the  masses  is  necessary.     Recurrences  are 
the  rT    If  thVbases  are  tn.Ued  by  superficial  cautenzat......  return 

'^c£S'iini;^Ss    (Chronic    Ophthalnua).     A    t.uH.ened. 

iu  j'.H.T'mdition  of  the  conjunctiva  sometnne.s  follows  an  acu  e  c.    - 

iunctivitis-  accomiwuies    blei>haritis    margmahs    in  <.ld  peojile  par 

ih  Id-  ends' on  partial  or  c.Muplete  closure  of   the  canahcuUe 

c'^.     If    the    puncta,  and    trophic   or  hv,K^rtrophic  rhuuU. 

Fr  .  rs  of  refraction  and  nu.scle  anomalies  serve  to  perpet   ;    >■  the 

oi  Iti  1       l'    old  people  a  flabby,  slightly  congested,  swollen  con- 

io     he  conjuictila  exists,  associated  with  enlargement  of  the 


DISEASES  OF  COSJVSCTIVA,  CORSEA,  A.W  SCLEJiA.       285 

<-aniiicl(\     These  cases  are    almost    always    accompanied  by  slight 
mucopurulent  discharge. 

Treatment  consists  in  correcting  all  conditions  tliat  staiul  m  a 
causative  relation  to  the  conjunctivitis.  Thi>  nasal  and  lacrynuU 
jiassiges  should  receive  can'ful  attention.  The  conjunctiva  itself 
should  Im' hrushed  with  a  solution  of  nitrate  of  silver  (1  to  2  j)or 
cent.)  if  secretion  is  present,  and  it  should  be  kept  free  from  secre- 
tion l)v  bathing  with  a  simple  cleansing  solution. 

Egyptian  Ophthalmia.  This  term  has  Ix-cn  ustvl  indiscriminately 
t(.  de.'^crilK'  all  forms  of  ophthalmia  that  affect  large  mnnbers  of 
individuals,  esjM'cially  the  forms  that  apjx'ar  ei)idcmically.  The 
term  has  been  made  to  include  acute  contagious  conjunctivitis,  gonor- 
rlucal  conjunctivitis,  and  trachoma.  The  la.st -named  disease  has  been 
most  generallv  indicated  when  the  term  was  employed. 

Atrophy  of  the  Conjunctiva  (Xerophthahnia).  This  comhtion, 
not  accompanied  by  the  presence  of  the  xerous  bacillus,  occurs  in  a 
number  of  forms: 

((()  Cicatricial,  as  from  trachoma:  extensive  burns  of  the  conjunc- 
tiva, as  from  lime  or  from  li(|uid  ammonia.  In  cicatricial  xerosis  the 
duct's  of  the  lacrvmal  glands  are  obliterated  and  the  gland  itself 
atrophies.  In  addition,  the  character  of  the  conjunctiva  is  entirely 
changed,  so  that  no  mucus  or  other  lubricating  fluid  is  secreted  from 
it.     The  cornea  becomes  opatiue,  and  vision  is  reduced  to  perception 

of  light.  .  .  , 

ih)  XiTosis  from  constant  exposure  to  the  air.  as  m  ectropium  and 
ui  lagophthalmos.  In  cases  of  this  kin.l  the  exposed  conjunctiva 
and  cornea  take  on  a  cutaneous  appearance;  the  eiMthehum  becomes 
thickeneil.  corneous,  and  drv,  a  provision  on  the  i)art  ot  nature  to 
l)rotect  the  deeper  lavers  from  desiccation.  In  this  torm  the  remedy 
lies  in  the  oi)erative  j)rocedure  necessary  for  the  restoration  of  a 
proper  protection  to  the  exjiosed  jiarts. 

Toxic  Conjunctivitis.  This  term  is  aj.plied  to  the  forms  of  con- 
iuiictival  irritations  th.at  are  caused  by  the  chemical  action  of  certain 
substances.  ( )f  these,  mav  be  mentioned  the  mydriatics,  the  myotics, 
chrvsarobin,  calomel,  the  dust  from  aniline  dies,  bites  of  insects,  cater- 
l)il!;ir  hairs,  fumes  from  formalin,  menthol  etc.,  intense  light,  as  1.....1 
the  electric  arc  light,  the  reflection  of  sunlight  from  the  snow. 

Mropinc  produces  two  forms  of  disturbance: 

ir/)  .\fter  long  use  of  a  non-sterile  solution  the  conjunctiva  becomes 
hvpera'inic  and  follicles  develop  in  the  fornix  and  tarsal  conjunctiva' 
There  is  a  scaiitv  mucopurulent  discharge.  The  picture  is  one  of 
mil. I  trachoma  iii  the  earlv  stage.  The  cause  of  this  form  of  con- 
junctivitis is  probalily  bacterial  infection,  the  bacteria  being  carried 
into  the  conjunctival  sac  with  the  solution. 

{h\  Six  to  twelve  hours  after  the  instillation  of  a  few  drops  of  a 
;-(>Kiti(>!>  of  atropine  into  the  eve  the  lids  become  swollen  and  brawny 
an<l  the  conjunctiva  injected.  "There  are  excessive  lacrymation,  a  sen- 
sation of  heat,  and  much  irritation.     Hyoscyaminc,  duboisine,  and 


•jHti 


liuiiiatropiin"  soiiK'liiiH'! 


Tin:  i:yi: 


Tliv'  •■fleet  b 


■lii' 


prtMliicr  tliis  (listiirlKiiicc  also,  hut   in  less 


,1  tnlMMliic  tn  idiosyncrasy 


iicirrcc.     1  IK' •■111  Ti  i>  ■"  IK  »• '•  ■ .      ,.■        •■  •       .1       ... 

Tlu.  treatment  of   tl,.-  f.rst  fonn  ..onsists   m  '''^<'"'''''''''"'^'     .";;       ' 
pin.,  orusii.^'  st.-rilr  solutions,  clcansni^  ,1,,.  ,.y,.  lrn,..rntK  with 
laturafil  solution  of  l.ori.-  aci.l,  an.l  usin^'  su.tal.l-  astnnp.-nts.     <  >f 
tlu-  s,.con.l  form,  in  ijiscontinuinfi  th."  use  ol  tli.-  atropnu-. 

Escrinv  solutions  son.Hin...s  .ausc  irritation  ot  tlu-  '•""J""''t>V:|. 
Vhn,snrM,u    tis.-.!  in     tin-    forn>  ot   an  ou.tnu.nt  on  t'"'  r";'       " 
psoriasis,  .nav  pro.lu.'-  intense  irritation  ot  the  eon.|un.•t.^a.  (  alo  u  1 
,lust,..l  on-  the  eonjun,.tiva  when  the  pat.ent  .s  takn.j:  an  .oil  .1.-, 
.suits  in  loeal  uleeration  an.l  n.ark..il  irr.tat.on  ot  the  eonjune  . 

Zmm-  when  api-iie-l  to  ih .njunetiva  proiluees  at  first  a  eontrac- 

,i.  he  l,loo.l v.'ssels.  hut  as  its  efTeet  wars  away  there  ,s  an  en- 

Ijoiement  of  the  vessels  whi.-h  stinn.lates  an.l  .rntates  the  e.-njune- 
tiva,  i.r...lucinj:  a  n.il.l  f..nn  ol  eonjunetivitis.  ..nVetion 

The  hiU-s  „l  insects  eonnnonly  oeeur  ..n  the  luls.  an.l  tlu-  atlut  .  n 
of  tie  eonjunotiva.  whieh  sometimes  hee..m.-s  greatly  ...lematous. 
is  due  to  extension  of  the  irritation.  ..■•.•  i    ;  i„ 

ieatment.     All  of  thes.-  f..rms  of    eonjunet.va     n-ntat.on  suhsule 
in  a  .^h.vs  if  the  eause  is  remov.l  an.l  si.uple  .•l..an]n...ss  ohserve.  . 
Mnia  So,losa     This  e..n.liti..n  is  .lue  to  the  pr.-s..nee  of  eat     - 
oill  r  hairs  on  th.'  e.mjunetiva.     The  atfeet.on  may  .'Xten.!  to    h. 
e. '    m.l  .■v.'n  to  the  iris.     The  n.,.lul.>s  are  yelL.w.sh.  senntra  s- 
"      '  l>ave   l,e,.n   .■on.,>are.l    to   tulH-rcles.      O.t   exo.sn.K     lu- 

Jllldules  an.l  .■xan.inin«  then,   un.ler    the  microscope,  Papenstach.-r 
fonn.l  the  hairs  of  eater])illai's.  •     .i .. 

Abscess  of  the  conjukctiva  is  .,f  rare  occurnmce.     It  forms  m  the 
suhconjunctival  tissue  an.l  is  alnu.st  always  traumatic. 

Treatment  should  he  that  as  ..f  ahscesses  m  ..ther  ,.arts  of  the    ... 
"chymosis  of  the  conjunctiva  is  .hu-  to  the  escape  ..f  hi...  1 
h.     ''ufirhe  c.njunctiva  fr.Mi.  whatever  cause.     It  pr... luces  hrifrht- 
r  ,!•  rk  re.l  patches,  an.l  mav  affect  all  hut  the  tarsal  con.iunc.va. 

ireaUent.     Thehl..^  ahs..rhe.l    sL.wly.     Hath.nir  w.th 

hot  soluti..ns  hastens  ahs..r].t...i..  .    •      i    u,.     „-,.llinp.   nn.l 

Chemosis.     This   is  a   c..n,.ition    charactenz.-.l   hy   swelling  an. 
thKng-f    1«>  "eular  c.njunctiva:  the  swTlln.p:  at  the  c.n.ea 
!:;;;,„,  fon..ins  a  raise.l  wall,  pn^ducing  a  shallow  circular  p.t,  of 
which  the  c.irnea  fori.is  the  Hon.. 

Pathology.  rheni..sis  is  n.oro  than  sin.ple  mlema  m  many  cases. 
iZtSv  is  this  s..  when  the  chen.osis  is  the  result  o  a  slow  u.flam- 
u.S  of  the  coniea,  iris,  ciliary  ho.ly.  an.l  cl...ro,.l.  Sec  ...ns  of 
;  ie,  oti  tis  ue  in  acule  cases  show  litth  hut  a  .listent.<,n  of  he  con- 
,e  hal  tissue  hv  s..r..us  or  sen.plastic  i.ifiltrat.on:  hut  .n  the  suh- 
ao  or  chr<.,.ic  forn.s  there  are  a  dense  infiltrat.oti  of  small  cells  ami 
""'l^erease  in  eo.u.ective-tissue  ele.uents  and  m  the  size  an.l  numher 

''imphyiini^the  conjunctiva  is  characterized  hy  puffiness  of 
thrZjmXt.  with  little  injection,  and  usually  w.th  the  appearance 


oi.sEAsKs  tir  co.\jr.\vTiy.\,      /.-.vam,  amj  scleha.     2«7 

.if  »iii;ill  ciifulMr  pale  |i(>iiits  jti>i  lifiicath  the  cniijuiirfivii,  which  iiidi- 
<"iti'  thf  iircsciict'  "I  air  in  thf  ti>.>'uc.  On  iircisinj;  tlic  cnnjutictiN-i, 
ihiic  is  a  faint  crcpitatiiiii,  and  the  circular  I'nints  chanp'  their  pusi- 
tiiiii  'l"hr  condition  is  due  to  the  entrance  of  air  info  'le  >ul)con- 
jnncliNal  li-sne  as  a  result  of  traniuatisni,  the  injury  tliat  most  fri-- 
c|Uently  ])roduc('s  it  heinn  fracture  (if  tlie  l.icryinal  Ixine.  On  lilow- 
\i\fi  tlie  nose  violently,  air  soinetinies  fin  its  way  into  the  orl)it,i! 
and  suiieonjunctival  tissues,  causinj:  them  to  putT  up. 

Treatment.  Tlie  air  in  the  tissues  dis.ip|M'ars  by  al)sor))tion  in 
:i  few  days. 

Injuries  to  the  Oonjonctiva.  It  freijuently  happens  that  foreign 
liodies  enter  the  conjunctival  sacs.  These  impinge  first  upon  the 
irlolie,  and  are  then  brushed  downward  by  the  ujnier  lid.  They  may 
remain  in  the  lower  conjunctival  pouch,  but  often  are  caupht  on 
llie  tarsal  conjunctiva  of  the  upper  liil,  from  which  they  may  Im'  re- 
moved on  everting  the  lid.  When  lodged  on  the  conjunctiva  of  the 
upper  lid,  they  are  foimd  most  commoidy  in  the  shallow  groove  which 
lies  innnediately  alM)ve  the  inner  angle  of  th(-  margin  of  the  lid  (sulcus 
marginalis  or  sulcus  tarsalis).  Rarely  the  foreign  Unly  lodges  in  the 
ictroiarsal  fold.  Slight  i)ressure  backward  on  the  glebe  after  the  lid 
i-  everted  will  ser\-e  to  expo.se  this  fold,  when  the  foreign.body  maybe 
ninovfil.  Hits  of  .steel  are  sometimes  imbedded  in  the  conjunctiva: 
they  may  be  removed  by  the  onlinary  .surgical  jiroceduros.  (irains 
of  iiowdiT  th.Mt  are  deeply  inibe  '  led  need  not  be  distuHx'd,  as  they 
produce  no  irritation  after  the  wound  made  bv  their  entrance  has 
healed. 

Wdiinds.  These  may  1h'  a.ssnciated  with  extensive  injuri(s  to  orbit 
.ind  lids,  or  may  be  simjile  lacerations.  I'nder  favorable  circuni- 
-t.Mices  they  may  be  riean.sed  and  the  margins  of  the  wounds  a|)- 
proximated  by  sutures. 

Hiinis  are  occasiimed  by  the  entrance  of  flame,  glowing  wooil  or 
metal,  powder,  ashes,  steam,  hot  water,  niclten  metal,  acids,  alkalies, 
nitrate  of  silver,  and  other  substances. 

Treatment.  When  th(>  burn  is  iccasioned  by  thermal  agencies  alone, 
the  treatment  should  be  by  n..  ans  of  bland  oils  or  vaseline,  to  Iw 
placed  in  the  conjunctival  sac  e  ery  two  or  three  hours.  If  molten 
metal  hiis  entered  the  eye,  all  of  the  particles  should  bo  removed  as 
early  as  possible,  and  treatment  instituted  as  above  outlined. 

Burns  from  acids,  if  recent,  should  be  treated  by  means  of  a  weak 
alkaline  solution  (bicarbonate  of  sodium,  sodium  hydroxide,  or  verv 
dilute  ammonia):  subso(|uently  the  conjunctiva  may  be  well  washed 
with  water,  and  the  oils  then  employe<l. 

Hums  frotn  lime  and  anunonia  should  bo  treated  by  first  removing 
all  particles  of  lime  or  mortar  by  means  of  forceps  or  cotton  pledgets, 
then  by  washing  thoroughly  with  oil,  and  subsequently  dropping  in 
simple  synip  made  from  cane  sugar,  .is  thi.=.  forms  an  insoluble  com- 
bination with  lime,  (lil  or  vaseline,  medicated  with  boric  acid 
(')  per  cent.),  may  then  be  used  until  healing  takes  place. 


in 


i-n,.r 17;:, »;;t:;;s:r;x;':i,: ':;:::  ::li:-'^;:-l;;: 

Argyna  '~Kyro8»)  """J'*"     ,  ,i^,,,i,,r.,,i,,,,  „f  tin-  mukm.us 

,.f  silver  n„  tl..-  .-nnjunHna     r     u  . .    i  1  ,,^  all.u.ninat.. 

.,f  .siiv..r  i..  .1...  tissM..  nt  t ..•  "'J ''•.*;•  Z*^^,;,. .,,;w i,r..w,. 

!:J:  SK;  t,"  :;nS  ..f  l  •  U  h.'wa„  ■•  ..as  ........  su.,..st...l  for 

''iZ^.      in    .nan,  >..aivi,.;..s  ;v,...   '-J-.-;-;,  ^ 

„,,    ,„sal    sul-    nt    "'':.!""";\';;;,„,,.„,,  ,,,,vati..n   ....•asuri..K  two 

nr   tl.rc.'   niillii.K'ti-es  in   (liai.H'tcr. 
Tins   tii.nor  is  at  ti.-st  niovabl'-  •'.. 
tlic  sclera.     It  foiisists  in  a  tliickc.i- 
iiifl  (•)■  the  (•(.njvnictiva.  particularly 
■„,  a,i  increase  of  the  elastic  film's, 
an.l    the   deposition    of    .luii.erous 
',„••    'te  livaliiu'  pai-tides.     The  yel- 
lo,     elastic  tissue   and   the   hyaii.ie 
Ix.dies  (livp  it  the  yellow  color.     II 
the  tumor  causes  annoyance  by  its 
api)earanc<'     or    hy    becoii.'.n}!    m- 
tlaiiied,  it  may  he  n'luoved  t)\   in- 
cision. . 

Pterygium,  rtevyjiia  may  be 
classed  as  "esvilar  and  irrefjular. 
Tlie  ivfrulai'  form  of  iitei-yfriuni  con- 
sists ii  ■  triaTiffular  fold  of  mucoes 
memhn.P.    oc.urrin}i  oi.  the  ocular 


nie    iia>;ii    ^"" 

ill  the  horizontal    meridian. 


Pterviiiiim.  A  w.mi.l.  >-.  is  rarrii-l  U'lumih 
thui^ia.'  "I-  tl.c  l.UTy''.c».  P  The.  .loitiM 
line  -h.iws  th..  vvay  in  wbieli  Uie  section  is 
:,mclo  ill  removim;  tlie   i.U>r>Kiuni.     C.  Car- 


:,m,U.  ill  removini!  the   l.U.r>Kiu.„.     (j  lar-     .■»■;■           .  l.irizoMtal     IIIC- 

nnrle     The  ml  ia,  enl   l.li-'a  semilunaris  li««     COIIJUI'.C '  '  Va     111     the     l.orlZO.nai     111. 
.    ...u..  ..,.., i...  1,.,™  of  tlie        •  1-  :,      1 l...;iwr  ..t  tlu.  (•.•HIT  ins. 


till,  le.       •  "^    .»-.,,.-    .  -  i-  ,1 

l«*ll  lialtelR.1l  .-lit  by  Ihe  len^i^e  loioe  of  the 
lileryniiiiii,  ni"l  is  hence  iiivi>il>le.  /'.  I  PPt'f 
piinctum  Ittcrymule.    iFicHS.) 


riilian,  'I  -  base  heiiin  at  the  canthus, 

its  apex  at  the  marpin  of  or  on  the 

cornea.      (Imk.    1:{7.)      The  I.I00.I- 

,.,.  ...„i.  <,n„.v  .,t  the  base,  diminish  in  size,  and  conyrrp<>  at  the  apex 

i>terv.num  occurs  h.   indivithials  of  m.d.lle  mula.tvanced  life,  nu-sl 

r     untlv.level..pinKon   the  nasal  side  of  the  cornea:  it  may  also 

M.  r  the  temporal  si.le.     Pterygia  n.ay  bo  either  progressive  or 


' 


WPPIPP 


/j/.sA.iA£'A  "F  coxji'ycrn.i,  coii.\tA,  a.\d  x  /.a;/m      2x{> 


«i;iti(iiiary.  In  pniftn'ssivi  ptfrypiiiin  the  folil  of  mucous  iii<'inl)raiif 
Iki>  a  lli'>iiy  a|ilK?araiu'»'  and  .l>  vessels  arc  prMiiuunci'd.  Tlic  a|M'\  of 
ilif  Krow'ii  is  pri'ccdt'tl  liy  a  urayisi.  zone,  one  to  one  and  one-half 
iiiilliinetres  wide,  wliicli  is  very  slijjlitly  raised  at  the  margin  of  the 
a|«'\  of  the  jrrowth.  In  non-proj;ressive  pieryuiuni  the  fjrowih  is  pali- 
and  Hat,  and  the  grayish  zone  is  narrow,  and  is  flat  or  slightly  shrunken, 
appearinj:  like  a  cicatrix. 

rteryciuin  may  advance  until  it  passes  the  pu)..;:  it  may  stop  at 
any  point  on  the  cornea  short  of  this. 

irregular  or  pseudopteryniuni  is  the  result  of  hums  or  ulcers  of 
the  cornea.  They  have  the  same  jreneral  shape  as  the  re>tulari)tcryf:ia, 
liut  the  ajM'x  is  often  very  irregular  in  contour,  takinjj  on  the  sha|M' 
oi  the  mar>;iti  of  the  ulcer  farthi'st  removed  from  the  limhus  of  the 
coujunctiv;i.  The  conjunctiva  at  the  margin  of  thi-  cornea  corre- 
>pondiMH  t'>  <!"'  nicer  Itecomes  swollen,  and  a  fold  of  chcmotic  con- 
junctiva hecomes  agplutinated  to  the  floor  of  the  ulcer.  As  the  ulcer 
clox's  and  cicatricial  tissue  forms,  the  mucous  memhrane  is  drawii 
onto  the  cornea,  at  the  .same  time  l)ecoming  hy|)ertroplii('d.  Tl  ■ 
plrryfjiiim  ni'ver  propresses  beyond  the  cicatricial  floor  of  the 

Hi'Kular  pterygia  are  undoulitedly  due  to  irritation  of  tlic  ■.■- 
junctiva  in  its  most  exposed  part,  corresjMmdinK  with  the  pa.,  - 
iiral  fissure,  hy  particles  of  dust  ai-..  various  minute  bodies  that 
impinne  on  the  ocular  coiijtmctiva.  This  irritation  results  first  in 
the  formation  of  pinguecula :  extending,  it  |)roduces  the  ptervfrinui. 
I'terypum  is  prone  to  Iwcome  indamed  because  of  the  lodgement 
of  noxious  germs  or  irritating  particles  in  the  folds  of  the  nuicous 
iiiembrane.  These  iiifianunations  may  lead  to  ulcer  of  the  conjuiu-- 
tiva,  ulcer  of  the  cornea,  and  serious  damage  to  vision. 

Diagnosis.     I'ierygiuui  cannot  well  be  mistaken  for  anything  el.s<'. 
Treatment.     Tlu-  cautery  may  be  used  to  destn  y  the  head  of  the 
growth,  or  to  cut  ofT  its  -.utrition  by  making  one  or  two  deep  gnxivps 
across  the  neck  of  the  ,■•   rygium. 

The  operative  procedures  resorted  to  most  frecpiently  are  exci.sion, 
transplantation,  and  strangulation. 

MxcisKiN.  The  neck  of  the  pterygium  is  grasped  by  the  fixation 
forceps  and  jiierced  close  to  the  limbus  by  a  shar]i  cataract  knife, 
ihc  knife  iia.-*sing  just  below  the  tis.«ue  of  the  pterygium  and  parallel 
,  h  its  surface,  the  edge  of  the  knife  beiig  directed  toward  the  cor- 
nea. Hv  .-I  to-and-fro  motion  the  knife  is  made  to  pass  iM'iieath  the 
iiead  of  the  ))tervgium.  dissecting  it  from  the  cornea.  Instead  of  this 
iTocednre,  a  thin  strabismus  hook  may  be  pa.-'sed  through  the  in- 
ii-ioM  made  Iwneath  the  neck  of  the  pterygiu!n  (  Triiu-e's  nietiiod), 
and  the  head  of  the  pterygium  torn  from  the  cornea.  The  body 
.'f  llie  pterygium  is  nowdis-sected  from  the  underlying  ti.-isues  for 
a  distance  of  three  to  .six  millimetres,  and  a  diamond-shii'  i  ;  '  ■c- 
exci.seu.  'he  imier  apex  lying  at  the  canmcle.  The  con.',  -ic',,  a  ■ 
now  loosened  from  the  underlying  tissues  above  and  belo  .  i;;  i  th 
edg     brought  tugeth'  ■  by  sutures,  covering  the  defect  as  n.r  ;)s  Tne 

ivt 


■J!M) 


THE  EYE. 


fll 


11 


iiiarjriii  of  the  (uiiica.  Tlic  cdnical  ilotVct  l)Ocniii('s  covered  witli 
epitlieliuiii  ill  a  few  days  and  liealiiifi  profiresses  satisfactorily,  leaviii;: 
soiiii'  opacity. 

Thanspi.antation  (Kiiapi)).  Instead  of  excisiiift  tin-  i)terypiiiii 
after  liaviii};  dissected  tiie  ftniwtii  toward  tlie  caruncle,  tlie  corneal 
tissue  may  lie  removed  from  its  head  and  a  suture  passed  tlirough 
the  ai)ex  of  the  pterygium.  .\  straifrlit  incision  may  now  he  made 
in  the  lower  hulhar  conjunctiva,  extendin;;  from  the  margin  of  the 
wound  about  four  millimetres  from  the  cornea, downward,  and  .slightly 
outward,  toward  the  fornix,  suthciently  long  to  accommodate  the 
free  part  of  the  pterygium.  The  suture  tlin.ugh  the  ajx-x  of  the 
ptervgium  is  now  pas.secl  through  the  conjunctiva  at  the  apex  of  the 
last  "incision,  and  the  hea<l  of  the  i)terygiuni  drawn  into  the  space 
and  there  fixed.  This  directs  the  ti.ssue  of  the  pterygium  into  the 
lower  fornix.  .\11  defects  other  than  the  corneal  are  now  covered 
by  suturing  the  edges  of  the  conjunctiva.  Instead  of  transplanting 
ail  of  the  i)terygiinn  below,  the  body  of  the  i)terygiinn  may  be  split 
—one-half  may  •>•'  trans])lanted  below,  one-half  above. 

SriiANCi  i.ATioN.  The  neck  of  the  pterygunn  is  grasjie.l  by  the 
fixation  forcejjs  and  slightly  raised.  .\  suture  with  a  needle  near 
both  ends  is  employed,  one  needle  passing  ujiward  beneath  the  neck 
of  the  pterygimn  at  the  corneal  margin,  the  other  needle  pa.ssing 
upward  beneath  the  neck  of  the  pterygium  three  millimetres  from 
the  corneal  i  argin.  The  ends  of  the  suttire  are  not  dr.awn  through, 
but  the  loop  holding  each  needle  is  cut,  liberating  the  needles  and 
forming  three  sutures.  The  suture  at  the  corneal  margin  is  tied 
tightlv  over  the  neck  of  the  pi'  rygium,  as  is  al.so  tb.e  suture  nearest 
tcrthe  caruncle.  The  middle  suture  encircles  the  base  of  that  i)or- 
tion  of  the  pterygium  lying  between  the  two  end  sutures.  The 
middle  suture  is  now  tied,  |)roducing  strangulation  of  a  section  of 
the  pterygium.  The  sutures  are  |)ermilted  to  retnain  until  they 
come  awav  spontaneously.  Deprived  of  nutrition,  the  head  of  the 
l)terygium  atroi)hies  and  ilisa|)i)ears,  leaving  only  an  ojiacity. 

Eecurrences.  These  are  not  infrecjuent  after  removal  by  excision, 
but  are  very  infrei|uent  after  transplantation  and  strangulation. 

Ljrmphangiectasis  consists  in  dilatation  of  some  (tf  the  lym])h 
channels  of  the  ocular  conjimctiva.  It  ajipears  as  slightly  elevated, 
transpanMit  vesicles,  usuallv  associated  in  chaiiK,  very  superticially 
situated  in  the  outer  or  inner  half  of  the  bulbar  conjtmctiva.  The 
vesicles  , ire  irregular  in  shape  and  vary  in  size,  seldom   exceeding  a 

dia ter  of  three  millimetres.     The  vesicles  may  be  readily  moved 

over  the  underlying  tissue.  They  produce  no  irritation  and  are  not 
a  source  of  ])ain.  The  vesicles  are  due  to  interference  with  the  lymph 
stream  by  ol>struction.  Klderly  individuals  are  more  fre(|uently 
atTected. 

Treatment.  The  vesicles  may  be  excised,  or  they  may  be  very 
satisfactorily  destroyed  by  means  of  the  fine  galvanocautery  point. 
Removal  is  necessarv  only  for  cosmetic  purposes. 


DISEASES  OF  COSJUSCTIVA,  CORyEA,  ASIJ  SCLEllA.       291 


Vascular  growths  in  the  conjunctiva  arc  seldom  primary,  hut  arc 
(■(inimoiily  extensions  from  tiie  tissues  of  the  lids.  Tiiey  apjM'ar  as 
arterial  prowtlis,  when  they  are  of  a  bright-red  color,  slif;litly  ele- 
\;ite(l;  as  venous  jirowths  (cavernous  anjiioma),  lncate(l  (jeej)  in  the 
conjunctiva,  dark  purple  in  color:  or  as  telangiectatic  growths — 
hright-re(l  patches  in  the  conjunctiva.  All  these  conditions  may  he 
|)resent  in  the  same  growtli.  \'ascular  growths  are  congenital.  They 
tend  to  increase  in  size.  Ivirly  removal  is  advisable.  (See  Removal 
of  \ascular  Ti.ssues  of  the  Lids.) 

Polypi.  The  occurrence  of  polypi  on  the  conjunctiva  is  prohal)ly 
always  asiaciated  with  ulcerative  iirocesses  of  a  more  or  less  chronic 
nature  in  the  conjunctiva.  Wounds  of  the  conjunctiva  that  <lo  not 
pro|)erly  close,  sy])hilitic  or  tubercular  ulcers,  simises  from  chalazia 
ojM'ning  onto  the  conjunctival  stirface,  sinuses  from  areas  of  orbital 
necrosis,  all  give  rise  to  the  development  of  polypi.  The  irritation 
from  wearing  an  artificial  eye  may  result  in  the  development  of 
jjolypi. 

Pathology.  Polypi  of  the  conjunctiva  are  composed  of  myxf)matous 
tissue  with  more  or  less  .small -cell  infiltration,  according  to  the  degree 
of  irritation. 

Treatment.  Removal  and  correction  of  the  conditions  favoring 
their  formation. 

Benign  Tumors.  Those  that  develoj)  ])riinarily  in  the  conjnnc- 
ii\a  are  adenoma,  fibroma,  gramiloma.  lipoma,  myxoma,  osteoma, 
l):ipilloma.  simple  cystic  tumors,  and  those  due  to  cysticerci  and 
ccliinococci. 

Ailcninna  occurs  rarely  as  an  extension   from  the  tarsus    or  as  a 
ilcvclopment  from  lacrymal  glandular  tissue,  or  from  the  caruncle. 
/■'ihriiiiHild  are  usually  the  result    of  chronic  conjunctivitis,  par- 
ticularly of  vernal  catarrli. 
<inniiiloiii(i  develoi)s  from  the  base  of  an  ulcer  and  from  wounds. 
l.ipiniKi  occurs  in  the  fornix  in  tlie  shape  of  a  soft  yellowish  mass. 
Mtjxnwn.     The  most  common  form  is  ])olypus. 
O.-li'iima  is  of   extremely  rare  occurrence.     (See  Congenital  Con- 
ditions.) 

I'npillnmn.  Ttiinors  of  this  nature  exist  as  small  multiple  pajHlhc, 
fonuing  soft,  pale-jiink,  villous  mas.ses.  They  may  develop  from 
any  part  of  the  ocular  or  palpebral  conjunctiva,  but  are  seen  most 
<'iinimonly  on  or  near  the  caruncle.  Papilloma  is  not  iiifn^juently 
mistaken  for  gramibtion  tissue.  To  avoid  recurrence,  removal  should 
lie  thorough. 

Simple  cystic  tumors  appear  in  the  [lalpebral  conjuncti\a  after 
chronic  conjunctivitis,  after  plastic  operations  on  the  conjiuictiva, 
anil  after  oi)erations  on  the  ocular  muscles.  They  usually  form  as 
a  result  of  the  invagination  of  epithelium.  The  treatment  is  excision. 
Cysts  dtie  to  entozoa  are  very  rare.  Cysticercus  cysts  are  large. 
ii  tiie  wails  are  thhi,  the  head  is  visible  as  a  white  spot  at  some  part 
"I  the  cyst.    They  are  easily  removed  by  splitting  the  conjunctiva 


2i>2 


riii:  EYE 


;„-;.,,„...,,   ™M «.. v..i,„i„U,n,,,,„*o.«.. .-iv.. 

tissii.'  "lit  of  tlif  wound.  .Icvcloi)   ^'lowlv,    tuul    ma\ 

oxt.-..a  int..  tlu-  orl.it  an.    pn.  '-'^1;  '  ,  ^.,,„,,,,^,  „f  „,,  .yst. 

,ysts  an.l  hnuklots  n.ay  >«■ /T    ;;.'•'    ,.     sarconu.    arc    th.-    n.ost 

:rri5u:r°s.-Hiis^  a  =  ->-'•  ^--^  -  ^^'-^— 

soc.on.larv.  that  is,  an  <-xt.-nsu.n       •    !^   '^^  J-  ^,„^i  ,.^,,,,,is  onto 

It  . srurs  wh(-r.>  pipn.-.tt  is  <'»*•»'"':,    „  ,\,,  ,„„iunctiva  of  the 
vhore  it  is  n.on.  ^^^^^^^ ^y^;.Z^.     San-ma  of  th.-  ;-,.- 

"^S.t.eat.    Complote  excision  is  the  only  treatn.ent  that   .   of 

vaUie.  ,    „  ;.  .,«vct^   the  ponjunetiva.  appears 

Lupus  erythematosus,  wl.;        ^f/,  '  ,\.ish  nuisses  of  exudatu.n 

as  snmll  in-ep.lar  pla.,.u-s  ''"^  i"  ^   h    punctat.-    ..xeoriati.ms. 

,„d   superficial  ^^^^^^xiJi^^^^'^^  conjunctival  .dTe.- 
Lupus.TytluMnat..sus..f  th(  la<      <«  ^^,,on,,,anie.l  by  shfjht 

tin!.      The  .lisease  pn,sresses  M(vU>-  -"" 
ivritation  an.l  increase.!  '•^•^^J;";;^^"^,,,,,  ,,is.-ase  of  th.-  face  accon.- 

Etiology  is  not  xvU  "!"l''\^^.;"  i^,.     i!  ;„.,sis  is  rea.lily  nuide. 
..aniesthat  ..f  th.- cnjunctna  tli.   .l.a.n 

Treatment  is  ..1  no  aviuL  ,.,„„r,tion  soinetinu-s  acconipanu's 

^'^^  f  *'«  ^T"?r    Th  to.;;;  'liu....tiva  usually  is  afTecte.l. 

'  AfiectionsoftheCarunceandSenuluna^^^F^^^^  ^^^^   ^^^^_^,^  ^^^  ^,„ 
,      ,,,uncl.-  n.ay  be  .lu.-  to  "  !\       ,,^,.,.,,      tIu-  ahsc.-ss  n.ay 

,,„,,„,,,.  res..lti,.^  in  the  f''"'';  '  /  1  „.onta,.e..nsly.  when  ^^ 
'«;:'"-'-l-  r  ;l  "^Se  liai;"  nil:  .'ivunele  nlay  hecon.e  a  source  ..f 
vviil  n-a.lily  hea  .      1 1>«  "'"'■.„„,•,,,,,  i^  the  n-n..''lv.  , 

-;1^'; <^;:s::i;»r  ;;i;;:;;'.;;:;s:-'i".«- ^ 

"^r»,'^..i- i™rs^i;;ru:;S=--!"r'"f 


DISEASES  OF  COSJVSCTIVA,  CORXEA,  ASD  SCLERA.       2^ 

Cuslic  viilnrqemnit  is  soiiu-tiinos  ..hsorvo.l.  rholhj  ih'po.ih  may 
„m.r  in  the'fila"'''^  "f  '•»'■  <"'>-uncl<',  ouusinK'  cnlamen.cnt.  Advmmn 
nu.v  <U>vcl(.i..  Wlict.  the  onlarK.-in.-nt  is  du.'  to  . level.. pincnt  ot  sar- 
coma or  opithelioma,  f.  c  term  cucontlms  mnhijna  is  applicl. 

Treatmeit  in  all  cases  of  enlargement    from  the  development  of 

iiew-OTowths  should  1m>  excision.  ,,,..1111. 

Symblepharon.     Cicatricial  imion  of  the  palpebral  to  the  hull.ar 

conjunctiva  is  terme.l  syn.hl.-phan.n.    It  occurs  a  ter  burns   mjunes, 

an,    son.e  operative  procedures,  an.l  as  the  result  ..f  P""''!'"'  ?;!"- 

iunctivitis,   pen>phipus,   and   trachon.a.     The   bands   of   c.catnc  al 

'sue  ma-  extelul  to  the  cornea.     ShouUl  the  union  between  the 

lids  and  El<.l.<-  be  complete,  the  condition  is  termed  symhlephnron 

M     If  the  union  extends  from  the  bottom  of  the  fornix,  partially 

uniting  the  li.l  to  the  fjl"l>f.  '^  '^  ♦''""f'''    symblepharon    posteruix 

ZZxhl  union  of  the  lid  to  the  eyeball  is  such  that  the  cuatncial 

Land  .Iocs  n<.t  extend  to  the  bottom  of  the  fornix,  the  condition  i.^ 

termed  symblepharon  antcrius  ■     ,      t  i  i„.,V,orr«n 

The  treatment  of  svmblepharon    is    surgical.     In  syrnble  haron 

a„     ius,  carefuUv  dis.sect  the  lid  from  the  eyeball  am    if  the  mlhcsion 

is  not  extensive;  the  surfaces  may  be  separate.l  .  a.  y  ""/.l  ccatri- 

.ati..n  has  taken  place:    a  ple.lget  of  cotton  f  ^^e.l  with  ol  ve  o 

n,av  1...  interpose.1  between  the  raw  surfaces  an.l  penn.tt.  .1   ..  re  na  n 

unt'il  healing  occurs.     The  bri.lge  of  tissue  may  be  hgate.l  and  the 

liuature  all.)we.l  to  slough  through.  ,  ,.    ,    .      ..v,    i    n  „, 

^In   ext<"nsive   anterior   symbl.'pharon,    the   defect    in  the  bulbar 

coniunctiva  may  be  c.vere.l  by  dissecting  the  <-""J""^\7,^,,^*.3^ 

honhT  ..f  the  .lefect  from  the  underlying  tissue,  making  sliding  flaps 

,-,„,„  both  si.les  an.l  m.iting  the  margins  of  ^^c  «'njunct.va  ov.-r  t^^^^^ 

,lef.rt  in  the  ocular  conjunctiva.     With  an  epithelial  ^^"'"f ^^7/ ^"^^^^^ 

to  th.>  .lefect  in  the  c.njunctiva  of  the  lid  the  .lefect  m  the  lul  nmH 

ci.'atrize  without  adherei-o.   to  the  glolie. 

Plastic  operati..ns  of  x-.  >us  ki.uls  have  been  advocated    .r  cor- 
.■...■ting  svmblepharon  posterius  an.l  fetalis:  but  none  of  the  n  is  pe  - 
fectlv  satisfac  orv.     After  the   li.ls  have  been   <lissect...l   from  the 
.,l„l,e  a  flap  .>f  .onjunctiva  from  a  rabbit's  eye  may  be  cnvey..  , 
with  antiseptic  precautions,   to  the  defect    an.l  nuule  to  cover  , 
l„.i„g  stit,.he.l  into  place.     A  Thi.-rs.-n  graft  may  be  ma.le    o  com 
,1...  d..f..ct,  or  a  thin  skin  flap  (WolfTe's  flap)  "'f /^.''"'jt  "  ^imi  ar 
n„.  fla..  is  in  position  a  shell  of  glass,  lea.l,  celluloi.l.  or  ^<'!'\'' ^"     ;''. 
.„hstal.ce  shoul.l  be  so  placed  a-s  to  hold  the  flap  m  position  until 
healing  has  taken  place. 

CORNEA. 

Anatomy.  Tlie  cornea  forms  the  anterior  part  of  the  f^^^^'^^^'f 
.,f  the  eve.  It  is  in  f.)rm  a  horizontal  ellipse,  measunng  11  tnnv  in 
iis  vertical  an.l  12  mm.  in  its  horizontal  men.hans.  At  !  »\P^'  Pj?';'^> 
It,,'  c.rnea  is  1  mm.  in  thickness,  but  at  the  centre  it  is  slightly 


2!t4 


THE  i:yi:. 


tliiiiiicr.  Tlic  r:i<liusnl'  (Mirvatiircof  the  aiitcriiir  surface  of  the  conica 
is  variously  estimated  at  7..")  nun.  to  N  nun.  Sinee  tlie  radios  of 
curvature  of  tlie  scleral  portion  of   the  <rloi>e  is 


Vl  nun.,  it  will  he 


readilv  seen  that  the  cornea  is  more  sharjily  curved  tiiaii  tim  sclera. 
A  slifiht  ariiuilar  depression  is  found  at  the  anterior  niarpin  of  liie 
sclera— the  union  of  the  cornea  witli  the  sch'ra— known  as  the  mdnm 


KIO.  lis. 


Sectional  view  of  cornea.    (Sohawer.! 

jsWcrT.  .Mthough  ova!  in  form  anteriorly.  |)osteriorly  the  cornea  is 
circular.  The  sclera  overlajjs  the  corneal  tissue  externally,  the  over- 
lap|)infi  beinp  }ir<'iitest  above  and  below.  The  cornea  is  composed  of 
five  l.'iyers  (l''ii!:.  lUS): 

1.  The  ei)ithelial  layi-r.  which  is  stratified;  the  sui)erticial  laypr  of 
colls  is  comi)o.sed  of  tessellated  or  pavement  epithelium.     The  ceii.s 


i>isi:.i.st:s  or  co.y.irxcTiVA,  corska,  aso  scleua. 


2ft.-, 


Ill  ilic  niidtllc  liiyt T  arc  incfiularly  culxiidal  in  fdiiii,  and  arc  sui)])li('d 
willi  ruiMicrous  fine  j)r(>('csscs  ("  prickle  cells")  wliicli  interlace  witli 
liic  luncesscs  of  the  adjouiin};  cell>.  The  cells  of  tlie  deep  or  liase- 
Mient  layer  are  cohinuiar  or  cylindrical  in  sha|)e,  are  somewhat 
irrejiiilar  in  length,  and  aii'  placed  on  a  basement  nieinhraiie.  All 
of  the  cells  of  the  cornea  are  supplit  d  with  nuclei.  i»ef;cneration 
of  cells  takes  place  from  all  the  layers. 

'1.  The  .second  layer  is  a  thin  niemhrani',  anil  is  known  as  Howman's 
niemhrane.     (Fij;.  V.Vi.) 

.'{.  The  third  layer  is  the  thickest  layer  of  the  five,  and  is  known 
as  the  yiilistiuiliii  propriii.  It  consists  of  numerous  bundles  of  con- 
nect ive-ti.'<sue  Hbres  associated  in  thin  layers— lamelke.  The  lam"lhe 
are  arrang.'d  parallel  to  the  surface  ot  the  cornea.  They  are  joined 
hy  connect ive-ti.ssue  fihres  which  pa.ss  from  one  lamella  to  another. 
The  connecting;  fihres  are  so  numerous  in  the  anterior  part  of  the 
substantia  propria  that  they  are   given  tiic  name  of  librw  arciinta. 

Fig.  139. 


Anterior  epithelial  layer  of  cornea.    (QfiiN.) 


I.yin<r  between  the  Innidles  and  lamella-  are  small  .spaces  known  as 
l.nuiia',  and,  imitiiifi  these,  numerous  small  canals  known  as  canaliculi. 
These  lacuna'  and  canaliculi  together  form  the  canalicular  lymph 
^vstem  of  Hecklinghausen.  In  each  lacuna  a  branching  cell  is  found 
whose  ))rotof)lasmic  ])roce.s.sps  extend  along  the  canaliculi,  anasto- 
mosing with  those  of  adjacent  cells.  These  cells  are  known  as  the 
lixed  cells  of  the  cornea,  in  contr.adistinction  to  the  leucocytes,  which, 
iiy  amo'bic  movements,  penetrate  to  every  part  of  the  cornea,  and 
;\yr  known  as  the  migratory  cells  of  tlie  cornea. 

t.  Tlie  fourth  layer  of  the  cornea  is  a  thin  homogeneous  mem- 
brane, known  as  Desremefs  membrane,  which  po.ssesses  chemical 
projierties  that  serve  to  distinguish  it  from  liownian's  moml)ranc. 
Uaiivier  is  of  the  opinion  that  this  corneal  membrane  is  the  product 

■  il  the  endothelial  cells  of  the  cornea  which  rest  upon  it.  The  mem- 
Inane  of  Descemet  breaks  up  into  numerous  fibres  at  the  periphery 
I'f  the  coni(>a.  forming  the  ligamentum  jK-ctinatum. 

■").  This  layer  consists  of  a  single  layer  of  polygonal  ceils  of  the 

■  •ndothelial  variety  which  lose  their  (tecuiiarities  at  the  ligamentum 


.:>6 


Tiii:  i:yt: 


^  t 


1  i 


,„,,tinatu,n,  passing  ovor  int..  .•-lis  that  an-  ...uch  thinner  a.ul  -nat 

•■'N^r;^''!.;:':^;':^!  Irian  ,1...  ^...  ..l-xus  fo„n.l  hy  tlu. 
,0.^  3' short  riliary  n.-rvos.  .  Fi,.  14.)..  ^rh-y  pass  tl.-uj^.  t - 
Jr.,  on  th<-  outer  ^i.le  of  Schlc.nn,-s  canal  an.l  l..nn  a  n.-t«..rk. 
t^^Z^l  .n.„l.,r..  in  th.  vicinity  of  tlu-  -^^:^;:;^l 
Fro,  ,  tl,is  pl.-xus  two  sets  of  t.Mjis  arc  pv.'.,  off.  one  set  !>''-  '  P 

lu.  l^onjunctiva.  wi,,.,.-  tl,cy  join  the  conjunct,val  nn-v..  an.l  fon 
u  olcxns      Fro,,,  tl,is  l-l.-xus  a  nu.nl.cr  ..f  ncrv   .ninlvs  a.,    sn 

V  whi..h  enter  the  c.rnea  .m-l  supply  -he  a.,  enor  JX--^^  ^^ 
structun-  Th.-  se<..n.l  set  of  tw.^s  pa>>  .hr.rtly  t..  the  ^ubhtantia 
pn.pria  cornea-,  cnterinR  it  near  I)esc.-n,ct  s  ,ne.nl.i-ano. 

Fio.  140. 


Obllq..e  section  of  the  hunum  cornea,  rt,o«i"g  ranuflcatlon  of  the  nerves,    (De  Weckee., 


Ra.iial  fibres  which  leave  t'.e  nerv.>  trunks  at  the  no.les  of  Rain  r 
pa"  t  Hown.ans  ,nen,hra,.e.  which  they  inerce  an.  f..nn  a  pUxu  , 
flu'  . uhepith.'lial  plexus,  from  whicl,  tennu.al  hhnlla'  are  .lenve.l, 
Ii;!,  ;.,!,1  ,,,  the  epith..lial  layer  in  .,erve  plates,  peculiar  c.nvolu- 
ti<.ii<   hulbs,  h.i.>ks,  an.l  frw  en.ls.  r    i  , 

lo,      <.s;.ls  .lo  n..t   ..ccur  in  the  cornea,  .-xcept   at     he  Im.hus, 
,vh'  n  the  episcleral  hl..o.lvessels  en.l  in  a  circle  of  h.ope.l  capillaries. 

Diseases  of  the  Cornea. 

Diseases  .,f  th.-  cornea  are  inclu.l.'.l  un.ler  the  gen.-ral  term  keratitis. 
Th..y  may  he  consi.lere.l  un.ler  tw.,  iiea.lings-.suppurative  an.l  non 

'"Clodcal  Considerations.  Regeneration  ol  Corneal  Tissue.  It 
is  ^  resX  c:,nce,le.l  that  th.-  n-Renerati.,,!  of  «>rn7  tissue  proce^ J 
fro  ,  cells  that  mifrrate  into  the  corneal  tissue  and  form  the  nuxe.I 


DIHEAHES  OF  COy.IUSCTlVA,  CORSEA,  AM)  SCLERA.       2!»7 

ci'lls  of  llw  cornea.  WIicii  rejtri-ssion  of  a  corneal  nicer  has  com- 
Mienced,  formative  elements  are  found  at  the  edfte  of  the  nicer  which 
jiradually  develop  into  connective-tissue  fibres;  this  process  con- 
tinues until  the  defect  in  the  cornea  is  filled  uj)  by  the  new  tissue. 
The  new  fibres  are  not  arranged  in  lamelbe,  nor  are  they  dispo.sed 
parallel  to  the  surface  of  the  cornea.  This  irregularity  of  the  dis- 
position of  the  hbres  causes  a  lo.ss  in  transpan-ncy;  the  tis.sue  so 
formed  is  opacjue.  In  the  liealinR  of  an  ulcer  the  surface  Iwcomes 
covered  with  epithelium  before  the  defect  has  been  filled  up  by  the 
ilepositlon  of  the  new  fibres.  The  development  of  new-formed  tissue 
continues  until  eventually  the  epithelial  layer  is  raised  to  its  normal 
heifiht.  In  a  certain  projjortion  of  ca.ses  complete  filling  of  the  defect 
iloes  not  take  place.  The  area  involved  in  the  ulcerative  process 
in  these  ^a.ses  is  often  flat,  forming  what  are  known  a^  jncctK.  How- 
man's  membraiii'  is  never  regenerated.  Accompanying  ulceration 
<if  the  cornea,  if  the  process  is  at  all  widespread,  and  in  some  ca.ses 
where  the  ti.ssue  affected  is  not  extensive  (the  invasion  not  dfH'p), 
irritation  of  the  iris  is  produced  sufficient  to  bring  about  an  exuda- 
tion of  lymphoid  cells  and  of  the  coagulable  portions  of  the  blood 
into  the  ante/ior  chamber.  This  exudate  constitutes  what  is  known 
as  hyjwpyon. 


Suppurative  Forms  of  Keratitis. 

Eczematous  Keratitis  (Phlyctenular  Keratitis;  Scrofulous  Kera- 
titis; Lymphatic  Keratitis).  The  etiology  and  pathologv-,  except  in 
regard  to  the  affection  of  the  tis.sues  of  the  cornea,  are  the  same  as 
ill  eczematous  conjunctivitis.  The  disease  is  met  with  most  fre- 
Hieiitly  in  children  between  the  ages  of  two  and  twelve  years,  but 
may  appear  in  individuals  up  to  the  age  of  forty  years.  In  many 
'it'  the  patients  with  eczematous  (phlyctenular)  keratitis  obstructive 
liiinitis  and  adenoid  tissue  in  the  vault  of  the  pharynx  are  found. 

S3rmptom8.     S<>vere   irritation,  as  of  a   foreign   body   in   the   eye; 
jiain  of  a  neuralgic  type,  often  extending  to  the  orbit  and  temjile; 
profuse  lacrymation:  photophobia,  which  is  often  intense,  causing 
ilonic  blepharospasm  in  the  milder  cases  and  tonic  blepharo.spasm 
ill  .'^evere  ca.ses.     In  some  cases  the  photophobia  is  so  intense  that 
liic  ]iatient  cannot  be  induced  to  oikmi  the  eyes,  even  in  a  moder- 
ately lighted  room,  but  avoids  the  light  in  ever\'  j)ossible  way.    The 
intense  photophobia   is  due   to   irritation    of  the   terminal  sen.sory 
nerve  filaments,  which  are  so  richly  supplied,  to  the  corneal  epithelium. 
I'ig.  Itl.)     On  forcibly  separating  the  liils,  there  is  often  a  gush  nf 
'  iciymal  fluid   mixed  with  flakes  of  mucus.     There  is   iiypera'inia 
•I  the  ocular  conjunctiva,  particularly  in  the  vicinity  of  the  phlyc- 
I'liule.     The  vesicles  may  ho  single  or  nmltiple.     They  may  fonn 
t  the  margin  of  the  cornea  onl\  ,  Tsiny  be  dif^tributoil  (npr  the  surface 
•I  the  cornea,  or  may  produce  peculiar  figures.      The  phlyctenule 
'"veloiis  as  in  the  conjunctiva,  the  apex  softens  and  disappears. 


•J!IH 


771  y;  i:yi:- 


,„.l  .,„  ulcT  results.     Tl..-  nlcT  in  mMi.y  cmsos  it.volv..s  tlu;  sii|M-r- 
.luc  t..  the  l..vs.'n.r  ..f  a  thii.  lay.T  ul  .Mcatncial  t.ssu. 


Fio.  141. 


,,.,,..,,1,  ec7.cmat««.    The  •i<'<l»''=.  "''ii'h  c.uUts  of  cells,  Uei 

Emor.-soence  nn  the  .onua  ...  "'"J"  ''';''  ""'^.'^T  „.hich  latter  Is  th„»  mis«l  so  as  to  form  a 
U.twee,,  ll.mma..'»  ...e...hrane.  «,«...!  the  ep   he     .m^A^^^^^^^^^ 

,,r,„„inenee.    1..  the  e,.i.helin.n  we  '"»""«>"^  ''f^^'     *,;;',  !\  .  ,,,;,ere,l  .H^twee..  the  epithelial 

!»^r;>'  '-;'-::;.:r::^,r;""i t;::':":':^: ^™,ii::;  t:..^  the  ,«,...chy.na  of  the oomea, 

:  j:::;;^;h;^:;;u.a.';;:.th,;:;,';;:-anii.  ain.t.y  i.,  aa.!,...  of  a 


,..,»  .„i«i«   s  i.s  illBtinKiii'ihed  by  its  more  rtelicate  fibril- 

Eczeraatous  efflorescence  in  the  l..>b,.a.    ^J-o  »cUm  .S^'^^'^^^^  H.    The  no.iule  i» 

lationao..  its  bl<x«lve»els  from  t!.e  "'"^«  h.^o^mmu,  n™  va^c         ^^^^^^^^  ^^,  „.,^  „,.„ 

,ituated  Ht  a  pMtit  ^"r'^-'P»"'''"^'°  ''^,''.^„"„"'"J,,^;^cked  roun.l  cell,,  bet«..*n  which  the 
the  sclera  than  over  the  eor.tea.  It  <=™*'f "  °\^f''^'^;J_l^„,o„,,,  ,trta;.  In  the  vicinity  of  the 
blo.«]ve^ls  are  recognizable  ..n<ier  the  form  "'"«'''"  ™^^"^,^ere<l  bv  extravasated  lenc* 
„cKi„le  the  ve^ls  of  the  conJuneUva.  ■•,  ^""^  !^^^7f;,';,'„'^  ^X.  nolole,  and  at  the  apex  of 
cyles.    The  epithelin.n,  E.  of  the  <■"""""■"*   f„"hermn"  cells  int..  the  epithelial  layer  itself, 

rrrr:;':rt;^:a-^:::r'';^:;'ru:nd  the  connective  ti«ne. ««,.««. 

(12X1.     (FlTHS.) 

Siufctiva  by  a  It-ash  i.f  vcs.sols  ^vluel^  Ik-  in  the  track  of  the  disease-. 


HJHEAfihS  itF  VOXJlWcTIV.i.  C'lJiM   I,  .IA7>  >/7,7,7M. 


2'M 


The  pn. cess  I  lit  (I  I  extend.-  far  onto  llie  cornea,  and  tornis  a  cwrved 
tract.  On  .-nh.-idiii);,  an  (i|)a(|iie  stripe  i.-  left,  which  has  heen  termed 
tlie  scnijiiliniK  IkiikI. 

Complications.  A  phlycli'inihir  idcer  may  extend,  rapidly  produce 
lierforation  of  the  corneji.  and  result  in  much  damage  to  tiie  eye. 

Diagnosis.  Ilczeniatous  keratitis  may  l)e  confounded  with  lieriK-s 
of  the  corne.'i.  luit  the  history  of  the  :'ii.sc  will  suHice  to  difTerenliatc 
between  them. 

Prognosis.     Is  favoral)le  in  nearly  all  cases. 

Treatment.  Local  and  constitutional  treatment  should  bcemijloyod. 
It  is  often  difliciilt  to  ins|M'cl  the  cornea  on  account  of  tlie  photo- 
phohia  and  l>lepharospasm.  If  a  drop  of  a  solution  of  cocaine  he 
instilled,  the  photopliohia  and  blepharospasm  will  In-  much  relieved. 
With  many  children  it  is  neces.sary  to  i)lace  the  head  between  the 
jihy.sician's  knees  before  attemptiuf;  to  expo.se  the  cornea;  a  lid 
retractor  is  off.  m  re(|iiired.  The  cornea  is  sometimes  hidden  under 
llie  ui)per  lid,  ,  il  it  is  neces.sary  to  wait,  with  the  lid  retracted,  for 
it  to  come  jim  tally  into  view.  In  severe  cases  a  little  ether  or 
chloroform  may  be  fjiven. 

Tlu'  eye  should  be  bathed  or  douched  three  or  four  times  :\  day 
with  .1  .solution  of  boric  aci<l.  Atropine  may  be  in.stilled  sufficiently 
olten  to  keep  the  |)Ui)il  dilated.  If  the  ])hlycteiuile  has  broken  down. 
I'.ilomel  may  be  dusted  onto  the  corneji  once  daily.  .\n  ointment 
of  the  yellow  oxide  of  mercury  (1  per  cent,  in  vaselinei  may  be  put 
into  the  eye  twice  daily.  Kissure  of  the  outer  cotnmissure  often 
exists  in  the.se  cases.  The  blepharospasm  may  be  relieved  to  some 
ext<'iit  l)y  touching  the  fi.ssure  with  a  stick  of  nitrate  of  silver  or  with 
.1  crystal  of  the  sulphate  of  cop])er  (Koller).  Obstructive  rhinitis 
and  postnasal  <irowths  should  receive  ap]iropriate  trciittnent. 

Systemic  treatment  should  be  instituted  as  for  eczema  of  tiie 
<'oiijunctiva. 

In  fascicular  k(>ratitis  the  cure  can  be  hastened  by  cutting  tiie 
liMsh  of  ves.sels  at  the  scleroconieal  margin  by  means  of  a  siiarp 
-pud. 

Ulcers  of  the  Cornea.  I'lcers  of  the  cornea  are  variously  clas.si- 
lied.  In  regard  to  their  development,  they  are  primary,  beginning  in 
the  cornea  itself,  or  secondary,  by  exten.sion  of  the  process  from  the 
conjunctiva  or  from  contiguous  ti.ssues. 

In  regard  to  [)osition,  they  are  marginal  or  central. 

.\s  to  involvement  of  tissue,  they  are  su[)erficial  or  deep. 

.Vs  to  shai«'.  *'"'.^'  '•^^*'  cin'ular,  crescentic,  punctate,  dendritifomi, 
iilamentous,  and  irregular. 

In  character  they  are  simple  or  infected.  To  the  latter  belong 
'\\i-  so-called  mycotic  forms. 

In  regard  to  the  stage  fif  development,  thej'  are  progressive  or 
:•  ;:n's.<ive. 

ricers  of  the  cornea  present  certain  symptoms  in  common.    (F'ig. 


MM) 


TIIK  KYE. 


„f  the  c.rn.'a  at    .»•  Mf;  <-»  '  »     '    ,■,       ,  "  .....rnivtir  f.-rin.     In.pair- 

='■^'1';;  •■  :■';::;. -rin ;;.'::  *:;  srih..  ..upinary  an.  i^ 

involvcl.  1 ;  '  .'^''  ;  "  /  -,.,.'  iris,  ciliarv  Ixxlv,  an.!,  m  nir."  .•as..> 
r:r.;it;:^.':;:r  inv...v...lin  ,,.  inliannnat..ry  ..n.-ss.  an.l 
sh..ul,l  n.n-iv  apprupnat.-  =';";";|;;;';  ,,,„„  „.,<  ,,„.i  ,„  ^ulvanr.-. 

'■'■■« ''''1'  mn..,!(.  uln-r  i-  usuallv  traumatic :  »n.t  the  tor...  is  also 
.,°rr-t.  tlS  tins  ..f  in.V.:t.l  ul..r  in  whicl.  tl.  pr..„vs.  .s 
speedily  arrested.  ,„,rlvii)s   the   use  of  a  hone 

JTSSL  i:f:£tT,:ti'^^ .. :  >"..».  ^^ »" 

that  is  re(iuired. 


Corneal  nicer.    (S*»mi«h.) 

Inkcled  Vlar     The  term  infeeted  ulcer  is  ap,)lied  to  ulcers  which 

lov         after  soluti(.n  -f  .-.mtimuty  ..f  the  corneal  tissue,  due  to  the 

'      .'^ly  a  ;;:Unic  .nicro-or,anisn.,  such  as  thcj^tap^iy  kj^^JU^ 

vumues   •uireus,    streptococcus,    pneun.ococcus,    etc.     Ail    '""    ^ 

K    n>  a^.riated  Jith  an  intiltratic.n  of  the  corneal  t-s-K. -^  ' 

V  n   Tu  \  BTviU-v  or  less  .legree  from  the  margins  of  the  ulcer. 

tie'    •uiompanips  eczema  of  the     .njunct.va.  sUaoh  has  b.vn  ''f-^   '''^" 
no         e'headinft   of    Eczematous    Keratitis.      Another        n     of 
'gna    keratitis  is  the  form  that  appears  m  the  shape  ot  a  long 


■^^ 


m 


DJsJi.isJiS  OF  coyji-ytriVA,  couyK.i,  .\si>  s<Lt:it.\.     ;i(»i 

crescent  involving  frmii  (iiir-til'tli  tn  two-tliinls  of  tlic  circunifcrciu't' 
fif  the  cdiiica.sdiiictiiiics  the  entire  circuiiiferi'iice(»f  tlu'coniea,  and  to 
wliieli  tlieterni  "  crescentic  ulcer  "sdinetinieK  \*<  applied.  Tliis  variety 
presents  itwif  as  an  interrupted  line  of  jirayisli  intiltratiim  ininiediately 
lieni'atli  tlie  epitlieliuni,  occurrinu  just  heyoml  the  free  margin  of  the 
liinliiis.  To  the  iinaidr-d  ey<',  this  seems  to  he  a  continuous  line;  iiut 
examined  with  the  lens  it  is  seen  to  Ik'  made  up  primarily  of  minute 
pustules  uliich  rapidly  coalesce.  Within  twenty-four  to  thirty-six 
hours  the  e|(ithelimii  covering  these  pustules  disappears,  and  a  su|)<T- 
licial  ulci'r  results.  This  process  tends  to  adv.'ince  toward  the  centre 
of  the  cornea  ri'gularly,  the  line  of  demarcation  lieing  ((uite  clearly 
cut.  Witii  the  advance  of  the  .su|ierficial  infiltration  the  epithelial 
cells  disap|M'ar,  hut  the  dee])  layers  of  the  cornea,  save  for  a  scantv 
inliltration  of  small  cells,  seldom  are  invaded.  The  afTection,  par- 
ticularly in  poorly  nourished  individuals,  may  advance  until  a  large 


Fio.  144. 


cicatrix  or  corneal  nicer.    (Saehisch.) 


part  of  the  epithelium  of  the  cornea  has  disappeared.  The  super- 
fnial  lamella'  of  the  cornea  are  also  sometimes  affected  to  such  an 
■  ■\tent  that  when  tlie  ulcer  has  healed  a  delicate  cicatrix,  indicated 
!i\  the  presence  of  a  thin  oji.icity,  remains.  (Fig.  141.)  This  form 
nt  keratitis  is  usually  iuoikk     ar. 

Cause.  It  is  highly  prohiilile  that  a  condition  of  the  corneal  tissue 
which  renders  it  less  ca|)al)le  of  resisting  the  inroads  of  micro- 
ti traiiisms  is  an  essential  «>lemeiit  in  the  develo|)ment  of  this  condition. 
\lii'i()-organisms  that  have  heen  ohserved  in  this  form  of  ulcer  are 
-inphylococcus  pyogenes  aureus,  Klehs-LoefHer  bacillus,  and  the 
I'liciimococcus. 

Duration  and  Symptoms.  This  form  of  marginal  keratitis  seldom  is 
iH'l  with  in  children,  hut  is  most  fre(|uent  in  adults  of  advance<l 
'  I  ars.  It  progresses  slowly,  is  attended  with  pronounced  symptoms 
I  irritation,  and  is  accompanied  by  more  or  less  secretion  from  the 
"njuiictiva.  Injection  of  the  palj)el)ral  as  well  as  of  the  ocular 
"HJunctiva  is  present.  Tlie  process  may  terminate  in  a  few  days. 
lit  in  some  cases  three  months  may  elapse  l)efoie  recovery  takes 


:ln.> 


Tilt:  K>  A" 


t 


Ix'ar 


,,la,T.      (Vrtitin    Inrms   nl    niaininal   -r   <  rrscnitic    k.Tatm> 
,.l„s,- n-sniihlaiKT  td.lriMliiiil'-.nii  k.-ratitis. 

DiagnosU.    Tl...  .lia,n.-sis  .,1  .■n.^.-ntir  ..I.mt  p.rs..„t>  mu  .hllu-ult...> 
sin.M.  tl..'  l..cati..n  an>l  I'.-nn  atv  ilw  .'ssrnlial  Iratnr.s 
In    a.iaitinii    til    tlif    1"<"'I    lii'aliiinit. 


Ilif    p-nrral 


III  the 
liamtic 


,1„.  lH..t,     I.Hlnfunii.  arist..l,  or  n„snplicn  may  !«•  \n>\x-r^'^ 

J  ,  itvufrasrs.  Ii..w..v,.r.  tlir  us.  uf  a  .•l....nu.al  .,,■  tliHiiial  rsr  laintu- 

:  u'rvinavi;.  appli.'.l  -linrtly  U.  tl...  ul.'.T  W  ..■..  t',.  ...,!,..> 
:  n  .  nv...l  ..v..n  I  art  uf  tl,-  .lis,.as,.,l  M.ria.v  slu-ul-l  «■  t.uirl.r.  .  A 
^.  i.    api.llatin„a.,ann.MluM.anU.,H.rf...^ 


pure  carlMilic  ac'ul. 

Othrr  forms  uf    marfimal   k.Matitis   srcoiHlary   to 
,,,h,r,.s  an.  oLscrvr,!.     Tin-.,  aic  .luc  to  mlcHion  nt 

,  ,„,„lv  pr-Hl,,.-  .■vf.nsiv..  ,l..strurtiun  ot  tlu;  rorn.-a,  lla-  t,  .at- 
;;:r;^ljs<.  uln..  •.  .imilar  to  tl.at  for  .1,..  .a.opatl>...  tnarpnal  or 
.•r(.sn.iitic  (ilc<'r,  wliich  l.as  Ixri.  ,|..scnl)c.l. 

..ir,.ular  or  at.  i.T..«i.lar  shap.-,     Tl..,v  .nay  n-sult   m  .l.-struH.-n  ol 

Fir,    U'>. 


operative    |iro- 
tlie  woiiiiil.  ami 


mav    ass\im('   a 


.,  .mall  or  a  larg.'  portion  of  tl.o  corneal  tiss„.>.  or  in  .1.-st ruction 
of  -ntin-  cornea      Tl.c  fonn  of  uIo.t  to  which  the  tern,  circular 

isa   plie  1  occurs  most  frc.ucntly  in  the  shape  of  a  cone  whose  a  k-x 

s  n'th<.  stnuna  of  the  cornea.  The  walb  ot  the  ulcer  presen  a 
L  vish  appearance,  an,i  iniiliration  of  th-  c  rn..a  extoiuls  q.nio 
regularlv    nto  the  ailjacent   tissues.     In  some  cases  hernui  o    th^ 

nt  Sr  cl.a.nlH-r  n.sul  s.    .  Fi^.  145.)    I  ,  some  cases  perforatH.u  takes 


i>isi:a.si:.s  ttr  cnyjiyrriVA,  cou.sE.i,  ami  scihji.i.     ;jn.| 

I'liHT,  aixl  ill  iillicrs  plastic  Iyiii|ili  t'driii^  at  llic  Ixittinii  ol'  tlic  anterior 
ihaiiilMr,  whfti  a  conilitinii  kimwn  as  liy|Mi|iyoii  is  jinx  luce,  I.  Tlic 
(•irriilar  iilcir  i>  usually  a  ri'lativt-ly  licnipi  roriii,  ami  rcKri'ssiini  sets 
in  Ixlwrt'  [icrloratioii  occiii-i.  The  ulcer  wlieii  first  iiotited  presents 
as  a  sii|M'rficial  loss  of  epitlielimn  with  a  >;rayisli-yel|o\\  centre. 
This  jrrayish-yelldw  centre  represents  a  mass  (if  superficial  ni'cn.lic 
tissue,  which  li.|iie(ies  and  extemls  slifrhtly  until  wiliiin  twenty-tour 
or  seventy-tw(»  hours  a  relatively  drep  loss  of  tissue  results.  This 
form  of  ulcer  may  occur  ;it  any  period  of  life,  hut  is  most  frei|uent 
in  adults.  Its  duration  is  usually  from  five  to  ten  days.  In  severe 
cases  |MTforation.  fistula,  and  partial  staphyloma  may  result. 

Treatment.  The  measures  previously  spoken  of.  omiprised  hv  the 
terms  cleanliness  and  ase|)sis.  should  !«■  employed.  In  many  cases 
the  ins|M'rsion  of  calomel  once  daily,  with  the  introduction  Of  the 
ointment  of  mercuric  chloride  four  times  a  day,  will  sufhce  to 
hrinji  alxHit  recovery:  hut  in  all  casi's  of  circular  ulcer  either  the 
.M-tiial  cautery  or  pure  carbolic  acid  may  he  employed  with  very 
excellent  results,  and  recovery  hrounht  aliout  much  more  rapidly 
than  hy  the  u.se  of  simple  medication.  The  condition  of  the  system 
-lioiiid  alw.ays  1m'  inquirecl  into,  and  siiitahh'  measures  instituted  ,o 
correct  irrejiularities. 

/////«)/)(/«/(    Kcnitilis.      In  all   pronounce<l  cases  of  corneal   ulcer 

the  :uit<'rior  segment  of  the  vascular  coat  of  the  eye  (iris  and  ciliary 

lio(ly)   is   mon'  or  less  irritated.     As  a   result,  exudation   from  the 

vessels  ensues.     The  jKiueous  humor  Ix-conies  more  alhumiuous,  and 

lilirin   forms.      Kihrin  is  deposited   on   the  |)osterior  surf.ice  of  the 

cornea,  and  often  on  the  other  surfaces  that  are  in  contact  with   the 

,ii|ueous    humor.     If   the    irritation    is   sufficient,    leucocytes  esca|K' 

from  tne  vessels  of  the  iris  and  ciliary  hody,  and  reach  the  anterior 

iIiiiimImm-  and  jiravitate  to  the  bottom.    If  sufiicient  fibrin  is  present, 

ilie  leucocytes  become  imbedded,  forming  a  pulta"eous  mass   which 

Anc<  not  change  its  position  when  the  position  of  the  head  is  changed. 

In  the  absence  of  sullicieiit  fibrin   the  collection   remains  fluid  and 

rli.inges  its  jHisition  as  the  position  of  the  head  is  ch.-ingi-d.     The 

Hiass  is  yellow  in  color,  and  resembles  pus.    It  contains  no  i)athogenic 

-iinis  and  is  itmocuous.     Its  |)resence  constitutes  what  is  known  as 

'lypopyon.    Tiie  suiwrior  border  of  the  hypopyon  is  often  slightlv  coti- 

\('\.     ( )n  looking  ()bli(|uely  into  the  anterior  chamlK-r,  it  will  bl'  set  n 

hat  the  pus  is  chiefly  depo.sited  on  the  jxisterior  surface  of  the  corn.'a, 

iie  surface  of  the  iris  In-ing  free  to  a  considerable  distance  below  the 

:|iper  m.'irgin  of  the  deposit.   The  researches  of  LcImt  make  if  evident 

lit  the  iirespuce  of  the  leucocytes  and  fibrin  is  an  attempt  en  the 

irt  of  nature  to  aiil  in  preventing  destruction  of  the  cornrid  ti.ssue. 

^'■iny  of  the  leucocytes  penetrate  into  the  corneal  tis.sue  b.-  way  of 

'Htana's  spaces  and   jjroceed   to   the   vicinity  of  the  ulcer.     The 

less  remain  in  the  anterior  chamber,  and  there  form  the  collection 

-I  described.     Older  ob.servers,  noting  the  convex  upper  border  of 

!■  niass  of  exuilation  in  the  anterior  chamber,  and  the  fact  that 


.•!()4 


THE  EYE. 


• 


the  iris  \v:is  free,  siijiposcd  tiial  tlic  (•(illcctioii  of  pus  was  hctwci'ii 
ihc  laiuciia'  of  tlic  coriica,  and,  ix'caiisc  of  tlic  rcsciuhlanoc  to  tlic 
Imiuia  of  the  fiiificr-iiail.  tcniuMl  it   iinijiiis  or  ..n/x  (nail). 

Tlic  presence  of  liyi»o|)yon  in  itself  calls  for  no  particular  treatment. 
With  suhsiilenci-  of  the  disease  which  calls  it  into  existence  it  <lisap- 
pears  1)V  al)S()r])tion,  sometimes  slowly,  sonu'times  rapidly.  It  may 
disappear  and  reappear,  and  vary  in  amoimt  from  day  to  (hty. 

Andc  SIoHiihiiKj  Vlnr  iScrfwiit  liar,  Saemisch).  Tiiis  form  of 
ulcer  affects  ailults  almost  exclusively.  It  may  occur  in  children 
del)ilitated  hy  exhaustinf;  disease.  Infection  through  a  wound, 
usuallv  superficial,  is  the  cause,  the  pathofienic  micro-orRanism  hcinfi 
introduced  either  at  th(>  time  of  the  traumatism,  or  subsequently, 
from  tiie  contents  of  the  conjunctival  sac.  This  affection  has 
heeii  ohserved  fre<|uently  in  farmers  ilurinj;  the  harvest  season,  and 
has  been  termed  "harvesters'  keratitis."  Stonemasons  are  par- 
ticularly liable.  .\  similar  form  of  corneal  ulcer  has  been  observed 
in  those  enjrasred  in  oiieninji  oysters,  and  has  been  termed  "oyster 
shuekers'  keratitis"  (  Rudoljjh)."  Tiie  micro-orfranisms  chiefly  engaged 
ill  the  production  of  acute  sloufihiiiK  keratitis  are  the  |)neumococcus 
(  rraenkel,  Weichselbamii,  Sattler,  (iasiiaiiini,  I'earls,  Ba.sso,  riithoff, 
and  .\xenfeld),  streptococcus.  Staphylococcus  pyoS<'"<'>'  aureus,  gono- 
coccus.  Klebs-I.oefHer  bacillus,  etc."  The  term  serpent  ulcer  is  not 
descriptive  of  the  disease,  and  should  be  abandoned. 

,\cconlin<;  to  Fuchs,  the  characteristic  clinical  picture  of  the  disease 
is  present  only  in  the  eaHy  sla<!;i'.  It  then  ap|)e;irs  as  a  disk-like  opacity 
near  the  centre  of  the  cornea,  the  centre  of  the  disk  beinj;  not  so  dense 
as  the  marfiin.  The  surface,  which  at  first  is  slightly  raised,  soon 
becomes  slightly  depressed.  Iritis,  cyditis,  and  hypo])ynn  develoj) 
earlv.  The  ulcer  advances  irregularly:  an  arrest  may  occur  in  one 
portion,  and  the  epithelimn  may  advance  over  the  edge  of  the  defect. 
.\t  anothi'r  part  the  gray  inhltration  advances,  and  loss  of  corneal 
tissue  continues.  Hernia  of  the  anterior  chaml)er.  followed  shortly 
by  perforation,  is  the  usual  course.  The  entire  cornea  may  become 
involved  and  slough.  .\s  comi>lications,  there  may  be  loss  of  the 
crystalline  lens,  escape  of  vitreous  Innnor,  detaciuneiit  of  the  retina. 
intra-oc\iIar  hemorrhage,  panophthalmitis,  etc. 

Treatment.  This  should  be  energetic  from  the  start.  If  the  ulcer 
is  small  and  in  the  e.arly  stage,  meiMcinal  treatment  may  be  employed, 
providid  the  patient  is  imder  close  ol)servation  and  can  devot(>  the 
time  to  licatmeiit.  This  consists  in  hot  bathing,  which  should  be 
eontiiuious  during  the  waking  hours.  .Atropine,  in  1  to  ',\  y  ■■  cent, 
solution,  should  be  instilleij  suflicii'iitly  often  to  keep  the  jun  Elated. 
Labarraipie's  solution.  1 :  10  to  1 :  S,  maybe  instilled  every  t\  -  hours, 
lodot'orm  may  lie  inspersed  and  a  compress  bandage  api)lied.  It 
tri'ated  as  an  "out"  ]iatient,  operative  procedures  should  be  resorted 
to  at  once.  In  the  eiiriy  stage,  if  .a  large  area  is  not  involved  and 
little  hvpopyon  is  present,  cauteri/.ai ion  should  be  rcMirted  to,  ]>ref 
rrably  with  the  actual  cautery,    .\tropiiie  should  have  twen  instilled 


■■H 


wmm 


wmmm 


JJIHICASICS  OF  COXWyCTIVA,  COJiNEA,  AM)  SCLERA. 


:U}-} 


|iivvioiisly.  After  cmitiTiziiig.  iodoform  may  be  dusted  into  the 
wound  iiiid  a  eompress  handiifte  applied:  or  the  eoiijimctival  sae  may 
U'  tilled  with  hiehloride  vaseline  1 :  otMK),  and  the  eye  hanihiRcd. 
The  eye  should  he  inspected,  the  remedies  used,  and  the  handape 
reaj)plied  from  one  to  three  times  in  twenty-four  hours.  In  ulcers 
i;ii'  .'ire  larjiewith  larjre  hypopyon  the  Saemisch  incision  should  Ix" 
peril. ;-)i.!  This  is  done  by  piercing  the  clear  cornea  at  the  margin 
I'i  the  u'f  •,  carrying  the  point  of  the  knife  into  the  anterior  chamber 
li(  neaih    he  ulcer,  and  making  the  counter-puncture  in  clear  cornea. 

I  h  •  inc.sion  is  comjdeted  by  cutting  through  the  floor  of  the  ulcer. 
The  a.,  leous  humor  is  permitted  to  escape  slowly.  The  lips  of  the 
wound  are  separated,  and  the  pultaceous  mass  forming  the  hypopyon 
IS  washed  out  or  lifted  out  with  a  spatula.  This  operation  permits 
of  incarceration  of  the  iris,  but  prolapse  .seldom  occurs  if  the  operation 
is  performed  with  ordinary  caution.  The  margins  of  the  wound  close 
rapidly.  It  is  advisable  to  open  the  wound  once  everv  day  for  n 
few  hours.  Bandaging  and  the  usual  medicinal  treatment"  should 
lollow  the  oiK'ration. 

ilccr  in  Variola.  In  jjatients  suffering  from  smallpox  the  cornea 
may  1k'  the  site  of  one  or  more  pustules.  The.se  do  not,  as  a  rule. 
lead  to  destruction  of  the  eyeball,  but  they  are  followed  by  more 
or  less  opacity  of  the  cornea,  which  greatly  impairs  vision.  In 
France  :]n  per  cent.— and  after  the  introduction  of  vaccination  7 
per  cent.— of  all  the  blind  lost  their  vision  from  smallpox.  In  the 
Inited  States,  wliere  vaccination  is  so  general,  blindness  due  to 
MiiallfMix  is  seldom  seen.  If  the  eyes  are  insi)ecte(l  daily  during  the 
illness,  and  cleansing  by  means  of  mild  anti.septic  .solutions  and  bland 
;iiitiseptic  oils  or  ointments  is  employed,  something  in  the  way  of 
prevention  may  be  accomplished.  In  addition  to  the  formation  of 
variolous  pustules  the  cornea  may  be  the  site  of  a  destructive  kera- 
'itis,  due  to  infection  from  other  germs,  as  occurs  in  those  who  are 
lint  infected  witli  variola.  The  results,  on  account  of  the  (iepress<Ml 
iiindition  of  the  individual,  may  be  very  serious  .«o  far  as  vision  is 
<oiicern(>d. 

.W/.vroN  o/  thf  Conira.  .\  process  terni(>d  :inmilar  abscess  of  the 
'I'nira  sometimes  occurs  after  perforating  wounds  and  after  opera- 
iiMiis  on  the  cornea  which  result  in  infection  of  the  coniea.  In  these 
'■■ises  a  yellowish  anmilar  ring  forms  in  the  central  jjortion  of  the 
'■ornea.  The  centre  of  the  cornea  and  the  zone  next  the  limbus  are 
'Kizy,  but  less  densely  so.  Tlie  yellow  ring  extends,  involving  the 
lit  ire  corne.-i.    The  corneal  tissue  sloughs.    Destruction  of  the  cornea 

II  these  cases  is  complete  in  three  or  four  days.     Destruction  of  the 
\<'  is  sure  to  result.     Fuchs  advises  enucleation  at  an  early  stage. 

Fi.^liila  of  the  rorneu  ai)|)(>ars  as  a  small  black  point  at  or  near 
'le  ceiitiv  of  the  cornea.  If  perforation,  the  result  of  ulceration. 
■ui-s  in  file  coTifre  nf  the  cnrnra,  it  may  nr.t  h<-  povf-red  by  tin-  iris. 
id  recovery  must  take  place  by  the  development  of  new  connective 
>ue  from  the  margins  of  the  ulcer.     Recovery  under  these  con- 


.'}()« 


Till-:  EYE. 


! 


ditiiiiis  is  slow,  and  it  .sdiiictiiiics  liiijipcns  tluit  with  closure  of  tlic 
pcifonitioii  the  iiitra-ocular  tension  issiiHiciont  to  rui>tiin'  tluMlclicatc 
ii('\v-t'onii(Ml  tissue,  and  tlie  anterior  (•lianil)er  is  evaciialed  and  a  fistula 
is  formed.  If  the  fistula  remains  open,  tlie  eyehall  firadually  atro|)liies 
or  infection  occvn's,  and  panoplitlialniitis  follows.  Tlie  fistula  may 
close,  and  on  restoration  of  the  intra-ocular  tension  may  ajrain  he 
o]iened.  This  may  he  repeated  a  mnnlur  of  times.  Infection 
usuallv  occurs  sooner  or  later,  and  lo.<s  of  the  eye  results. 

Treatment.  In  recent  cases  an  attempt  may  1)0  made  to  secun- 
closure  by  applying  a  comi)re.ss  liandage,  and  myotics  may  1k'  em- 
ployed to  keep  the  intra-ocular  tension  reduced.  If  the  anterior 
chamber  becomes  restored,  an  iridectomy  may  be  ])erformed  for  the 
same  purpose.  Cauterization  of  the  walls  of  the  fistula  is  resorted  to 
.sometimes  for  the  production  of  a  firm  scar;  but  it  should  be 
em|il()y(Hl  with  care,  to  avoid  woundinfr  the  lens.  I']xcision  of  the 
walls  of  the  fistula  may  be  resorted  to,  and  the  opennifi  may  be 
closed  by  a  suture. 

Filanicntiins  Kc'n'ilis.  This  disease  may  be  classified  as  idio- 
|)athic  or  traumatic. 

(/.  Iiliojxttliiv  jllitwcntoiix  kcr(ttiti>i  is  characterized  by  the  forma- 
tion in  the  corneal  i'i)ithelium  of  epithelial  fjlobules,  measuring;  usu- 
ally 1  mm.  to  Ij  mm.  in  diameter,  which  are  pushed  jibove  the  level 
of  the  epithelium,  and  finally  become  pendent  from  the  epithelial 
surface  and  coimected  by  small  pedicles  (Xuel,  Mess).  The  globule 
consists  of  epithelial  cells,  of  the  tessellated  variety,  which  are 
uiideifioing  mucoid  degeneration.  In  the  centre  a  hyaline  body 
u  ually  is  ()hs(>rve(l,  resembling  coceidiuin.  The  ])edicle  consists  of  a 
central  core,  composed  of  epithelial  cells  which  have  become  elon- 
gated until  they  assume  the  appearance  of  fibrilhe.  These  an'  twisted 
into  a  small  thread.  The  masses  rise  and  fall,  accompanying  the 
movements  of  the  lids.  The  filaments  last  from  thre(>  to  four  days. 
A  fresh  grouj)  of  the  gloliules  may  appear.  The  number  of  globules 
may  be  but  two  or  thre(>,  or  they  may  be  n\niierous  ;ui(l  cover  almost 
the  entire  cornea. 

This  disease  is  peculiar  to  advanced  adult  life,  and  is  observed 
more  frecjuently  in  eyes  that  have  been  the  scat  of  an  inflammatory 
process  affecting  the  anterior  segment.  Shnilar  globules  may  form 
from  the  floors  of  ulcers  that  are  in  the  |)rocess  of  healing. 

h.  Trdiimatic  lilamr»li>iis  krrdlilis  is  probably  due  to  the  adher- 
ence of  ])artly  detached  threads  of  e]>ithelium  rather  than  to  fila- 
ments derive,!  from  the  eruption  of  globules  as  above  described. 

Symptoms.  The  development  of  filamentous  keratitis  is  accompanied 
by  symptoms  of  irritation,  slight  injection  of  the  ocular  conjunc- 
tiva, a  sensation  ;is  of  a  foreign  body  in  the  eye,  and  the  |)resence  of 
scanty  mucoid  or  mucop\nulent  secretion,  ))ortions  of  whi?h  adhere 
to  the  coriie.al  surface,  Slight  f(>brile  reaction  sometimes  is  ol)servc<l. 
Treatment.  Treatment  should  be  constitutional  as  well  as  local. 
Local  treatment  consists  in  keej)ing  the  cornea  cleansed,  using  mild 


DUiEASES  OF  VOSJISCTIVA,  COIiSEA,  AM)  SVLEUA. 


3(»7 


.■ii]tisc|)tic  sdliitidiis -solution  of  horic  jiciil  f.S  per  cent  )  or  pota-^- 
simn  pcnnaiipiimtc  (().L>  to  I  p<"r  cent.)  niav  l)c  cniplovcd.  In  addi- 
tion, niiich  I'onifort  is  };ivcu  tli."  patient  if  a  lubricant  in  the  form 
of  horated  (.")  per  cent.)  or  hicliloride  vaseline  ( 1  .oOOOi  is  intro- 
duceil  into  the  eye  tlir ir  four  times  daily. 

The  systemic  treatment  consists  in  the'  eiiijjlovniciif  of  general 
Ionic  remedies.  Tiider  this  form  of  treatment  we  mav  hope  for  a 
suhsidence  of  the  affection  in  from  tliree  to  five  davs."  Hecurreiice 
may  take  place. 

Ikndrilic  Kmitili.--  {Furrow  Kenililis ;  Mi,r„tic  Kmililis  ■  Kcra- 
hti.  Arh„r,sn„s).  Th<>  term  is  applied  to'  a  superficial  form  of 
keratitis  supposed  to  1><-  due  to  the  presence  of  a  specific  micro- 
orKiiiiism.  The  process  usually  begins  at  the  peripherv  of  the  cornea 
l.iit  may  al.so  begin  in  the  centre  of  the  cornea.  It  is  characti'rized 
by  the  appearance  of  a  narrow  gravish  line  of  infiltration  in  the 
corneal  tissue  near  the  surfac( .  accomiianierl  hv  an  elevation  of  the 
^•pithelium.  'I  he  ejuthelium  covering  this  line  of  infiltration  breaks 
down,  and  a  shallow  groove  f  furrow")  is  formed.  Preceding  or 
tollowmg  the  destruction  of  the  epithelium,  offshoots  from  the  original 
Ime  ot  infiltration  are  observed.  The  offshoot  fre(|uentlv  terminates 
111  a  minute  grayi.sh  enlargement  (colonvi.  These  offshoots  imiltii)Iy, 
'iiitil  eventually  a  tree-like  ("arborescent")  formation  is  presented! 
I  he  infiltration  is  not  confined  to  the  grooves  and  lines,  but  advances 
into  the  surrounding  ti.-^sue  for  a  short  distance  as  the  process  con- 
tinues. The  advance  of  the  process  differs  in  different  cases.  As  a 
rule,  the  advance  of  the  disease  is  relatively  slow,  a  minilxT  of  days, 
perhaps  weeks,  elajjsing  before  f"ll  <levelopmeiit  is  reached.  fh(> 
-uperticial   nature  of  the  process  •  be  continued  throughout  its 

'oiirse.  Involvement  of  the  deep,  i.s.sues  mav  supervene,  and  in 
'xception.a!  ca.ses  perforation  of  the  cornea  may  take  place.  When 
the  deeper  tissues  are  involved,  it  is  the  result' of  a  mixed  infection 
ot  the  cornea. 

Symptoms.  The  symptoms  of  this  affection  are  frequently  verv 
'hstressing:  the  i)atient  comi)lains  of  a  sen.sation  as  of  a  foreigii  body 
m  the  eye:  i)holophobia  to  a  very  annoving  degree  (leveloi)s.  Xeu- 
!.i  gic  pains.  ;ifTecting  the  distribution  of  thesui)ra-orbifal  and  iiifra- 
-iliital  branches  of  the  fifth  nerve  are  experienced.  Those  svmptimis 
iiiay  suddenly  ceji.se  and  Im'  absent  for  a  dav  or  two,  and  then  sud- 
eiiiy  recur.  The  intensity  of  the  svanptoms  deiieiuls  directiv  upon 
'he  activity  of  the  jj-ocess. 

Cause.     A  cause  h;is  not  as  yet  been  determined.      The  apijcar- 
iiices  indicate  the  presenc(>  of  a  micro-organism. 

Diyurolioii  Kmititi.y  {K<ratitisr  Lofiophthalnm).  When  the  cor- 
'Ma  is  ,.x,,osed  for  any  length  of  time  without  suitable  lubrication, 
le  epitlieli:,!  cells  iH'come  dry  and  irregular  and  the  cornea  l)eeoui08 
liL'lnlvo.,a.|ue.  Kxp..sure  leads  to  one  of  two  things;  the  corneal 
>Mie  either  takes  on  a  cutaneous  cf.ndition,  or  the  corneal  sub- 
'•■'iice  is  lost,  and  ulcer  occurs.     Keratitis  from  desiccation  occurs 


Il)l 


•MH 


THE  EVE. 


ill  cases  (tf  cxtrciiic  cxuplitlialiniis,  ri'tractiiiii  of  tlu'  Irvalor  (ial|)fl)ra' 
sii|HTiiiris.  cxlninc  cctniiiidii.  paralysis  ut'  tlic  i)rl)i<Milans  palpc- 
liramni  iircvcntin;:  closiirf  (if  tlic  cm's:  in  licltilitatiiifi  diseases,  as 
tvplidiil  f<'\('i'.  siiiallpnx.  ami  in  the  later  stajies  of  disease  eiidiiip 
in  tlie  deatii  of  tiie  patient,  wiiere,  from  in.aiiility  to  close  the  eyes, 
the  corne.a  is  exjiosed.  In  all  cases  of  desiccation  keratitis  the  por- 
tion of  cornea  first  afl'ecte<i  is  the  exposed  |ionion. 

Desiccation  keratitis  is  prohihly  most  fre((uently  observed  in 
laf;oi)litli;ilmos.     The  ulcer  •  rofiress  and  destroy  nion-  or  le.ss 

of  the  cornea. 

Symptoms.  The  symptoii.s  are,  as  a  rule,  not  severe,  Ahire  or 
loss  pain  referable  to  the  eye  is  complained  of,  and  in  cases  of  in- 
volvement of  the  iris  and  ciliary  body,  .symptoms  peculiar  to  di.sea.se 
of  these  structures  develo]). 

Treatment.  The  treatment  consists  in  jiroviding  protection  for 
the  exjiosed  cornea.  This,  in  the  cases  of  hifiophthalmos  and  exoph- 
thalmos is  accomplished  by  the  ai)])lication  of  protective  bandages 
and  the  u.se  of  lubricatiiif;  ointments.  In  cases  not  admitting  of  relief 
bv  spontaneous  recovery,  tarsorrhai)hy  to  an  extent  sufficient  for  the 
|)roi  ■ciion  of  the  cornea  may  Im'  performed,  .\fter  cicatricial  ectro- 
pion plastic  operations  for  restoring:  the  lids  should  be  resorted  to. 

Kcriitiiiiuilitciit.  Keratomalacia  accompaiiies  xerosis  epitheiialis, 
atTectin^  infants,  and  occurs  in  the  hiter  staf;es  of  exhausting  diseases, 
such  as  typlioid  fever,  scorbutus,  etc.  It  is  characterized  by  a 
prayish  discoloration  of  the  cornea,  increase  in  thickness  (if  the 
corneal  tissue,  accomjianied  by  softeniiif;  .and  coin|)leto  loss  by 
sloufihing.  Keratomalacia  is  .seldom  seen  in  adults.  The  condition 
beloiifis  almost  entirely  to  X(>ro.sis  affecting  infants,  as  has  been 
stated  in  the  descii|)tioii  of  x(>rosis  (see  Conjunctiva),  and  needs  no 
further  reference  here.  A  lethal  result  almost  invariably  takes  place 
in  those  alTectcd. 

Treatment  manifestly  is  of  no  avail. 

Xciiroixtrdhilir  Kcr(ilili.'<.  Diseases  of  the  fifth  n(>rve  occurrinp 
(>ither  in  the  trunk  of  the  nerve,  in  th"  (las.serian  fraiijilioii,  or  at 
the  i\ucleus  of  the  nerve,  produces  insensibility  of  the  cornea,  and 
at  the  same  time  removes  the  source  of  stimulation  for  the  lacrymal 
<:land,  c.ausinir  a  dimimition  in  the  secretion  of  the  jilaiid.  With  loss 
of  the  sensibility  of  the  cornea  and  conjunctiva  the  individual  fails 
to  appreciate  the  presence  of  foreijin  sulistances,  .and  is  not  m.ade 
•aware  of  atmospheric  influences  on  the  surface  of  the  cornea,  which 
uiider^rocs  desiccation.  W'inkiii};  is  not  performed  sufficiently  fre- 
(|uentlv  to  maintain  the  proper  moisture  of  the  (-(irnea  or  to  remove 
foreign  substances  from  its  surface.  This  co>  :'iition  leads  to  jiartial 
loss  of  ejiithelium  and  permits  of  the  entrance  of  destructive  bacteria, 
briiifririK  about  a  keratitis  which  at  fifM  is  superficial  and  general, 
but  later  may  develop  into  deep  ulceration  with  loss  of  substance, 
perfor.ation,  and,  in  the  sevrer  cases,  complete  loss  of  vision.  It  is 
held  by  sonip  writers  that  this  process  is  not  entirely  'lue  to  exposure. 


DISJ-SA^ICS  OF  CoyjiWCTIVA,  VOIiyKA,  AM)  SCLEHA. 


.•!(»!) 


l)iit  tliat  linpliic  ilisHirl):iiiccs  occur  consciiticiit  on  tiic  ilcstnictioii  of 
the  ncivc.  Since,  liowcvcr,  it  is  not  proved  that  tropliic  nerves, 
so-called,  exist,  we  are  not  warranted  in  assuiniiij;  tlu.l  tliey  d() 
exist,  and  we  must  attribute  the  clianfies  that  occur  in  the  cornea 
to  insensil  !ity  of  the  cornea,  to  exfiosure,  and  to  the  entrance  of 
noxious  jjerins. 

Cases  are  cited  by  :■  number  of  writers  in  which,  after  protection 
to  the  cornea  has  been  fiunished,  the  process  has  not  aliated.  but 
has  contimied,  and  destruction  of  the  cornea  has  resulted.  These 
observations,  lujwever,  were  made  jirior  to  a  perfect  understanding 
ol  asepsis,  and  it  is  possible  that  destructive  micro-organisms  were 
jiresent.  and  that  tlie  continuation  of  the  diseased  jtrocess  was  due 
to  theui. 

Treatment.  It  is  found  that  protection  of  tlie  coriipa  eitlior  by 
means  of  a  |)rotective  bandage,  tarsorrhai)hy.  or  bv  the  use  of  oint- 
ments sulliciently  fre(|iiently  applied  to  keep  the  cornea  covered, 
will  l)rin<j:  about  a  restoration  of  the  corneal  tissue,  and  will  prevent 
lurther  dev(>lopinent  of  the  keratitis. 


Non-suppurative  Forms  of  Keratitis. 

Pannus.  This  is  a  form  of  sujierticial  vascular  keratitis,  and  is 
the  result  of  an  attempt  on  the  i)art  of  nature  to  i)rotect  the  cornea 
Irom  irritatin-i  influences.  It  is  observed  most  fre(|uently  in  tra- 
choma, and  occurs  in  that  stage  of  trachoma  in  which  the  I'levations 
Mil  the  surface  of  the  conjunctiva  are  hard  and  dense,  and  are  cai)al)le 
nl  producing  dis|)laceinent  of  the  e|)itheliuni  of  the  cornea  with  which 
they  come  in  contact.  The  vascularity  may  affect  the  whole  or  a  part, 
usually  the  u])per  portion,  of  the  cornea.  In  ca.ses  of  trachoma  in' 
which  the  lower  lid  is  but  slightly  involved,  the  pannus  of  the  cornea 
may  be  lini'te.!  exclusively  to  the  ui)|ier  half.  It  sometimes  occurs 
Ih.'it  the  irritation  of  the  corneal  tissue  affects  cnly  the  lower  half 
uf  the  cornea,  in  which  case  the  pannus  is  limited  to  this  part.  \"as- 
<ular  i)aniiiis  may  be  extr(>mely  slight  {/xiiutiis  tenuis),  or  the  vas- 
'ularity  may  be  very  proiioimced  (jxinnus  niscularis);  it  may  be  so 
intense  that  the  cornea  is  converted  into  a  condition  resembling  a 
tieshy  mass  (iHiiniKs  rrn.-<!<uy  or  nirnosny).  The  vascularitv  remains 
■1--  long  as  the  irritation  is  present,  and  then  gradually"  sub.sidps, 
•'tteii  leaving  bui  few  traces.  In  sev(>re  ca.ses  complete  opacification 
■t  the  cornea  may  result.  In  the  later  stages,  when  few  bloodvessels 
lie  present,  the  condition  is  known  as  pannus  siccus. 

Pathology.  The  blood'  essels  in  paiuuis,  in  the  earlier  stages  and 
mhter  forms,  are  found  immediately  beneath  the  epithelial  layer. 
Iliey  lie  in  a  scant  stroma  of  new-formed  connective  ti.s.sue  or  forina- 
i\e  cells,  and  are  accomi)anied  by  a  more  or  less  plentiful  small-cell 
'ifiltriitiun  In  p:uuius  tenui.-^  Bowukui's  membrane  reniain.s  almo.st, 
I  iii.t  ((uite,  mtact.  In  the  severer  forms  of  pannus  the  superficial 
lUiella-  of  the  substantia  propria  are  involveil  and  Bowruan's  mem- 


:i\t) 


Tin:  i:yj:. 


I)r;iiic  is  };rc;itly  (•Ii:iiij"m1,  l().>in>r  its  cliar.-ictcr  ciilircly.  It  is  never 
restiireil. 

Treatment.     Tliis  consists  in  feniuvirif;  tlie  ("iiise. 

Herpes  Corneae.  This  disetise.  which  reseniMes  eczema  cornea'  in 
some  respects,  is  to  lie  dit't'erentiateil  liom  it.  It  occurs  as  an  accom- 
paniment of  herpes  lelirilis  most  l're(|iiently,  liut  also  accompanies 
lierjies  Irontalis.  It  is  characterized  hy  the  appearance  in  the  cornea 
of  two  or  more  vesicles,  wliicli  at  first  are  transparent,  but  soon 
become  cloudy  and  of  a  yellowish  color.  The  ejiithelimn  then  gives 
way.  Mud  there  is  ;i  su|)erficial  ulcer  with  shreds  of  epitlielium  hanj;infi 
from  it.  The  floor  of  the  ulcer  is  ana'stlietic.  hut  the  surroundinjr 
cornea  is  not.  Tin  a|)pe.arance  of  the  vesicles  is  preceded  by  sliariJ. 
prickiii";  pain,  by  lacrymation,  and,  at  times,  by  nuic(>])uru!ent 
.secretion.  The  jiniy  inhltration  at  the  base  of  the  vesicle  may  not 
extend,  liut  tine  lines  of  inhltration  extendin<;  into  the  surrouiidinji 
cornea  may  be  present.     Crops  of  vesicles  are  a|)t  to  occur. 

This  form  of  keratitis  attacks  adults  of  luiildle  life  most  fre<|uently. 
Vounj;er  individuals  may  lie  attacked.  Accomjianyinj;  herpes  of  the 
cornea  there  may  be  herpetic  vesicles  on  the  lips,  iio.se,  face,  and 
eyelids. 

llorner.  who  described  this  atTection  in  ISTl,  oli.served  it  followiiifr 
pertussis,  intermittent  and  typhus  fever.  .Vccordin;;  to  llaab,  the 
outer  layers  of  the  cornea,  Howman's  membrane,  .and  the  epithelial 
layer  may  i)e  elevated  by  the  process.  In  cases  that  are  suit;d)lv 
treated,  recovery  occurs  as  a  rule  in  a  week  or  ten  days.  In  neglected 
cases  sec<indary  infection  may  occur,  accompanieil  by  more  or  less 
destruction  of  the  cornea,  hypopyon,  and  iritis. 

Treatment  should  be  local  and  constitutional.  ( 'le.ansiiiji  the  eve 
with  a  '-i  per  cent,  solution  of  boric  acid  three  or  four  times  daily, 
and  the  introduction  of  bichloride  vaseline  (  I:.")()()0»  after  each  balli- 
iiij:,  will  be  sutlicient. 

('oiislitutional  treatment  should  be  directed  to  improvement  of 
the  general  .system. 

Keratitis  punctata  superficialis  begins  uitii  symptoms  of  acute 
conjunctivitis:  it  is  related  to  herpes  febrilis  cornea',  but  does  not 
form  \-esicIes.  Small  gray  spots  form  in  the  superficial  layer  of  the 
cornea,  occupying  the  central  portion:  the.se  may  be  very  numerous, 
or  may  be  limited  to  six  or  eight.  The  corneal  surface  is  rendered 
uneven  by  the  elevation  <if  the  epithelium  lying  over  the  spots  of 
infillrali<iii. 

Bullous  Keratitis.  This  condition  consists  in  the  formation  of  a 
large  vesicle  or  vesli'les  on  the  cornea,  usually  occujjying  the  lower 
portion  of  the  cornea.  It  occurs  in  eyes  that  are  affected  by  a 
chronic  iridocyclitis,  after  sujierficial  traumatism,  and  in  those  whicli 
;u-e  subject  to  increase  <if  tension.  The  presence  of  the  bleb  or 
!>u!i;t  is  ;u'con:paliird  !iy  syUiptotiis  .if  l;>il;tlioii.  There  art'  ('XC<';ssivr 
lacrymation,  iihotojihobia,  and  mucopurulent  sec.etioii.  The  affec- 
tion is  jieculiar  to  adult  life. 


i:_ 


i>i.si:asj:.s  of  co.v./r.vcv/r.i,  c»iiM:.i,  .i.vy>  sclicua.     .hi 

Duration.  'I'lw  l,|,.|,  usually  persists  for  ;i  lew  ilavs.  tlwn  niptiircs 
the  tliivjKls  of  cpitlicliimi  liMiijiiiifr  fn.in  the  iiiar<;iiis:  il,,.  ,l(.nu,|,,i 
surlacT  IS  rapidly  rccdVcriMl  hy  ciiitlicliiiin.  In  soinc  case-  tli..  Mrh 
nf«'ns  spuMtaiK.msly  al  th."  siiprrior  part  aii.l  tlir  hid,  wall  l.ccnincs 
nattaclKMl  to  the  cnriK-a.  l{(Tnrr..nc.'s  aiv  lr(>(|ii.'iit,  tin-  nriirrnicc 
takiiif;  place  iii  some  cases  within  a  tVw  davs.  aiul  in  some  cases 
months  or  years  atterv.anl. 

Pathology.  'I'lie  outer  wall  of  the  hleo  consists  of  the  entire  epi- 
lii.'lial  layer  of  the  cornea,  which  h,i.>  heeome  raise.l  by  the  tr.aiisu- 
I  ation  of  fluid  through  Howman's  nienihrane.  lirufrjrer'  helieves 
that  the  first  step  is  an  infiltration  of  the  .substantia  propria  of  the 
<Y'".ea  with  fluid  which  could  not  escape  bv  the  liinims:  iiev;  tissue- 
'•nnenis  lorm  beneath  the  epithelium  of  Bowman's  membrane  and 
the  ei.ilhehal  layer  eventually  becomes  detached  and  is  pushed 
torward.  ' 

Treatment.  It  is  sometimes  sufficient  to  puncture  the  vesicle  and 
.•ipply  a  compress  bandage.  It  becomes  neces.sarv  in  sonn>  case-  to 
remove  the  anterior  wall  of  the  vesicle,  ami  to  "treat  the  denuded 
suriace  by  an  api,lication  of  a  solution  of  nitrate  of  silver  0  5  i.er 
cent,  to  1  per  cent.,  or  by  superficial  caut.Tization.  In  some  ca«es 
removal  ol  the  superficial  parts  of  the  cornea  has  been  resorted  to 
It  IS.  ..t  course,  desirabli'  to  cure  the  condition  which  makes  the 
lorniation  of  the  bleb  p,,ssible.  The  ultimate  result  in  the  vast 
iii;i,iority  ot  ca.ses  is  favorable  for  retention  of  the  eve  .aiid  the  pre- 
servation of  some  defrree  of  vi-^ion.  In  rare  cases" removal  of  the 
irldbe  becomes  necess;irv. 

Parenchymatous  Keratitis  (Int^stitial  Keratitis;  Diffuse  Kera- 
titis!. l';ireiiehymatous  keratiti/mav  develop  from  the  peripherv 
■■I  the  cornea  or  first  manifest/self  by  thi-  apjuNiraiice  of  oj,aeitie"s 
"n  or  near  tiic  centre  of  tlir^ cornea.  A\heii  developing:  from  the 
|i''npliery.  its  free  border  is  irrejrular  an<l  is  usuallv  less  dense  than 
■Il  the  marjrin  of  the  cornea.  If  .-an-fully  c-xamined.  the  infiltration 
will  b.'  I.,und  to  be  uneven  in  den.sity,  fre(|ueiiflv  beinjr  made  u])  of 
:.  number  of  loci.  Thickening  of  fhe  conjunctiva  "at  the  sclerocorneal 
.iunction  accompanies  the  process,  the  limbus  apparentlv  advancing 
:i  sh.irt  distance  onto  fhe  cornea.  The  limbus  here  is"deei)ly  con- 
i;i;st('(l  and  pre.-^ents  a  bright-red  border.  The  extension  of  the  ve.s.sels 
"t  the  conjunctiva  onto  the  cornea  is  limited  bv  a  sharp  line  of 
demarcation,  and  sel.lom  exceeds  I  mm.  or  H  nim.  Soon  vessels 
ni.ike  their  appearance  in  the  i)arenclivma  of  the  cornea  and 
■Mend  into  the  infiltrated  .area.  The  inf'iltratic.n  .advances  toward 
'l|''  centre,  and   may  eventually  involve   the  whole  of  the  cornea. 

I  lie  op;icitication  may  become  limited,  afTecting  onlv  a  small  portion 
•I  the  cornea.  It  .seldom  occurs  that  infiltratioii  of  the  cornea 
Hlvanemg  from  the  margin  involves  the  entire  margin  of  the  cornea 

!^il.,nn!y.     In  the  majority  of  cases  infiltration  begins  in  the  lower 

II  SI  I  (luadraiii. 

'  .Mou.     f  Aug,  Ueilk..  1886,  vol.  x.xiv.  p.  500. 


.$12 


Tin:  lAi:. 


The  scconil  iiiikIc  nt  utisct  is  that  in  wliicti  tlic  oparity  fifst  iiiaiii- 
tVsts  itself  ill  tlic  ('('litre  uf  the  ('(iriiea.  In  tliesc  cases  thi'  iiitihratidii 
iiccurs  ill  miiiieniiis  foci  in  tiie  centre  iif  tiic  cdrnea,  ^fachially  spread- 
ing until  the  greater  part  of  tiie  CDrnea  is  involveil.  (Fig.  14(i.)  The 
vessels  of  the  liinlms  throughout  the  whole  pi'riph  ry  of  the  cornea 
are  soineuiiat  inject<'(l,  hut  the  |iriiici|)al  vascuiai  ty  occurs  in  the 
deep  tissues  of  the  cornea,  advancing  from  ihi"  periphery.  In  hotii 
forms  of  onset  the  -urface  of  tiie  cornea  becomes  soP'ewhat  irregular, 
thit"  to  numerous  iiiimite  elevations,  \ision  is  impaired  in  propor- 
tion to  the  density  of  the  intiltratioii.  The  intiltration  of  the  cornea 
advances  rapidly,  in  s<ime  cases  involving  the  entire  corneal  tissue 
ill  from  two  to  four  weeks.  In  some  cases  the  advance  is  much  less 
ia|)id,  the  height  of  the  atTection  heing   readied  only  after  two    or 


Fill.  1411 . 


■' '''  ■ 


.v.„%j5j;' 


i.^*"*-"  ■-*•»»," 

;       ti-JE-% 


Section  ol"  interstitial  keratitis.    (Wkdl.) 

three  months.  In  the  average  case  the  corneal  tissue  recovers  its 
transparency  almost  entirely,  but  on  close  examination  with  briglil 
illumination  o|)a(|ue  tissue  may  be  detecteil,  and  a  fine  network  of 
lines  representing  the  site  of  the  vessels  may  be  made  out.  In  many 
ca.ses  the  tissue  of  the  cornea  does  not  appear  to  have  been  greatly 
affected  by  the  jiroccss,  but  in  the  severer  ca.ses  sclerosis  of  the 
tissue  results,  the  cornea  becoming  thinned,  and  its  diameter 
increased  by  stretching  due  to  the  mtra-ocular  pressure.  In  some 
ca.ses  only  a  ]>ortioii  of  the  cornea  becomes  scleroseil  and  (>ctatic. 

Duration.  In  the  average  c.'t.se  the  disease  runs  its  course  in  from 
five  to  ten  months — selilom  less  th.'in  five  months  even  in  the  mild 
cases:  In  tiie  severer  cases  the  clearing  up  of  the  cornea  does  not 
reach  the  ma.ximum  in  les.s  than  two  or  three  years. 


DISEASES  or  coyjryvTiVA,  cnjtsj,.i,  a.\j,  svlui. 


31.} 


tlic  eye- iris,  ciliary  l)u,|y,  aihl"  (•|,„n)i,|. 
Symptoms.     More  or  less  irritation 


increased  lacryinatioii,  photo- 


,  1,   1  •      •  ■•..■..,,,  nil  n-.i^rii    acrviiiaiion    Dlioto- 

: ;':,;::  ''TT" '"  ""■  ';''"'"^>'  "^  -iva,u.e.i.nt  o  ti  r 

'c.n ^vni in:'";;'  "'"■"""•'  ^t'  "■  ''"«^«-  -""•*""-  -luit.. 

Cause       P ,  ."•■•'  r"'  "•'  .''"■  ••■"'I''"'   ="■'■  '•XFKTic.ur.l. 

Cause.  1  an.nfl.y.natous  k.'rat.tis  is  -luc  in  ti.c  va.st  niajoritv  of 
;-.iM>  to  syph.l.s.  .Mth.-r  inlH.rit.Ml  or  ac.uin.d.  InlH..it,Mi  s  •  L  is 
s  ,y  ar  th..  most  l,v,u..Mt  <aus,.,     m...un  mtisn.  an<i  p.u    l?.      '^ 

.   aps  m  very  t.w  ..asos,  an.l  in,l,.finit,.  ,|ys.rasia  Ly  also   .'aid 


'"  l"".lucr  ii  very  small   proportion  ui  the  cases.     As' 


liid 
result  of 


Fig.  H7 


_^§^fili^ 


IVmmrieiit  Incisors  of  inherited  syphllli). 


Rachitic  teeth. 


i"li"il"l  «.vr.l,ilis.  it  ,„„,-  „(I„1  i,„livi,l„.-,fc  l,o(,v,,.„  ll„.  «,„  „f  ,i,,. 

::;  t':::s:;;«c;,[:. "-"" " ' "■ '-—"  .i:'.;» 

Accompanying  parcnchytnatoiis  keratitis  ,lue  to  inherite.i  svi.l.ilis 
;|  <•  .-.Ttain  pecul.anties  in  the  conformation  of  tlu'     ,!^1  ^^ ?     . 

^■;.p-:t..Smt;;:;fr^;:;;;^--;;L;in:^^^^ 

;n;.<n.,.  principally  the  n^^tL^'^.^.  ^^^  ^tt^ 

no  H     r/,;   t  ,e  fn    'llr;  e'r      Tr-'""r''  '^^';  ir«-ha,,ed,  and  present 
'""h  ni  tm  ine  border.     This  form  of  de.itition  was  described 


:il4 


I  III:  iivi:. 


I 


hisi  l>v  lliitcliiiisi.n  ;i>  iiccuiiiicmyiiif;  lln>  Ml'lVctimi,  mid  is  known 
as    Ihacliinxm    Icc'ili.     ( Tij;.   ItT.i      ll    -limilil    not    lie    (•(.nluun.U-il 

witli  lliul  in  wliicli  ti nainci  is  (Ictcctivc  at  tiic  a|ic\  of  the  trctli, 

(11-  in  whicii  1)V  a  |iria<'i''l  aniicarancc  of  the  i-naincl  ililTrnMu  |)li:i.s«'s 

ii,   its  ilfvclui MU    arc   tvinvscnlcl.     'IVcih   nf   iliis  cliaiartcr  arc 

usually  llic  rcMilt  «>!  rickets  ami  ol'  oilier  forms  of  nialniilrition  ni 
the  iiii'ant.  (I'ifl.  UN.)  N"'  infrequently  the  heariiif;  in  infants 
with  iiarcnchyinatoiis  keratitis  is  defective,  due  to  involvement  of 
the  auditory  nerve 

In  pareiichviiiatous  keratitis  the  result  of  ac(|iiircd  >yi)lulis 
involvement  of  the  cornea  occurs  from  six  months  to  as  many  years 
after  the  ajipearance  of  the  primary  sore 

Treatment.  The  treatmeiit  should  Iw  local  and  constitutional.  In 
puretichymatous  keratitis  .lue  to  inherited  syphilis  the  treatment  is  not 
the  same  as  that  employed  in  the  cases  due  to  acipiired.  syphilis.  In 
the  lirst  form  the  local  treatment  consi.sts  in  the  use  of  atropine 
for  the  purpose   of    maintainiiif;  ililatatioii   of    the   pupil;    the  use, 


ordmarilv,  <> 


tl 


le  cornea: 


if  stinmlatinn  ap|ilications  to  induce  vascularization  c'f 
iiid  inoditication  of  the  lij;ht   by  dark  plasses,  suitable 


shades,  or  by  keeping  the  patient  ui  a  da 


:irk  room.     In  manv  cases 


)f  this  disease  stimul.ition  is  m 


t  necessary  in  the  early  stafie,  but 


stimulation,  altlioujih  not  necessary  m  many  ca.ses,  is  never 


harn 


fill,  and.  ill  the  opinion  i 


if    the  writer,  is  desirable  even  in  those  cas 


II  which  the  onset   is  relatively  ra| 


Stimulation  i 


IS  effected   bv 


means  of  the  introduction  of  suitaiiie  ointments,  either  ointment  ol 


yellow  o 
i  1  ■.■)()(l()l 


\ide  of   iiiercurv  il    to   !..')  |ier  cent.)  or  mercuric  ( 


•hloiic 


)r  the 


iiistill.-ition   of  stimiilatiii>;   druiis 


the  wine  of 


Ilium,  or  by  hot  a|>plicatioiis  t<i  tin 


eve,  usually  liv  means  of  ;iioist 


heat  ihot  batlini!;! 
acid  three  or  four  timi 


ither  with  salt  water  or  a  hot  solution  of  boric 


.1  da\.  lifteen  to  thirty  minutes  each  time). 


Powders  may  be  dusted  into  the  eye.  the  best  beiiiji  calomel.    Caloni 


when  employei 


1.  shoulil  be  introduced  i 


nice  a  da\ 


Internal  treatment  consists  in 


the  WMieral  tonic  treatment  of  the 


iniliyiiliial 


iiid  the  administration    of    a    iiK-reurial   with,   po.ssibly, 
have  apparently  a   lietter  effect  than 


potassium  iodide.      Mercuri: 
the  iodide  ;  tlii'  mercurial  m.iy 


ninisti 


red  satisfactorily  in  tin 


form  of  calomel,  0.1  firain 


four  times  daily,     ("hildren  bear  n 


'dicii 


tion  of  this  kinil  even  better  than  ailult 


I'arenchvinatous  keratitis  due  to  ac(|uire<l  .syphilis  ordinarily  doe: 


not   recjuire  stimulation.     In  other  respects  th 

similar 

tre;it:iii'!it     is 


ll   treatment  i^ 


to  that  eiii])loyed  in  the  inherited  form.     The  constitution 
(■    as    that    ordinarily   employed   in   acquin 


tl 


le    s;ili 


sviihilis.     It  should  be  rijrorously  inishei 


Sclerosing  Keratitis  (\oii  (Iraefe 


riiis  form  of  keratitis  accoin- 


Danvinsi  scU 


■litis  is,  in  fact,  an  extension  of  the  pn 


•ocess  into  the  cornea. 


The  opacity   is  of  a 


layers    ot 
'  >ill 


tl 


le    cornea. 


avish-while   color  and   liivotve>   the   deeper 
It    advances    slowly,    seldom    reaching    the 


pupillary  area. 


The  oiiaciflcation   ol    the  cornea  ( 


does  not   extend 


II'"  opacity  Ml    tlu-  n.aruin  n.ay  l„.,.u„.,.    ,1  ,11^1,4  ,1,.    "  i,   ,,,,  ,„ 

-"'■'..a    tissu,.  ,s  a,  na  tin.,,  thi.-k,-....,!:    as  tl.,    ..panfi     ,1  „    1  s- 
I-<ars   tl...   n.UH.al    tissue    inav  l.,r..„„.   n.lur.Ml    i,    (I     k      ''  ^ 

l.-n.,n..s  .nvjiuar,  an,l  s,„n,.  ,|,.f,.,.ts  in  it  n.av  .Krur 

Symptoms.      I  „■  syn.ptu.ns  arc  thus,.  r,.f,.,,,i.|,.  f.  th,.  scN.ritis   an.i 
uill  I),.  ,l,.s(.ni),.,i  under  that  hcailinj;  '  '"" 

lHv.ti:,.nt  .^th,.  pnniary  ath.,.ti..n-th,.  s,.l,.ritis 
Stnated  Opacities  of  the  Cornea.     .\ft,.r  „p,.rati,.ns  n,.c.,.s.i,a,in.r 

"■'"' '  ^''"  '•"■•"-'  <'-""■  -  .  n.sult  ,.t'ti«ht   handa^in."    a    r 

'     ;:"■  ••'"■^  ^" •"I^.nyn.R  ulceration  „f  th,.  ,;.rn,.a,  !,.n^   rurn  w 

^  MVish  s,r,,,,.s  are  ,.hs,.rv,..|   uhi,.h   trav,.rs,.  th,.  ,.,.rn..a   h    "•  ,      ^ 
'"'■.•tn.ns.      !hey  ar,.  .•.ppar..ntly  una..,-oM,pani,.,l   l.v  inflann   •    i  n 
!-    >"in.  n,..,s,ons  ..t   ,h,.  ..„n...a.  th,.  strifls  ...wnnvn..,.  a       n       v 
at  tlie    nMr.m,  .,.  the  n.c.s,,,,,  an,|  ,.xt,.n,l  in  ra.hatinjr  hn..s',     •        ;. 
--   .l.'.j..anc,.  iron.   th..  .„un.l.  s,,nK.tin„.s  tra^;rsin,  th,.';.,;    n. 
'"„,,.      Il.ex  app,.ar  in  Ir.wi,  turnty-lour  to  t„rtv-,.ijrht  hours  ..fier 
I-    n,,.,s,on    ^   n,a,ie,    and   disapp,.ar   v,.ry  «raduallv.         .    !s         -^ 
7",."'-''''-l    '•;,  ^vlwl.    th,.  ^r,,,vish   hn,.s   r,.n.ain,..l   p,.rn,a..,.  ty 
"'!■  '""■•"■  "l'.a'ahcation  n.ay  W  so  slight  as  not   to  i't,.,  er .      i{h 
Mon  ,n  any  w..y.  an.l  ,nay  h,.  sulfi,.ientiy  ,|,.nsc.  to  .-aus,.  a     e<^  h^ 
"""...ion   .n   vision.     In  striat,.d  opacitv  of  th,.  ,.,.rn,.a   r.'  u    iiVJ 

■;:  . '  1;  '\  "'"  :'«"'*^' ;'"'  '";-'"='>•  '•••-  --i'  -ti.--  i"  aii  .nn.."  i  ^ 

..-  nsimlly  most  n.ark,.d  near  th,  ,.,.ntn.  of  the  ..oriu-a.  In 
;  '""I  oi.a,.|h..at,on  a.-conipanyinf,  ,„,,n.al  uic,.r.  the  stria-  radia  ,! 
,""'  th,.  n.a,-«ins  ot  ti„.  uh-,.,-.     Knies,  Fuehs.  an.i  oth,.rs  at!  i       e 

•ml':'  ,^:;;;';-"'  "'-•"'-":-  ♦"  -nnklingof  I,osc..n.,.fs  ni,!^ 
"an,     that    occurnnK  att,.r  M.c.sion    of    the   cornea    l.eing   due    to 

n.  I  at  tro,.,  ban,  ajre  pivssur,.  to  a  r,.,iuction  in  lie  tension  of 
'  doh,.  or  fiatt,.n,M«  ,.(  th,.  ,.orn,.a.  H,vk,.r  an,l  von  Heck!  ,1- 
"iM.n  .ien.onstrat,..!  th,.  fa-t  th:,t  the  !vn,ph  ..hannrls  in  i 
--  aiv  son...tiin,.s  .iis,..n.i..,l  an.l   th,.ir  .-ontlnts  til  Th  ^ 

>ti.ufrht  In.es.     It   has  l„...„   thought   that  the  channels  thn.ugh 


.'U6 


Till-:  /•.»■/.• 


whul.  tl..'  ...TV  tnn.k.H  pass  iMMMmu-  lillr,!  will,  t.ul.hl  tl.i.a  a...l  ....... 

^'c;^:;'T;;;.;:'r  lit,... .......  .,r  .his .i,i....  u.;......- 

„C.s  pla.v  i..  .!..■  ...ajo.ily  ..f  ..as,.s,  a...l  .!..•  t.-a..spar.-,.rv   ol   th. 
"StiXn  Of  the  Cornea  Originating  from  the  Posterior  Surface 

l,"Ts   vvl>.n.  a..   ..x..aa..on.   a   I....S  .lisl.K.at...!   ...to   th.   a  ..-■..n 
,'    ,;„,,   „,  ,,  ,vsl  Mi  th.'  i.is  h..s  af:ai..s.  .!.•  <-nr....a,  a.,  npac'v  ...a> 

r    w!.H.h  ...ay  ...v..iv..  ,h..  ...>ti.v  .hi.-k.K.ss ...  t  .•;-...;.•       •;; 

,...n..>a  ai.i>.-a.-s  t..  !.«•  ...ac.af.l  a.  th.  p.....t  .,f  ......ta.'t.  th.-  >..... 

uZi-  slilrhtlv  .■i.-vat...l  ai...v.-  that  ..f  th-  ^nnnnud^nii  .•-.r  ..'a.     I-    •- 

'"Deep'vascular  Keratitis.    This  ,lis,.as.-  ..f  th.-  .;..n,.-a  .l.-v.-loi.s 

1,V  tra.lvann-....-..t  ..f  ...i....t.-  v.-sm-Is  In..,,  th.-  ...a.p"  ...to  th.-  .l.-j-l. 

HV  .     ,  —  pa.v.,.-hv.Ma  ..f  th.-  .•...-...•a.     It  a,.,..'a.s  a.  a  ............  pal.- 

,f   th.-  .•...-...-a:  it  K.a.h.allv  l.r-.a.l.-i.s  a.i.l  .•xt.-...U   .....  thy  .......a 

ts   r  ^Zn  passu.«  l>.-y..n.l  th.-  p..pillary  ...a.^i...  a...l  ....t  ^u.^^^ 

...  ,ha..  ....l-.p.a.t.-.-  ..!■  th.-  .•i.Tm..lVn-...-  ..    th.-  <;";>-=^-     "^  -,' 

VUT..W  .,.a.gi..  ..f  i..tiltrati....  p.v.-.-.i.-s  th.-  vas.-ular  pat.-h.     Th.-  i        I 

"  ![,.,-s.!st  at  th..  ...a.t;i..  of   th..  .•or.u.a.  (tra.lually  h.............  n  .,„..-. 

until  it  C(.as('s  ahii.l.tiv  at  its  fr...'  li..nl..r. 

"  SyJi^ms.     Th.-  aiM-as-  is  a,..-o„>pa.,i...l   i.y  sy,np..,...s   ....•.- 

XhT<Lh^  .nstu.-ha.,.-.-s..f  visi...i,a..a  phof.phol-.a.      1  u-  ...-uia.  ..  ..- 

S;;;;;:,iva  is  '-......-stc-l  l..  tlu-  vi,-i..ity  ..r  .l.-  vas.-,.lanzat,o,.  o,   ,h.- 

'■"cause  l)...-pvas..ula.-i/ati....of  th.-  .-onn-a  is.h..- 1.....!..-.'  i..h.-ri..;a 
o.-  .riuir...!  s'pi.iiis.      It   .s  p.-ol.ahly  ......    with   .-.".v  •-■.■.....■..'ly   ". 

-r;i:''^'T.;;;;:s;ix^^^^^^ 

f..,vTwi.h  l.v  t.v,tnu.,.t  ...ay  last  fro...  th.-.-.-  to  >,x  m.....hs  Ph' 
!:;;,;«..,  l..-.-o,..c.s  ..•a,.spa.v..t  wi.l.  ,1...  .•x-.-p..o..  o.  a  v.-.y  sl.,h. 
clou.h....ss.     lv-.ati..-tasia...ay..v....t.iallytollow. 

Treatment.     Tn.:miu...t  shoi.l.l  Ih.  local  a.-.  1  syst.-,.,ic_     Loi-a    I  .at- 

„.^"^:^ists  i„  s,„n.,lati..,  .h..  ,.•  ..vss  hy  hathm^  w,th  ho    s.  J.  uh.s 

soiutio..  ..f  l...ii<-  a.-.a,  :{  p.-.-  .-.■..t.,  l..-...f;  usually  .-i.plo>.-ai,  th..     >< 

<r       .    ,     t..  pn-v,-..t  postU..r  sy...-.-hia- in  .•as.M.f  .nv..lv......-..t  ..^^^^1^ 

:  1...  fn.M......t  i..t.-oau..tio..  ..f  s...,H-  .....t.......t.  as  th..  y.lK-Nv 

;;Sa".f.u......■^^l-• '•'■■>'••''■• ''^''-■•''''^t^li^^ 

iuiK-val   <ac       Th..  svst........    t.-.-at....-..t    shoul.l    Ih-    the    o..lu.a..% 

"    <;     ,ili...-  ..■oat.,..-..-t,  .-nploy.-a  vgon.usly  h.r  th.-  h.st  f"-  ^v-k>• 
,  ;„'„,,.„,,„„,  ,„  ,  „..,.i.-.-at.-  ^vay  f".:-".;.n""ths  subs...  ._.    Iv. 

Ribbon  Keratitis  (Trophic  Keratitis;  Bandolet  Keratitis:.         ^ 
.    '""""'f.  ..  ,  _.    ..f  ,,,.„„,,,,r..,„.n  uf  th.-  a.it.Tior  lavci^  ..f  the  coru.-a. 


It 


(.(•(•urs  ...  ey. 


that  have  Ix-c.  l«>st  thi-.)ugh  glauc.).. 


affpctca  l>y  iiittai..i..atioii 
m.iro  .)r  less  d.-p-.i.-ratio. 


ith 


if  tin-  antcrioi-  s(-fi.i.«'.it  of  thi-  jclol..-.  w 
of  the  cor.K-a.    The  .^pithcliu...  "f  that 


/>/.S/;.l.N/..v  „t   CKSJI  SvltVA,  CUliSEA,  AM,  SCLtJU.       .-{17 

P">'i'"i  "I  III.'  <-nrti...  n,m.~pun,linK  I"  tin-  n|„,,in«  ,,f  U...  |,:,l,H.hnl 
■  w     lias  >pa,v   lH...n„u.s  .■lou.l.v.   Mini    wln.i.s|,    ,.la,,u,.s  ms<.,„hlin« 

a  y-v  j.nl.i  ty,H..     \,s,o„  is  int..rf,.r,.,l  ui,h  Lrau..  „f  ,h      .,   ..  ! 
Ii"ii  <.l  the  n,,;M,u.-  strip  ..v<.r  the  pupillarv  area 

Treatment.     A.ulr   Inm.   tl...  (..nnati.,,,  ..f   an   artificial   p„,,il   f.,r 
\isual  ])urpust>.  trcatiMciit  is  ol  n,,  avail. 

Non-inflanunatory  Conditions. 

Arcus  Senilis  Corneas  (Oerontoxom.    This  „cnirs  as  a  nam.w 
^'rMy..i,-wlMt,.  |,,,M,|  wlnrh  appears  at  tl...  nu.rKi,.  n(  the  o-rriea     The 
I'aiHl  IS  scparal...    tn.n.   the  lii„l,„s  l.y  a  narniw  strip  „(  uvrivctW 
.•-ar  .•..„,.,•>:  t  „■  Im,.  of  tnmsiti,,,,  is  sharply  cut;  tmvl.nl  tl...  n.„tr;. 
;;,    I'"  .■.„•„,.,  th,.  ^rray  1,...„.|  ta.l,.s  Kra.h.aily  into  transparent  .•unira 
ll.i>  pay  han.l  ,s  .hu-    t.,    th,.    pr..s,.n..,.  „f    tninuf..  kI..1,u1.-s  „f  fat' 
hyanu-  in,iss,.s.  af.j  snn,Hi„„.s  ,.alfar,.„us  granules  in  the  snp..rfi,.iai 
la.v.Ts   ul    the   eoi       .,     Th,.   ehanft..,    which   is   ,K.c„liar   to   a.iuit. 
'Uvrinl.  ..,1  s<.mi.    ;      ,       atrophy  of  th(.  wsm-Is  at  the  litnl.us 
Treatment  is  not  ..i-      sarv. 

Ectasias.  The  cla.s>ifi..ation  adopted  l.y  Fuchs  is  a  v.-rv  ..xcellent 
-!"■.  Me  .hvules  ectasia-  into  those  of  inf!a.nn>at..rv  .,riKin,  which 
include  ..,,/,,y/.„„,  and  k;rnt,ctasia :  and  those  of  non-inHa.nn.atorv 
'Tijrn.  which  include  Lrmtoco„w<  and  krmloqlohiis 

Staphyloma  in.-.y  he  either  partial,  total,  or  multiple.  Staphvlon.a 
1-  a  protuherant  cicatrix,  the  result  of  a  perforating'  ulcer  of  th.. 
<-rn..a  with  mvoh,.m,.nt  of  tl...  iris.  Th.-  iris  mav  Im-  simply  incar- 
■•■  rated  Hit  It  IS  usually  primarily  pr..laps..,l.  Aff-r  a  i...rfoiatinK 
uNcr  ol  the  ..oriu.a  the  cicatrix  that  forms  mjiv  hulf,'..  as  h..alinK 
I'lofrre.s.-,  m  which  cas-.  it  is  termed  prinmri/  sl„f,/n/l,„„n  ■  or  th.- 
'^'•■■iinx   in,.,y  1„.  Hat  an.i   l.uljre  sul)s..,|uentlv.   t.-rm..,!  in  this  .-as,- 

""'."'";■"■;'"/'''■'""""■    Th..  shai f  th..  stapln-l.,ma  is  usually  c<..ii..al 

!'-"ti..ularly  m  the  partial  staphylomala :  in  f.tal  staphv l-.x  it  may 

-■■  -ph..ncal.  ._|tt..n  th..  e.l^n.s  aiv  al.rupt,  and  they  nmy  eV.-n  oy.-rhanp 

"•  ••oni.-a.      111,.  d.-j;re.-  of  th.-  protrusi..ii  yari.'s  jireatly.     In  certain 

.j'hylomabi  cic-atricial  han.ls  .levelop  across  th..  surfa.....  .-xten.linK 

various   .  irections,   pro.luci.ifr  a    lol.ul;it..<l   ..onditi.m    kn.iwn   a- 

•■"  iiiiii'v  sidphiiliniiii. 

>i.iphyl.,ma  may  d<.v.-l.,p  ..ith.-r  heciuis.-  of  the  protrusion  of  the 

■■■'  nx  due  t.,  th..  normal  t..iision  of  the  ghilK-,  th..  tissue  being  to.. 

'  ak  to  withstand  the  pn-ssur.-.  or,  as  is  m.)st  fmiuentlv  th.-  .-as,-, 

"•  -tapliylonm  .l.-vel.)ps  Ix-caus.-  .,f  an  incr.-ase  .)f  intra-..pular  tensi.).. 

I  .•o.whti.m  of  s,.condary  irl..u,CMma.     In  p.'t-t-  when-  ihc  entire 

ii'illary  margin  of  th<-  iris  is  involv.-d  in  the  ci.-atrix.  the  oniniuni- 

' ''''♦^ve.-n  the  ant.-nor  and  p...steri..r  chamlwrs  is  shut  oti'  and  an 

■  i''.i-«-  m  t..nsi..n  naturally  f.-llows,  Ix-caas.-  .)f  a  cl.)surp  of  the  nat- 


:]18 


Tin-:  i:yi:. 


iiral  wavs  U<r  tlic  csciipc  of  seen 
Th 


tiiiii  t'rniii  tlic  interior  of  the  eye 


increase  ni  tension  usually  conu 


on  extrenu 


Iv  si 


owlv. 


Il 


I  rare 


however,  tlie  inerease  in  tension  is  rapid,  and  may  lie  attended 


1)V  inliainniatory  sytuptoius  and  by  pan 


Consequences.      In  tiie  early  stajii 


s  of  tiie  formation  of  .stapiiyioma 


vision  is  interfered  with  in  proportion  to  tlie  extent  of  opaeihcatiou 
I  the  involvement  of  the  free  mar>rin  ol   the  ii;is 


if  the  fornea  am 


im- 


I'nless  .secondary  fjlaucoina  supervenes.  perce|)tioii  of  lifjlit  is  mam 
» .: I  1 o,.  ,",i'    .■■.t..i,f  i,.M    i.f    the    integrity  of  the  ih-eper  tissue: 


tained  because  of    retention    o! 


o: 
enlarsje, 


f  tiie  Klobe.     W  ith  increase  in  tensii  u  the  stajihyloma  c.intiiuies  to 
the  retina,  choroid,  and   ciliary  body  become  atropine. 


In  inanv  cases  the  traiisi)areMcy  ot 


the  len-  IS 


lost,  the  lens 


lUlllK 


and  in  soim 


■ases  is  transformecl  into  a  thin  opaque  ( 


hsk.     li 


■itaphylomata  tiie  apex  is 


or 


take 


times  re 


aneous  coiuhtion. 


freiHieiitly  exposed,  and  iiecomes  ulcerated 
Kctropion  of  the  lower  lid  some- 


<ults. 


The  anatomical  conditions  present  are  a; 


>ll< 


The 


ins  alwavs 


lines  the  posterior  surface  of  the  protrudinji  portion:  suiierimi 


i()se( 


on 


the  laver  of  ins  is  a 


of  the  coniea  that  have  not  beei 


layer  of  cicatricial  tissue,  plus  the  eleinent.s 
destroved  i)y  the  ulcerative  process: 


covennj; 


an< 


this  is  a  laver  of  epithelium.     The  ('[litlielial  layer  is  thickened 
less  of  the  cicatrix  varies  in  different  parts. 

found,  but  at  the 


1  irrefiular.     The  tliicki 


,\t   the  aiiex  of  the  staplivloma 


no  c(iriieal  tissue  is 


sides  corneal   tissue  is  ]>!   -en 
variety  it  fre(iueiitl 
mation  of  the  pnn 
be  extremeh 
rtl 


cornea. o 


ir\-  mav 


t.     In  tot.al  staphyli'ina  of  the  spherical 

lis  that  no  corneal  tissue  enters  into  the  for- 

..});  portion      The  walls  of  the  staphyloma  may 

|ierhai)s  one-third  of  the  thickness  of  the  iionnal 

be  thick  and  dense  and  contain  calcareous  deposits. 


Accoiiii)aiiyii.«  tiie  protnision  ( 


if  the  cicatrix  of  the  coniea  we  may 


also 


have  a  freneral  eiilarfiement  of  the  jjlolx 


Treatment 


Much  mav  be  done  to  prevent  the  foniiation  of  staphy- 


loma 111 


nartial  anterior  svnechia'.  followiiift  ulceration  of  tin'  con 


lea. 


DiiriiiK  the  proce; 
a  compress  banilap 


lornie< 

there 

tl 


Tl 


le  eve 


f    healiiifi   of    perforatinj;   ulcer   of   the  cornea 
sjiould  be  retained  until  a  tinn,  flat  cicatrix  is 

d  if 


liould   be  examined  from   time   to  time,  a 


('Villi 


nee  of  mcreasei 


I    tens 


r    evidence   of    bulsins  of 


le  cicatnx,  a  broad  i 


loma  has  fonued,  if  it  is  partial  an 


M'come  eiinn 


ridectomy  should  be  made.     After  a  stapliy- 

tlie  anterior  chamber  has  not 

1 


Iv  ()l)literate<l,  excision  of  a  small  crescent-shaped  piec 


O! 


f  thestaiiliyloiiia 


y  be  practised  in  connection  with  the  iridectomy. 


TlK' 


eve  mav 


,    then  be  b;iiida>ied.  and  the  baiidafje  retained  until  a 

trix  has  fonii<''l.      It  may  be  necessary  to  remove  the  lens 
tills  manner,     .\blation  of  the  apex 


firm  cica 

in  some  of  the  cases  treated  in 
if  the  staiihyloma  may  be  practi 


loinata,  tiie  lens 

pn 

mav  be  c 


1)1  removed  at   the  same  t 


d  in  partial  and  in  total  staphy 


line 


T 


le  pip 


thus 


duce.1  HKiy  be  prrmilted  to  close  under 


iiress  baiidaire,  or  il 


losed  by  sutures.     In  extensive 
plan  is  to  close  the  opening  by  means  o 


taphvloiiia  a  verv  excelleni 


'1 
f  the 


COIIIUIK 


tiva,  with  or 


lJISlAi;i.S  OF  COSJi-SCT/VA,  COJiSEA 


A.W  aCLEUA.      319 


l><-uclij  suture  „r  l.v  in  ,.rn   .f,  '  "  ''.""""""u^  U.-bacco 

'»u<-l.  pain.     l^Tf,.rulin„  artlH-  .  Kx    f      '  ''"S^';'^'"'"  occasioning 
tan.'.,usly:  following  this     ,.     ,oi'  1       '^  h!!'  ?'  fl  '"''•r  ■"^f^"'" 

..^s..„t  at  th.  ajK.x  of  the  pn.trusion.     Keratecta!;.;  i^h^o:;  t:^ 
This  ron.iition  shoul.l  not  bo  confoun.l,.,]  with  l<oratoronus  k.-nto 

I  fjrayish  aroa-thc  nifiltrate.l  n.amns  of  the  uleor       !'../.,♦     , 
-nay  follow  k,.ratocole,  l.ein,  the  n^iit'ofU..!  .,,;,„  ^ ^S 

:    ?n^       h    i/"'    "Tl^  ""•a.reration  or  prolapse  of  the  iris  f o - 
Res^l     „f  ^         1'    ■"*  fonnation  of  a.!h,T<-nt  leueo.na. 
Results  of  Keratectasia.     Vision  is  .listurhe.i  not  onlv  on  aeeount 

:::£;;j;f  f^^^^^^^^  .--^ 

."." tolSt!:  ""'"■'""  •"  '™^'""  '^^  ^^^""  -  ^-  visual Uposci 

^"IJnNilf '  '*'°'^  M^  ^r**'  Staphyloma  PeUucida).   (Fig.  14!..) 
>^  <-  ulit.on   r,.se,„|,|,.s  kerateetasia;   it,  however,  is  unasiiate 
''  "'"'"»'>'at...n.  an.|  does  no,  present  opaciHcat  on     f    h     Ipex 


:?2() 


rilE  EYE. 


until  tlic  cLiiilition  lias  muhctl  an  advanced  stapc.  It  is  due  to 
thinniiiii  of  the  cornea  and  loss  of  power  to  withstand  the  intra- 
ocular tension.  It  hcRins  hetw(H-ii  the  ajjes  of  twelve  to  twenty 
years  and  affects  females  more  fnuiuently  than  males.  The  condition 
;ieveli)i)s  ill  those  who  sutler  from  malnutrition,  in  those  debilitated 
i)y  illness,  and  occasionally  in  those  who  use  the  I'yes  excessively  for 

close  work.  •■     •.         r    . 

Symptoms.  Keratoconus  is  not  accom])anied  \>y  jjaiii  in  its  earliest 
stages.  Its  development  is  hrou^dit  to  the  notice  of  the  patient  by 
the  etTect  on  vision.  With  the  bulging  of  the  cornea  myopia  and  astig- 
matism are  produced.     The  patient  seeks  relief,  and  is  supplied  with 

glasses  which  s i  nvpiire  change.     With  advance  in  the  conchtion 

vision  becomes  much  imi)aired,  and  because  of  the  conical  shape  of  the 
cornea  relief  cannot  be  obtained  by  glas.ses.  as  suitable  glasses  cannot 
be  made  to  correct  the  jjcculiar  curvatures  imiduced.  The  change 
ill  the  .shape  advances  in  many  cases  until  the  conical  coii(htion  is 


roiiii'Bl  o>rnea.    (Pai.kymi'LK.) 


very  marked.  The  ajM-x  of  the  cone  becomes  opaipie  and  the  process 
limited.  Spontaneous  perforation  and  resolution  do  not  occur  in 
these  cases.  .     , 

Diagnosis.     In    the   very  early  stage  ot    keratoconus        gnosis   i> 
not  easv,  but  careful  examination  liy  me;ms  of  the     .  .  ■oineter 

and  liyVlacido's  keratoscope  makes  the  diagnosis  po.    :    i. 

Treatment.     The   use  of   gias.s's    in    th.'   <'arly  sta   .  dvi.sable. 

In  the  later  stage  improvement  in  vision  may  be  (  .  d  l)y  the 
use  of  the  stetiopd'ic  slit;  IJaehlman's  hyiM-rbolic  lenses  are  of  service 
in  -^nme  cases.  In  advanced  ca.ses  improvement  in  vision  may  b<' 
obt.dned  bv  methods  calculateil  to  i>roduce  cicatricial  contraction 
of  the  cornea.  This  may  lie  bnnighl  Mbout  by  puncture  at  the  apex, 
by  excision  of  a  portion  of  the  tissue  at  ijie  apex,  or  by  use  ol 
the  cautery  ai)l)lied  to  the  apex  of  the  cone,  {{emoval  of  a  small 
eiicular  piirtiuii  at  the  apex  of  tin-  ct.rnea  by  the  trephine  h!t«  also 
been  resorteil  to.  Operative  measures  aflVctiiig  the  ajM-x  of  the 
cornea    increa.se   the   opacification,   whicii   is   in   almost   every   case 


OISKASKS  OF  roxn-SCTIVA,  roRSKA,  AXV  SCLERA.      321 

-li'vctb-  i"  the  pupillary  area.     As  a  c.ms,.,,u(.nco  it  beecnies  neces- 

Ti.^  ^ff  Jt^""  'Hy*^»PJ»tJ>*l°?o'»;  Keratoglobus;  Megalo  Cornea). 

lin>  atr,.cfn„  consists  ,n  a  unifonn  oi.largon.ent  ,.f  the  d„b,.  I 
^.Pl-ars  at  or  shortly  after  birth,  and  is  suppose.l  t„  be  due  'e... 
^len.tal  Klaue.,„ja.     The  e.,„.iiti.,n  usually  aff.>ets  both  eye^    I  - 

^Messes,.xtre,Melyslowly.     In  buphtha'n.os  the .ii-mu-ter,^  the  oo  m  , 

a.  iKr  us  ailj  .ieeper.  I  he  lens  fre,,uently  UTonu-s  disloeated, 
.  n     .     t le  .hseas,.  advanees  v.s.on  ,s  slowly  nxluee.!  and  son.etirne 

l^lhHi.ln)     m  otlH-rs  ,t   beeon.es  eh.u.ly.   the  condition  then   beine 

Treatment  is  of  little  avail.  The  general  condition  of  the  patient 
su.uld  be  nnprovjMl  as  ,nud.  as  ,K.ssible.  Shoul.l  the  tension^o  he 
^'lobe  be.  mcrease,!,  piloearpn.,.  or  eserine  may  Ik-  e.nployed.  A  e 
best  the  prognosis  IS  unfavorable.  ^i me 

Injuries  of  the  Cornea.  Injuries  of  the  cornea  of  all  .iegrees  of 
...v..r,ty  occur  W  ,th  abrasion  of  the  cornea  the  patie  t  lv^ffc>r 
intense  pan.  at  hrst  o  n  sn.arting,  burning  character,  and  a  fee  i^g  a. 
-t  a  foHMgn  bo.ly  „,  th>  eye.  Photophobia  is  also  experienced  T- 
.nt<.nse  d,s  turlKU.ce  produ.-ed  by  abrasion  of  the  cornea  i  iueto  le 
miu.,-  ,o    he  sen.s,ry  nerve  filan.ents  that  tenninate  in  th^      yer 

he  s>  np  on.s  ,K..^.st  fro.n  twenty-four  to  fortv-eight  hours  as 
t  i.'  '■I.ithehu.n  IS  regenerated  they  disapiK^ar.  In  im-i.se.i  wo  „,  S 
;;'  the  cornea  the  pan.  is  relatively  slight'  \\-ounds  ,,f  tl  ,■  c  S 
-■lune  treat.ne..t  to  prevent  h.fection.  c.nsisting  of  careful  cle  s! 
u.,  w.,h  anOseptH-  .solutions.  Where  the  wound  is  an  '^tensive  e 
lliMiiargnis  n,ay  be  approximated  by  n.eans  ..fsutuie 

Foreign  Bodies  in  the  Cornea.     The  pro,ni,K-nt  position  of  the 
- n-a  .■xpo.ses  ,t  to  the  contact  of  foreign  bo.lies  of  all  kinds.         hen 
a  tn,v.g,    body  stnkes  th,.  cornea,  if  the  sen.sitiveness  of  the  c  r  e 
'<  normal,  ,he  ey..hds  clo.se  involuntarily,  and  if  the  fon>ig     bo  h   i 
n  .    (.xed  n,  th,.  rorneal  tissue  it  will  ,|,..scend  into  the  low.-r  cul-de-sac 
"    ••■'■'•nie  hxed  on  the  cmjunctiva  of  the  upiH-r  li.l.     If  ,he  f,  re  en 
'""l.y  .emanis  attache.1  to  the  cornea  or  imlKMl.led  in  it.s    is.ues'^a 
-    J.c  „.g  s,.nsat.on  n.  the  lids,  u.sually  the  up,K>r  lid,  .s  ex,v>rie,^;.. 
n  1   tin.s  ,.s  re,K.ated  whenevr  th,>  eye  is  opened  ..r  closed      The 
"-.■-gn  body  may  1h.  snnply  adherent  to  the  epithelial  laver   it  may 
.  u   n.  e    1...  ep,thehu,n  and  project  fron.  the  iurface,  it  ,na;be,"me 

.  1  >   nnbedde.l  m  the  cornea,  or  it  may  pierce  the  corneal  ti.ssue 

nd   pi.je,.t    mto   the  anterior  chamber.     Particles  that   enter  the 

y  nea  do  not   as  a  rule,  produce  .liscoloration  of  the  corneal  tissue; 

.  a  hot  cin.l,.r  pro,luces  an  eschar  which,  after  the  cinder  is 

■nimed,  .'ippears  iu*  a  circular  ring  of  brown  fi.ssi.e 

I  no  pr,.,s,.|.,.e  of  a  fon>ign  body  on  the  crnea  is  accompanie,-  " 
i'li"topliobia,  lacrvmati  •    -       ■  ■■■(.aiuM 


icna 


n,  and  often  by  pain  that  docs  not  entireli 


rt  (.ven  when  the  lids  ar<'  kept  (luiet,  aiid  l)V 


21 


pain  n.f(.ral)le  to  the 


fi2-2 


THE  EYE. 


^ 


i-ycball  tiiul  to  tlic  corrcspondiiiK  sido  of  tlic  lioail.  Soon  injcctioii  of 
the  c.fular  conjunctiva  ilt-velops;  this  injection  may  he  very  iniUl, 
or  il  may  \w  marked,  varying  according  to  the  degree  of  irritation 
produced.  If  the  foreign  l)ody  is  iKTinitted  to  remain  in  the  cornea, 
it  may  iM'come  loosent!tl  in  a  few  liours  or  days  and  We  removed  from 
tlie  cornea  by  the  ineclianical  action  of  tlie  lids.  It  may  liave  earrieil 
micro-(jrganisms  into  the  tis-sues  of  tiie  cornea,  producing  ulcer;  the 
defect  in  the  cornea  may  l)ecunie  invaded  by  germs  from  the  co'i- 
junctiva,  whicii,  gaining  entrance  into  the  tissues  of  tlie  cornea,  niu^ 
themselves  set  up  a  destructive  inHammation. 

Treatment.  After  instilling  a  dro])  (4  to  10  per  cent,  solution)  ot 
cocaine  the  removal  of  the  foreign  body  should  be  attemi)ted.  For- 
eign bodies,  if  superficially  imbedded,  may  often  be  removed  by  means 
of  a  small  probang  of  absorbent  cotton  wound  around  the  end  of  an 
applicator.'  If  tlie  foreign  b>dy  is  firmly  imbedded,  it  should  be  lifted 
from  the  corneal  tissue  by  means  of  a  spud  or  sharp-pointeil  foreign- 
body  needle.  In  certain"  cases  it  is  necessary  to  cut  the  corneal 
tissue  about  the  margin  of  the  foreign  body  to  get  iM-ncath  it  to  ,iit 
it  out.  In  ca.ses  where  the  foreign  body  lias  penetrated  the  cornea 
and  projects  into  the  anterior  chamber,  it  is  at  times  neces,su-y  to 
support  it  from  behind  while  the  tissues  are  cut  away  suthcieiitly 
to  enable  the  surgeon  to  grasp  it  with  a  small  forcejjs.  .Vfter 
removal  of  the  foreign  body  the  defect  in  the  cornea  occasions  the 
individual  some  annoyance  until  the  epithelium  has  extended  oyer  the 
afl'ected  area.  During  this  time  the  eye  should  be  cleansed  with  an 
antiseptic  solution  from  time  to  time  (boric  acid,  3  per  cent.):  and 
if  infection  is  feared,  more  energetic  antist>ptic  mea.sures  should  be 

emploveil. 

Blood-Staining-  of  the  cornea  sometimes  fr)llows  injuries  to  the  eye 
which  result  in  hemorrhage  into  the  anterior  and  posterior  chambers. 
The  pigmentation  of  the  cornea  is  due  primarily  to  the  entrance  of 
luemoglobin  in  s(.lutiim  into  the  corneal  tissue  by  way  of  F(mtana  s 
spaces,  the  luemoglobin  being  the  result  of  disintegration  of  red 
blood  corpuscles.  It  permeates  ilie  lymph  canalicular  .system  of 
the  cornea,  .iiid  there  undergoe-  a  change  into  luemosiderin,  an 
iiisol"ble  product  which  is  (h-posited  in  the  corneal  tissue  in  the 
shape  of  minute,  irregular,  octahedral  crystals.  These  crystals 
occupy  not  only  the  sjjaces  between  the  lamelhe.  but  also  the  spaces 
iH'tween  the  connective  bundl(>s  and  fibres  of  the  cornea.  The  color 
of  the  corne.a  at  an  early  stage  is  olive,  with  a  tendency  to  red.  This 
soon  becoiiH's  a  deep  brown.  The  staining  of  the  cornea  occupies 
the  central  jiortion.  reaching  almost  to  the  limbus  in  marked  ca.ses. 
At  the  liml)us  an  annular  ring  of  transi)arent  cornea  is  found,  measur- 
ing one-half  to  one  and  one-half  millimetres  in  width.  The  traiis- 
paiviit  ring  of  the  conica  i'^  due  to  the  n-mova!  of  the  hLemoglr)l)iii 
from  the  corneal  tissue:  also  to  the  fact  that  the  alkalinity  of  the 
cornea  is  maintained  at  the  |M'ripliery  through  ilie  iiiHuence  of  blood 
in  the  capillaries  of  the  limbus  conjunctiva-,  preventing  the  change 


imKiai:^  of  joxj i:\ctiva,  corxea,  a.\d  svleua.     ,32.3 

int..  ha«ni<)wi,lerin.  The  staining  of  tlic  cornea  (icvcl.m.s  rciativelv 
.-lowly  alter  llio  Hrst  api^-arann-  is  notice,!.  It  may  take  from  one 
to  lour  weeks  for  it  to  reach  its  heiKJit.  In  some  cas.'s  the  stainini: 
nnnams  with  little  cliange  for  months,  but  in  many  absorption  goes 
on  shjwiy,  and  eventually  the  cornea  may  regain  its  transpar.'ncv 
Actonipanymg  this  condition  we  may  have  secondary  glaucoma 
()ss  ot  vision,  and  pain,  depending  not  on  the  condition  o'f  the  cornea' 
hut  on  the  condition  of  the  eye  itself.  ' 

Treatment.  There  is  no  'treatment  aside  from  stimulation  by 
means  ol  moist  heat,  that  is  of  value  in  this  condition.  Fr.Hiuently 
the  condition  ot  the  eye  is  such  tiiat  enucleation  becomes  neces.sary 

Bums  of  the  Cornea,    liurns  of  the  cornea  are  not  verv  infre,,uent 
1  hey  are  due  to  the  entrance  of  molten  metal,  cinders,  steam,  acids, 
alkalies,  burning  gunpowder,  etc. 

Molten  metal  hnpinging  upon  the  cornea  seUlom  does  much  harm 
1  lie  sui-hice  epithelium  may  be  destroyed.     The  metal  usually  escapes 
Ironi  the  eye  at  once  or  falls  into  the  conjunctival  .sac,  where  tlic 
j;reater  damage  is  done. 

Glowing  embers  aligliting  on  the  cornea  may  ix>come  adherent 
and  destroy  the  corneal  tissue  to  .some  depth;  ordinarilv  tlie  burn  is 
-uiM'i-ficial. 

(Slowing  cind.Ts  that  fiy  into  the  eyt;  sometimes  become  imbedded 
111  the  cornea,  rendering  necrotic  the  tis.sue  that  comes  in  direct  con- 
tact with  the  cinder.  Before  recovery  takes  place,  this  necrotic  laver 
ot   tissue  must  be  cast  oft'. 

Steam  entering  the  eye  may  destroy  th(>  epithelial  layer  in  tiie 
poition  of  cornea  expos<'d,  u.^ually  a  narrow  strip  Iving  in  the  hori- 
zontal meridian  corresponding  to  the  paljx'bral  lis.sure.  The  treat- 
ment consists  in  cleaiLsing  the  eye  and  instilling  an  anti.septic  or 
aseptic  oily  preparati(m  sufficiently  oftt'ii  to  protect  the  affected 
•lira,  usually  three  to  four  times  daily.  Olive  oil.  with  5  per  cent. 
lit  Ixjric  acid  oi  vaseline,  may  be  ii.sed. 

Burns  of  tlie  cornea  from  acid  usually  affect  the  entire  .surface  of 
ilie  cornea,  turning  it  a  grayish  hue,  destroying  tlie  epithelium,  tlie 
Miperficial  layers  of  which  .-^oon  Ix-conie  detached.  With  burns  of  this 
iliaiacter  tiiere  are  some  .s(-cretion  from  the  conjunctiva,  increased 
l.urymation,  and  .sw<>lling  of  the  lids,  the  a-.pearance  presented 
I'l'lK-iting  a  grave  lesion.  Ilxcept  in  rare  ca.ses.  burns  from  acids 
are  recover.-d  Ironi  with  little  if  any  loss  of  tissue  or  ix-riKanent  in- 
jury to  the  eye.  The  treatment  consi.sts  in  thoroughly  cleansing  the 
I  ye,  using  weak  alkaline  solutions  (bicarbonate  of  sodium  or  very 
weak  ammonia),  and.  as  in  iiurns  due  to  thermal  agencies,  the  instil- 
l:itioii  of  an  oily  substance, 

Huins  of  the  eorne.a  due  to  an  alkali  are  most  frecjueiitiy  occa- 

-iiiiinj    i)y    the    entrance    of    nuicklimc    into    the    eye.     The    fine 

I'ticle.s  ()f  lime  U'coine  iml)e<lded  in  the  corneal   t'ssue,  and   the 

'-    iar,>tic    action  is  continued  for  some    time.      When   first   seen, 

'li'    aHected  area  presents  a  grayish  discoloration,  frequently  not 


324 


TUK  EYE. 


very  <U'n.-(".     The  up  var.i-uc o    Mi.   cornea  after  e(iiiil)usti(.ii  I'n.in 
limv,  as  first  pr.'seiitetl.  i..,im11v  induees  a  more  favorable  prognosis 


than  is  warrantable 


The 


iticatu  >  in  almost  all  eases  inereases 


in  intensity  as  the  liealni};  p.o'-,..s  a.lvanees.     Treatment  m  these 
eases  is  to  free  the  eornea  as  rapidly  as  possible  from  partieles  of  hine 
bv  washing  with  olive  oil,  which  is  probably  the  most  suitable  for 
this  purpose.     Af'-'r  the  particl(>s  of  lime  have  been  removed,  the  eye 
sliould  Im'  filied  with  syrup  of  cane-supar,  as  sugar  forms  an  insoluble 
compound  with  lime,  preventing  extension  of  the  destructive  process. 
The  sub.se(iuent  treatment  of  burns  from  lime  is  like  that  of  burns 
with  acids  and  thermal  agencies.  ..... 

Tumors  of  the  Cornea.  Tumors  of  the  cornea  originatmg  m  tlie 
cornea  an-  extremely  rare.  Cysts  sometimes  develop,  but  tliey  are 
the  result  of  inflammatory  processes,  are  usually  extremely  small,  ani 
seldom  rc(iuire  treatment.  Tumors  of  the  cornea  usually  cxtenii 
onto  the  conjunctiva;  they  are  dermoid,  papillomu,  fibroma,  epithe- 
lioma, and  sarcoma.  These  have  all  l)oen  treated  of  in  the  chapter 
on  dist>ases  of  the  conjunctiva,  and  need  no  further  mention. 


SCLE&A. 

The  sclera,  together  with  the  cornea,  forms  the  fibrous  coat  of 
the  eye.     It  is  the  segment  of  a  sphere,  the  rsvlius  of  curvature  of 
which  is  about  12  mm.     At  its  junction  with  the  cornea  a  depression 
is  found,  which  is  known  as  the  sulcus  sdene.     The  sclera  is  thickest 
at  its  posterior  part,  where  it  measures  alxmt   1  mm.  in  thickne^ss; 
thinnest  near  the  e(|Uator,  becoming  slightly  increas<>d  in  thickness 
in  its  anterior  portion,  where  it  receives  the  insertion  of  the  r(>cti 
muscles.     The  anterior  portion  ;)f  the  sclera  is  pierced  by  a  number 
of  minute  openings  through  which  pa.ss  tli(>  anterior  ciliary  arteries  and 
v(>ins.     Some  small  iierv(>  tw.f;s  also  pass  through  the  sclera  a  short 
distance   back   from   the   corneal    margin.     At    the  e(|uator  of   the 
globe  the  sclera  is  pierced  by  four,  .sometimes  five,  relatively  large 
openings,   which  give   passage   to  the  large   vetue  vorticosir.     Pos- 
teriorly a  number  of  openings  are  found  which  give  passage  to  the 
short  ciliary  arteries  ami  ciliary  nerves,  and  a  large  opening  to  |)ennit 
the  passage  of  the  optic  nerv(>  fibres.     This  oiM'iiing.  which  measures 
about  \.T^  mm.  in  diameter,  is  traversed  by  connective-tissue  V)undles, 
which  are  continuous  with  the  sclera  proper,  forming  what  is  known 
as  the  cribriform  plate.     The  sclera  is  made  up  of  connective-ti.s,sue 
fibres,  which  are  not  disposed  in  regular  lainelhe  as  are  those  of  the 
cornea,  and  which  run  in  various  directions.     Between  these  bundles 
of  connective-tissu(>  fibres  sjjaces  are  found  resembling  the  lacuna' 
of  the  curnca.     In   the  ^cli-ni  about   the  optic  nerve  entrance  and 
in  its  anterior  portion  branching  pigment  cells  are  found.     These 
are  most  plentiful  near  the  inner  sm-face  of  the  .sclera.     In  certain 
individuals  the  i)penings  for  the  passage 


)f  the  anterior  ciliary  veins 


I)JtiJ-:.i^J-:s  OF  COX/UXCTIVA.  VOJtXKA,  ASV  SfLElt.X.       ;i25 

Mv  pifriiicnt...l  giving  tlio  appoarimce  „f  a  mimLcr  ..f  black  points 
'•n  ll.c  scrni.  In  m-tain  iiulivi.Iuais,  particularly  tii..sc  „f  the  colored 
ran',  the  piKinentation  of  the  sclera,  aiileriorlv,  is  v.-ry  in'irkeil 

At  Its  aiitenor  margin  the  tissue  of  th.'  sclera  is 'continuous  with 
that  of  he  cornea.  Near  the  anterior  margin  of  the  cornea  an<l 
separate.!  from  its  mner  surface  by  a  thin  laver  of  connective-tissue 
Imn.i.es,  is  the  venous  smus  known  as  Schlemm's  canal  Kxternallv 
the  sclera  is  c.jvere.l  by  tlu"  visc-ral  layer  of  Tetx.rrs  cai.sule.  Inter- 
nal y  It  attonls  at  its  anterior  part  attachment  for  the  ciliary 
b.M  y  by  means  ot  th.-  Iigam..ntum  annularis.  P.,steri..rlv  the  inner 
surta.'e  of  the  s<-lera  is  cover.'.!  by  the  lamina  fus<-a  of  tl.e  ch.)roi<l 
th.'  .sclera  being  s,.parate.l  fr.)m  the  choroi,!  proper  by  the  supra- 
.•h..roi.lal  lymph  space.  Hut  few  bloo.  I  vessels  are  f.)un.!  in  the  sub- 
>tan.'.'  ot  tlu'  sclera.  The  episcU'ral  tissue,  h..wever.  is  richly  supplied 
with  bloo,lvesscls.  particularly  in  its  anteri.)r  portion.  The  nerve 
suj.ply  of  the  sclera  is  extremely  scanty.  P.)steriorlv  the  tissue  of 
llii^  sclera  is  c.)ntmu.)us  with  the  sheath  of  the  optic  nerve 

Scientis.     Inflammations  of  the  sclera  are  of  relatively  rare  occur- 
reii.'.',  an.!  may  be  .livi.le.!  clinically  int.)  two  f.)rms;'  cpi.scleritis 
I'/)  tugaeious  an.l  (h)  persistent,  and  deep  .sderitis. 

Fuiiacioiis  Episcleritis.  A  transient  inflammation  of  the  epi- 
scleral tissue  sometimes  occurs,  the  attack  b<Mng  cliaracterized  by 
the  appearance  of  an  injccte.l  area  with  .slight  el.-vation  ..f  the  con- 
junctiva, the  t!i.s."a.se  usually  occupying  from  1  fi  to  1  5  of  the  surface 
"I  th.'  .sclera  in  ts  anterior  segm.'iit.  Th.-  ajipcarance  of  the  inflamed 
ai-.'u  is  acc.nnpanie.1  by  symptoms  of  irritation,  manifeste.i  by  an 
nicn'a.se  of  lacrymation,  jxThaps  very  slight  mucoid  secretion 
-li^'ht  paiii  in  the  eyeball  ra.liating  to  the  temple  and  forehead,  and 
photoph.ibia.  Tlu>  irritation  is  increa.se.l  by  u.se  .)f  the  eyes  for' near 
work.  This  inflammati(5n  .)f  the  episcleraf  tissue  reaches  its  height 
III  troin  three  to  four  days,  and  then  gra.luallv  subsides,  every  trace 
•  lisippcariiig  at  the  end  .)f  a  week  or  ten  days. 

Till'  affection  is  met  with  in  in.livi.luals' at  the  age  .)f  puberty 
ind  111  .-arly  adult  life,  an.l  is  prone  t.)  recur  when  the  svstem  is  in 
■I  nin-down  coiiditi.m. 

Cause.  i:pisc!eritis  .)f  this  nature  is  met  with  most  fre<iuently 
:n  thos.'  wh.)  pr.'s<'iit  a  rh.'umatic  or  uric-aci.l  .liatliesis.  I'ndue  u.se 
"I  111.'  cy.'s,  .'v.'strain  c.)n.se«nient  .)n  imperfectly  corrected  errors 
'I  icIiactKiii  and  imbalanc-e  of  the  ocular  muscles,  exjMJsurc  to  inclem- 
'Ht  w.'ath.'r.  use  of  the  eyes  in  a  bright  light,  .listurbance  of  dige.s- 
"'"I.  .  I  may  ontribute  to  bring  on  an  attack. 

Treatment,     Treatment  consists  in  correcting  any  err.)r  of  refraction 
lilt   may  .-xist,   in  correcting  the  ondition  .)f  the  syst.-ni   which 
1  ■I'lisiM.ses  to  attacks,  and  in  prot.'cting  the  eves  from  "the  influence 
■1  l'^^'ht  light  when  this  is  a  fact.)r  in  the  pro.luctl.m  of  the  .Us- 
ui ii.tiice. 

l:iHKrl,ritis  is  characterized  by  inflamed  nodules  which  occur  near 
I'"  margin  of  the  cornea.     The  area  of  inflammation  is  often  firgle. 


:!i'ti 


Tin:  i:ye. 


! 


'riic  tissue  at  tlif  |M. lilts  alTccli 


Ic, I  is  slinlitiy  raised,  and  is  of  a  deep- 
red  ur  purpiisli  iiue.  I'he  l)lu..dvess<-ls  ..I  llir  eoiijuiictiva  (iverlyiiifi 
llie  iutlaiiied  ana  aiv  enlarged  and  iiijeele'  Tlie  itiHatiiiiiatioii 
advances  slowly,  and  is  atteiideil  liy  syiuptoiii.-.  oi  irritation  tliat  are 
niueh  more  sevei"'  in  some  cases  than  in  otiiers,  and  rather  deep 
neuraij;i<-  pain  wiiii  photo|)hol>ia  is  also  ex]M'rieiiced.  Both  eyc-s 
usually  aiv  attackeil.  and  fresh  areas  may  Iw  involved  before  subsi- 
dence of  the  process  in  the  part  (irst  affected. 

Duration.  The  affection  jtersists  from  four  to  eijjht  weeks,  but 
may  continue  for  a  lonn<T  period.  Uecurreiices  are  the  rule,  and 
another  attack  may  occur  immediately  after  the  subsidence  ot  one 
attack,  or  may  not  occur  until  veais  have  elapsed. 

As  a  ivsult'of  the  iiitlammatory  process,  there  is  usually  a  slight 
bluish-colored  patdi  in  the  sclera,  but  recovery  may  lake  place  with- 
out leaving  a  trace.  Tliis  diseasi-  usually  attacks  adults,  but  may 
occur  at  the  period  of  adolescence. 

Cause.  Kheumatism  and  gout  are  common  causes.  In  some 
cases  the  cau.se  is  ol)scurc.  It  is  probable,  however,  that  digestive 
disturbances  are  accountable  for  the  greater  iiuiuIkm-  oi  cases. 

Prognosis.  The  prognosis  is  favorable,  as  a  rule.  In  rare  cases 
ectasia  and  inflammation  of  the  deeper  structures  may  result. 

Treatment.  Ueuss  advocates  the  u.se  of  the  constant  current. 
8<'ariticatioii  has  been  advised  in  cases  where  pain  is  severe,  and 
ointments  of  various  kinds  are  indicated.  The  process  is  most 
favorably  inlhienccd  by  internal  meilication.  consisting  of  the  sah- 
cylates,  'iodide  of  potassium,  ami  the  mercurials  in  small  continued 

The  deep  form  of  sclerltis  cannot  readily  be  distinguished  in  its 
onset  from  the  superficial  form,  except  in  degree  of  severity.  Pain 
ace  'iipanying  deep  scleritis  is  usually  more  severe.  The  afTected 
\\\'  is  of  "a  deei)-purple  hue.  The  elevation  is  somewhat  more  pro- 
n.  uiced.  The  affected  area  is  larger,  and  may  extend  around  the 
iiitire  cornea. 

.\ccompanying  deep  scleritis  we  freciueiitly  have  mtlammation 
of  the  cornea  in  the  vicinity  of  the  affected  area,  and  the  deeper 
structure  of  the  eve  iris,  ciliary  body,  and  .'interior  |)ortiuns  ot 
the  choroid  -also  are  afi'ected.  the  process  attacks  both  eyes  and 
i)rogresses  extremely  slowly. 

The  change  that  "takes  place  leads  to  attenuation  of  the  tissue  of 
the  sclera,  reduces  it  in  thickness,  and  lessens  its  jjower  of  resistance, 
so  that  it  cannot  withstand  the  normal  intra-ocular  jm-.ssure,  and 
iH'comes  ectatic.  The  bulging  of  the  sclera  is  usually  irregular;  it 
sel<lom  ext.'iids  around  the  entire  cornea,  but  in  the  few  eases^in 
which  this  does  occur  the  entitv  cornea  is  imshed  forward.  The 
ectasia  usually  occurs  after  subsidence  of  the  inffammation.  When 
the  s<-leritis  subsides  the  afTected  area  presents  a  dark-blue  a|)pear- 
ance  on  account  of  thinning,  which  permits  the  pigment  of  the 
uveal   tract    to    show    through,     .\ccompaiiying   ♦he   formation   ol 


/>/AAM.s»  OF  CoyjlMTJVA,  C()tl.\J-:A,  AM)  SCLEHA.       ;J27 

ilicsc  stiipliyloinatdus  j)r()triisi(nis  (lisDrnaiiization  of  the  interior  of 
llic  fjlohc  is  ohscrvcd.     )isioii  is  ordinarily  very  iiiucli  iiiipain'd. 

Sclero-kerato-iritis  (Scrofulous  Scleritis;  Anterior  Uveitis).  This 
coiidilioii  is  one  closely  allied  to  dcn-p  scleritis.  but  differs  from  it 
ill  that  the  whole  anterior  segment  of  the  jtloU-  is  affected.  The 
iiitlaiiiiiiatory  piocess  usually  hepiiis  at  or  near  tiie  sclerocorneal 
junction,  and  progresses  as  adeep.-cleritis  involving  the  cornea  (which 
i.ikes  on  a  condition  of  sclero.sis),  the  iris,  the  ciliary  hody,  and  the 
anterior  portion  of  the  choroid.  In  addition  to  the  appearances 
and  .syniptoins  tiiat  accompany  scleritis  and  .sclerosing  keratitis, 
symptoms  jx'culiar  to  involvement  of  the  anterior  jjortion  of  th(' 
uvea'  tract  are  present.  The  iris  JM'comes  congest«"(l,  loses  its  trans- 
parency,  takes  on  a  du.sky  hue,   and   is   thickened.     The  acjueous 

hiiiiior  l>ec 's  turhid  as  a  result  of  transudation  of  plastic  lymj)!! 

Irom  the  bloodvessels  of  the  iris  and  ciliary  Ixxiy.  There  is  pai:i  refer- 
able fteiierally  to  the  temple  and  forehead."  The  anterior  jMirtion  of  the 
vitreous  body  l)econies  hiled  with  flocculi  consisting  of  hbrin.  Tlie 
(lisea.se  pri>gres.ses  very  slowly,  both  eyes  IxMng  commonly  affected. 
Individuals  in  early  childliood  and  at  the  age  of  pulxTty  are  nir).st 
tiiMiueiitly  attacked.  They  are  individuals  with  inherited  .sypliilis 
,111(1  those  whos<'  condition  may  1k'  described  by  the  term  .scrofulous. 
.\s  a  result  of  .sclero-kerato-iritis,  sclerosis  of  the  anterior  portion  of 
liie  sclera  and  of  the  cornea  occurs,  followed  in  many  cases  by  sclero- 
I'ctasia'.  Tile  ordinary  results  of  .severe  iritis  are  also  preseilt.  The 
choroiditis  is  followed  by  atrophic  changes  in  that  membrane.  The 
ciliary  body  In'ounes  atrophic  and  niucli  elongated  by  the  stretch- 
ing that  accompanies  the  ecta'i'-  process.  The  coriu'a  is  thinned 
throughout  the  area  involved  in  the  sclero.sis  and  becomes  more  or 
ess  opaipie. 

The  effect  on  vision  is  pronounced,  the  diminution  dejH'nding  on 
the  degree  of  opacity  of  tiie  cornea  and  the  interference  with  the 
tiaiispaicncy  of  the  media  of  the  eye.  As  a  result  of  this  ])rocess 
the  ciystalline  lens  not  infre(iuently  Ix'comes  opa(|ue.  shrunken, 
:iiiil  till'  .site  of  calcareous  depo.sits.  In  cons<"(|ueiice  of  the  dianges 
.itlccting  the  filtration  angle,  increase  in  tlx-  tension  of  the  eyeball 
ilrvciops,  secondary  glaucoma  results,  and  total  los.s  of  vi.sion  n.ay 
lollow.  The  increase  in  tension  may  also  lead  to  .spontaneous  rup- 
ture of  the  glo])e,  the  rupture  occurring  at  some  pohit  in  the  ectatic 
purtion. 

Treatment.  Treatment  directed  to  tiie  correction  of  any  dyscrasia 
cj  liie  system  that  may  exist  should  iie  instituted.  If  "tlie  condi- 
tion ;tccompaiiies  liereditary  syphilis,  anti.syphiiitic  n-medies  should 
be  employed  If  a  uric-acid  diatliesis  is  present,  it  should  i)e  cor- 
iic1c(|.  Local  treatment  consists  in  the  endeavor  to  prevent  tiie 
tdnn.ition  of  posterior  synechia'.  Hot  liathing  with  a  solution  of 
iMiru'  •■ti'ii!  ;i!i(!  tlie  introthiPtion  of  a  lucn-unal  locally  are  of  .-ser- 
vice. Ointments  of  the  yellow  o.xide  and  mercuric  chloride  apjM'ar 
Id  be  iM'st  suited.     As  a  matter  of  fact,  local  treatment  .seems  to 


.■{•_>M 


THE  EYE. 


\ 


have  little  ctTci-t  in  arresting  tlie  progress  of  tliis  condition.     In  eyes 
atTceteil  l)y  tiiis  iliseas*-  more  or  less  serious  daniage  is  wrouglit. 

Scleral  ectasisB  (staphyloma  of  the  sclera)  an-  elassitied  a.H 
antenor,  eii-iatorial,  and  posterior.  Anterior  eeta.sia-  may  l»e  single 
or  multiple.  Tliey  may  Ix-  annular,  extending  entirely  around  the 
jM'riphery  of  the  eornea.  At  the  e(|uator  the  eetasia'  may  present 
the  same' conditions  present  in  the  anterior  sj'gment.  l'o.sterior  ectasia' 
are  usually  single,  and  fre(|Uently  include  the  optic  nerve  .'iitrance. 
Scleral  ectasia'  present  a  bluish  ap|M'arance.  iK'caase  of  the  pigmented 
uvea,  which  shows  through  the  thinned  scK'ra. 

CauBe.  Staphylomata  are  produced  either  In't'ause  of  a  reduction 
in  the  power  of  the  sclera  to  withstand  the  nonnal  intra-ocular 
pressure  or  tension,  weakness  of  the  scleral  coat  Ix'ing  either  inherent 
or  the  result  of  di.s«'ti.se;  or  it  is  due  to  an  increa.se  in  the  intra-ocular 
tension  alH)ve  the  normal  and  above  the  iM)wer  of  »he  sclera  to 
withstand. 

Scleral  ectasia-  are  most  friMiuently  due  to  scleritis.  When  intra- 
ocular pressure  only  is  the  cause,  eiiuatorial  staphyloma  usually 
results.  If  the  weakness  is  structural  and  congenital,  the  staphyloma 
usually  occurs  at  the  posterior  pole.  Staphyloma  not  infre(|uently 
accompanies  neoplasms  of  the  interior  of  the  eye.  In  certain  cases 
ectasia  of  the  sclera  reaches  enornjous  dimensions,  as  in  the  case 
of  scleral  cyst  accompanying  microphthalmos. 

Treatment.  After  ectasia-  of  the  .sclera  have  developed,  treatment 
is  of  no  avail.  .\s  a  prophylactic  nwa-siire  in  inflammatory  comlitions 
which  have  resulted  in  the  formation  of  posterior  synechia',  iridec- 
tomy may  be  useful,  and  in  ca.ses  of  glaucoma,  either  primary  or 
secondary,  the  same  procedure  may  prev(-nt  de\  'I.)pment  of  ectasia- 
by  reducing  the  intra-ocular  tension. 

Syphilis  of  the  Sclera.  Syphilitic  involvement  of  the  scleni  is 
seldom  observed.  When  it  does  occur,  it  manifests  itself  in  the  form 
of  gunnna,  usually  iift'ecting  the  anterior  segment  of  the  sclera.  Cases 
have  been  observed  in  which  th(>  ])osterior  jjortion  of  the  sclera  has 
been  the  seat  of  a  gummatous  ma.ss.  When  gumma  of  the  sclera 
occurs  ill  a  visible  portion,  it  presents  itself  first  as  a  small  nodule 
sinuilating  a  large  phlyctemile.  It  incn-a.-^es  in  .siz«-  (piite  rapidly,  the 
elevation  becoming  pronounced,  th(-  base  of  tlie  elevation  iM-ingdeep 
red  in  color,  and  the  congestion  extending  for  some  distance  into 
the  surrounding  tissue.  The  apex  of  the  elevation  is  of  a  yellowish 
hue.  The  growth  is  circular  at  its  b.'isc.  It  may  reach  a  diameter  of 
I  cm.  to  1  cm.  If  treatment  is  not  instituted,  ulceration  takes  place 
at  the  apex,  due  to  breaking  down  of  the  tissue,  and  destruction  of 
the  eye  may  ensue.  The  tumor  is  rather  firm  in  consistence,  and  Vf 
elastic.  It  may  be  mistaken  for  sarcoma.  \  microscopical  examina- 
tion of  excised  parts  may  disclo.se  the  presence  of  cells  which  dosf-ly 


tt 


i(i>e  tif  s;trcoMia(ous  li.ssue.     Sarcoiha  of  the  .M-iera  as  a 


])rimary  disease  is  extremely  rare,  and  the  presence  of  a  growth  such 
as   has  just    Ix-c-n   descriln-d   should   always   awaken  suspicion   of 


i>/sh:.\sf:s  OF  rns.irscTivA,  <oi{m:a,  am*  svlfma.     :\2\\ 

a  sypl.ilitic  ..riRin,  The  liistory  „f  tin-  ca-s.'  is  not  always  tu  Ik> 
IV  if.l  upnii  t„  suhstaiitiatc  tlic  <lia«M.)sis.  Cminiia  of  I  lie"  sclera  is 
.-.•Idoiii  met  Willi  III  cliildrcii,  hut  is  an  omisionai  nianilcstalion  of 
lirtiaiy  syphilis  in  a.lults.  The  writer  has  never  seen  a  pn.eess  of 
this  kiii.l  (.(ruiTiiiK  as  a  result  of  inlieriteil  syphilis.  In  these  cuses 
the  tissue  of  the  sclera  is  inva.le.l  h\  a  sniall-eell  infiltration.  I-il'ires 
III  the  sclera  are  |)re.s.se,l  aj)art,  and  some  .lisap|M'ar  ah.solutelv  \s 
Ihe  |)roee.sssul)si,|es,  if  .scleral  ti.-  mc  has  Ihm-ii  (lesf<.ye,l.  it  is  replac.Ml 
l>y  cicatricial  tissue. 

Treatment.  Inder  vinnrous  antisyphilitic  treatment  of  the  usual 
kind  jtuinina  ot  the  .sclera  suhsidcs  with  marwilous  rapidity  and 
il  lh<'  deejM'r  tissues  of  the  kIoIm>  are  not  involved,  no  trace"  iif  the 
liuiior  is  lelt. 

Tumors  of  the  sclera  other  than  that  just  nieiitioncl  do  not  occur 
as  primary  fjrowths. 

Injuries  to  the  Sclera.  Tli<.  sclera  is  sul.ject  to  injuries  of  various 
kinds:  iierlorating  wounds,  inci.sed  wounds,  lacerating;  wouJids  and 
iu|ituic  ot  the  sclera.  Perforating  wounds  of  the  sclen;,  if  made'with 
Miaipand  noii-infected  instruments,  are  usually  of  little  importance 
provided  the  p.-rtoration  he  small  and  occur  hack  of  the  ciliary 
lejjion.  II,  however,  tli<'  wound  is  large,  i^'riiiittiiiK  i>r()lapse  of  a 
portion  ol  the  ciliary  hody,  the  effect  on  vision  may  Ik'  disastrous 
Noii-infected  woumls  heal  rapidly.  It  occurs  from  ti'me  to  time  that 
pertoratinK  wounds  of  the  sclera  result  in  total  detachment  of  the 
retina  without  suppuration  .nid  without  iiiHamniatorv  reaction  of 
.my  appreciahle  .lepce.  A  cas,.  in  point  is  that  of  a'wonian  wiio, 
^^llell  shakiiif;  a  carpet,  felt  a  twing..  in  the  ev<-,  ami  found  tliat  a 
larpct  tack  had  pierce.l  the  sclera  ahout  7  mm.  from  the  .sclero- 
|-..rneal  margin.  Sh<-  removed  the  tack  hy  traction  aii.l  |)res<-nte<i 
lieiself  at  the  hospital  within  twenty-four  hours.  At  that  time  a 
-niMJI  opciiiiifr  could  he  d-.t<.cted  in  the  sclera,  into  which  a  he.-id  of 
vitivoiis  projected.  There  was  hut  slight  injection  of  the  .sclera  and 
'•"njiiiicnva,  and  the  opening  in  the  sclera  had  already  hecoine  clo.sed 
l>v  plastic  lymph.  K.xaminatioii  with  the  (iphthalmo.scope  disclosed 
the  point  of  entrance  of  the  tack.  There  w.-is  no  h.'iiuirrha".'  in  the 
vitreous  and  very  little  hlood  surrounded  the  oiieiiing.  The  eye  was 
li^iiidajie.l  and  the  jiatient  removed  to  her  home.  No  intiammatioii 
loulted.  In  the  cour.s<"  of  four  weeks  complete  (let  ichment  uf  the 
iitiiia  developed. 

I'eit'orating  wounds  of  the  .sclent  may  re.suit   in  infection  of  the 
■■.vehali  and  loss  ot  the  gloln-  hv  panophthalmitis. 
Lacerating  Wounds.     Lacerating  incised  wounds  of  the  sclera,  if 

occur  iiosterior  to  the  ciliary  region  and  are  not  of  gre.it  extent. 

he  closed  either  hy  a  scleral  or  conjunctival  suture,  and  recovery 
'■•ly  occur  with  little  or  no  loss  of  yision.     Clean  incise! 


tliry 

•VAX 


clera,  even  th(>s«>  which  involve  the  cilian' 


'imds  of 
region,  may  al.so 


ai.  if  properly  clo.iod,  without  lo.s.s  of  y 

wound  in  the  sclera  the  prolap.se  of  vitreous  and  i)rolapso"of  Xh 


ision.     In  the  latter  f 


orm 


.•!.!i» 


I  in:  LYf- 


U 


rili;iiv   l.(,.lv.    It    tlK'V   ..mir,  -huuM   l-c  v\v\>-'\      'ni..   ^011^^1  n,;.v 

then  I.C  ilip>f.|  liv  >rlcrill  III-  <-n|ijUll(!iv:il  suture, 

1    .vratiiKJWuun.Uatffctiiij;  tlif  nil      ^  ImmIv  rrsiill  >ii  ;ilini>-i  >       ry 

,.,^^.  i„  l„ss  of  ll V.-.     IJ.'inoViil  of  the  .->■.•,  fivqiH  utiy,  is  i.^      >i 

oiirc  iu'(fssarv:  Inil  .i^  tlif  scar  coiiinicts  panifui  sym|.ioiii>  .li\ 
aii.l,  in  s(,iuf<"-iis.'s,  symptoms  of  syini.alh.-tu  iiMurhaiic.  .t  the  li'-r 
i'vc  liccoinc  ppiiomicnl  Mini  rcii.iri  .•iiucl<itioii  in'ccssar\ . 
■  Ml  ,.  ,s,.s  of  uuuii.l  to  the  scliTa  sl-uM  !»■  tivatr.l  011  strictly  :intl- 
s,.|.ti.'  hriiicijili's.  IVolMpMiiK  iissu>  -t.ouM  !«■  .•\ns<-(l  il  an  attempt 
is  to  Ih  ma.l.  to  sav.-  tlic  >:IoIk-.  !  :.r  onhuary  ciiTUinstatuvs  tl,.' 
palirnt  wh.-thcr  siitT.Tinfi  Ini  1  porl-natui^  wouii.l,  iin  iiu-i«.'.l  .r 
.,  lac-iaiih);  woun.l  "f  tlic  uloi..  -^lioul.l  !«■  -n  to  IhkI,  an.!  .M.mpivss 
■•■iiiil:i"cs  applii'.l  until  recover'    is  \v(  !1  uil\  iiu  rii 

Rnpture  of  the  Sclera.     l{oi -ureof  the  sclera  oecur-  m  tli.    t.ajorit 
,,1   caM     within   the  /...ne  in.    ,!.•,!   ui  a  strip   I   ••in.   ••vule  in.  ;i  U. 
m-ir  Ml     .1  the  conu^a.      A  l>lov.  on  trie  eve  from    vliat.-     r  source  niax 
npHhin    -uch  a  lui.ture.     Tl,     ruptiu     tak.'s  place  ,      ve  most  tro- 
,1.  ■  ah       It    ..••■urs  in  the  sh.,|H'  ot  :,,-,  irr.>:iilar  line  cxt.  imIiii^  h-.m 
ue,'    tiie     Kirpn  of  the  cornea  .li,--.'oiially  hackwar.l,  ai:  .  mea.sures 
i„  the  majority  of  cases  ah-    it  'l  em    in  lenRth      The     iluiry  U    v 
ami  th.   anterior  portion  of  ti   •  choroul  are  usually  push.      11. 
wont,  i   an.l  I  n-s«-nt  n~  a  .1  >-  hnc  following  the  wound: 
crvsialline  l.Mis  ir   v   '  •■  for,    .1  out  of  111.'  eye  an.l  he  h        -■'.:  in'" 
conjunctiva.     Sui..-..  .ian<''iva!  iK^niorrhacc  cciirs,  ■.vhich  ihIs 

soiile   aistai.ce   from    the   womd.  soni.  tim.  ^  .vteiir  mk  h.        'h  1 
entire  ocular  conjmn't  Th-  antei     r  aial       ire.     -  ehamlHi-  a 

,„..i-e  ..r  l.'ss  lill.Ml  '."..1.     Sucii     oun.ls  ire<|u.  "ccur     ^\n- 

oiit  rui  'uf.    of  till-  f..i.,uu'tiva.  ■      ,  . 

Kupl,  •    .>f  the   -.l.'iM     -   not    llecessa-ily     ..nlilie.l   '      tli.  eiHM 

.ejjmenl  .     thetiloh.       In  laie  cases  it  .iccui     M  thei...sien..i  lent 

of  the   -ll.''.-.      It   i-      '"'ll    111    nilVst    hy    a   ^';.  uT  -i     »'.•-      .Icj; 
e\-iph!halmos  .hie         'l"'  I'l'-'^"  ■■■''  "•'  '''"" 
("a.se-  111   which   the     uptur.    is   very  slifjlit 
with.' It  lo-s  of  vi-i.iii  and  witlioii'  a  paiiifu 

rare 

In  til.     ariv  stajic  ot  rii|  Mire  ..I  u       .■i<'ni 
may  l)e  relatively  sliftht.  aid,  to  ili.        \\"  ' 
favorable  recovery  may  app.ar  hrr         II  • 
.litioiis  above  .lescrilx'd   alino-t    n       -ial 
,  i|-i  lie  r.'-. irt.'il  to. 

Foreign  Bodies  in  the  Sclera      i        ;:ii 

-eld.itn  pr.  .-elit   witlioul    p-rfont, 
chanibe:    of  tl;.-  eyi,    ih"  ri'.sult    \" 

<!  iiplv      \\\v      til'-   !■  ''V  has   fen 

-lu.ul.l  be  ret..   >e,l,  its  ivnioval  bein;.      leetedby  the  nieaus  onliiian 
employed  !.■   -einove  uwinii  bo.iies  .    .10  oil,.  V      -sues  of  the  bv..) 


in  tin  'll  al  t!.s.-iues 
liv  re^^ult  11.  recover} 
,>Im',  Im  t  such  are  vcr> 

■■■     y  H'K.    '•  pahi 

j)ros|H'  if  a 

lly  -011- 

nu  tioii 


tl 


■  Ulii   .'lltr;. 
sclera  be. 


•lera 
:,.t'  post, 
lallv  a      •' 


..'.I   imbe.l.i'       111  'he  sclera. 


<    HA  PTKR    VII, 

niHinol.OfJY  OF     HK   IK;   ANOMALIKS,  DISKASKS. 

AM'  INJriill  >  OV   THE  IHIS.  (lUAHV  MoDY, 

(  IIOHOII).  AM)  VITUKOl  S. 

'»Y    1      \       \  !  RDKMA-W,    MD. 
EMBRYOLOGY  OF  THE  EYE. 

Gmi'-a.i  Development.    Th       .■  U-giux  its (Icv.h.j.nKmt  a.,  a  hm,^ 
in>..         M'rii(-....i,.riiiic!in<lccl  ic  layers  of  tlucmhrvo.  .■ullcl  the 

""'  )'<"•        'fit',  c-onm-ct.  h  the  brain  l»y  the  "optic  iH-dicio 


Mfrior  Ctrttra/  l^uck 
^y      s^Oplic  Vesicle  ilM 

^^Ine  nf  SfcHatf  -^ite  t .  4 
-M/dd/e  Cerebri '  t'fiKle 
fbiferiorCereii'.     mcM 
Aut/'forjf  Budi 

Spinil  Cari 


Entire  embryo  of  a  fh)(!     (After  Fick.) 

'r  >ta!k   whiHs  «uh^'qi:(>nt!v  lu-nuiu-s  tlic  nptir  nonr.     (Fig.  150.) 

.'"  '''■vt'loimu'iit  of  th»> ^oderini.-  portion  is  so  slow  in  the  majority 

'1  «iMt)ryo>  that  the  vesid,.  is  not  fully  covered  l)y  this  structure, 

( 331  ) 


^ 


3:12 


THE  EYE. 


ami  tiius  rciiiains  in  iiitiiiiatc  (■(iiiiicctioii  witli  the  (■clddcnii.  Im-Iiij; 
at    first.    Iiistoldjficallv,    vci\    iimcli    like  the    l>rain   vesicle,      i  I'late 

The  priiiiarj'  ojitic  vesicle  then  ix-coines  thicker,  becoming  invafii- 
iiateil,  t'lirininf?  the  primary  optic  cup  (I'late  X.,  H);  the  eetuderni 
lyinj;  over  the  eyehud  becomes  thickeneil,  and  at  the  .same  tin  e 
sinks  into  the  subjacent  inva}iinate(l  optic  vesicle,  forniin>i;  a  de])i'es- 
sion  known  as  the  lens  pit  or  secondary  optic  cu|).  i  Plate  X.,  ('.  i 
The  mesoderm  does  not  cover  this  place,  but  the  ecto(lerni  thickens, 
ultimately  forininf;  the  lens.  .Vt  this  time  the  eye  has  .somewhat 
the  form  of  a  pair  of  sci.s-sors,  the  points  projectiiift  upward,  i  Plate 
.\.,  !).)  These  points  soon  coalesce,  coveriuf;  the  secondary  cup, 
dosing;  over  the  lens,  and  developinf;  the  cornea.     (Plati'  X.,  K.) 

.\s  development  goes  on,  the  iiivajjinatioiis  profiress  with  uni- 
form rapidity  until  the  lens  sac  reaches  completion,  when  the 
expansion  of  the  inner  wall  of  the  latter  no  lonj^er  keeps  pace  with 
the  pushing  in  of  the  optic  vesicle,  and  thu.s  forms  a  s|)aee,  the  primi- 
tive vitreous  chamber.  (I'late  X.,  !•'. )  The  portion  of  the  wall  invagi- 
nateilby  the  j)rocess  of  involution  undergoes  |)roliferation,  forming  the 
retinal  layer.  The  outer  l;iyer  of  the  o|)tic  vesicle  increases,  but 
becomes  so  attenuated  that  by  the  time  the  retinal  layer  comes 
into  contact  with  it,  it  is  so  thin  that  it  forms  ultimately  but  a  single 
layer  of  cells,  the  retinal  epithelium.  (Plate  XL,  .\,  F,  (!.)  The 
inner  wall  thickens  and  forms  the  ess<'ntial  nerve  elements  of  the 
retina.  The  lower  [Kirtiou  of  this  double-layered  vesicle  is  not  coiii- 
plete(l,  but  forms  a  hiatus,  the  f(rtal  ocular  or  choroidal  cleft,  which 
soon  narrows  and  finally  closes,  but.  before  doing  this,  allows  the 
entrance  of  mesod(>rniie  tissue,  which  constitutes  the  primary  vitreous 
stroma.  The  impri.soned  mesodermic  ti.ssue  in  the  optic  stalk  is 
represented  later  by  the  central  vessels  of  the  retina  a!id  the  as.'^ociated 
comiective  tissue  of  the  optic  nerve.  The  optic  stalk  becomes  the 
optic  nerve    chiasn.,  and  tract. 

Lens.  .Ml  of  the  lens,  (>\cept  tlir  capsuie,  is  of  ectodermic  oiigin. 
i-larly  in  develo|)ment  the  optic  cup  closes  ( Plate  X.,  ]•]),  the  inner  w  all 
becoming  thicker  than  the  outer.  The  thickening  progresses,  so  that 
by  the  time  the  lens  sac  has  become  completely  isolated  from  its 
attachment  to  the  surface  ectoderm  its  walls  consist  of  two  or  three 
layers  of  e|)ithelial  cells,  limited  externally  by  a  delicate  nienibnuie. 
the  lens  capsule.  Tin  obliteration  of  the  cavity  of  tlu'  lens  .sac  and 
the  conversion  of  the  organ  into  a  solid  mass  are  effected  by  a  phe- 
nomenal growth  ;ind  elongation  of  the  e])ithelial  elen;ents  composing 
its  jjosterior  or  internal  wall,  which  rapidly  increa.ses  in  length, 
Ix'Ciiriiiag  converted  into  the  primitive  len.s-libres.     (Plate  XI.,  .\.) 

From  the  unusual  demands  made  by  the  young,  rapidly  growing, 
.and  non-vascular  lens  on  the  surrotmding  ti.ssue  for  nutrition,  a  special 
temporary  structure  develojis,  the  tunica   vasculosa  lentis  (Pig.  I'lU^ 


which 


1  compietj'ly  surrounds  the  young  lens  Irom  (lie  seci 


)nd  month 


toward  the  end  of  gestation,  at  which  period  it   usually  lK'er)me: 


PI-ATE   X 


A.  AVcf/oH  through  Cmbrijonic  froy  Head. 


C,  Duck. 


ti.  Fruif. 


CetoJwm 


Muttritr    l(Wi/»  of 
^ittnar^  0»t ,  Cup 


Corner  i,d 


fK/piiliff  MrfnO'inf 


Le/t}  vtuc/t 


P'gmtm  tp.ti,tfnm 


k.   Ouck 


f.  Cat 


Development  of  the  Eye.     (  Fick. 


-sBrrr" 


PLATE   XI 


Devol<i|>im-i 


I    c  >f  the    Evi 


Fick. 


EMBRYOLOIiY  OF  THE  KYE. 


333 


•i>|)liicil   and  (lisiipiM'ats:  when  jxTsistont,  it   is  called  jxTsisting 
pillaiy  inenii)rane.     (I'late  XIII.,  V\g.  12.) 


at  I 

I'"l   .      -    .  y  ;  --;•    "     -    — ' 

Vitreous.  The  vitreous  body  is  eoni|)()sed  of  connective-tissue 
elenii'Mts  I'oniied  from  tiie  mesoderm.  In  the  pro.(.>is  of  development 
a  I'ud  of  mesoderm  is  pushed  into  the  eye  through  <he  clioroidal  cleft, 
which  soon  grows  and  ac(|uires  hloodve.s.sels.  Through  these  vessels 
leucocytes  aid  round  and  spindle  cells  are  produced:  the  foriner 
have  amcelioid  movements,  and  the  latter  are  fixed  cells.  These 
actively  pioliferate,  tilling  the  space  JK'tween  the  primitive  lens  and 
the  retinal  layer  of  the  optic  cup,  forming  the  substance  of  the 
\  ilreous. 

Bloodvessels.  The  bloodvessels  of  the  eye  are  developed  from 
ingrowths  of  inesodermic  tissue.  (Coincidental  with  tlie  growth  of 
the  primitive  vitreous  ;in  .•irt<'ry  and  vein  develop  in  the  optic  nerve, 


Arttnesof  Pvpit.Memti. 


Veins 


LtfiS 

Ca.pitl»ffZen^ 
If'trrai/s 

'rttritHfilMtl 


Crcutvs  ArtfrlQS'JS 


^cessrs  of 


Aneriti  oftht 


Vw..  ir.l.— BliKirtvessels  of  the  embrynnic  eye.  PIk  embryo.  M»(fnlfle<l  l\i  diameters.  (After 
Srnn.T/f-;.) 

Ki..  1  ij  -The  impillary  mcinbraiiu  and  bloodvessels  nf  the  lrlf<.  I'lg  embryo.  The  arteriea 
^l.nm!lnJ;  Irom  the  I'irculii-  artcriowiin  iif  the  pupillary  membrane  are  lint  visibk'  In  the  pupil. 

MItT  S4MVI.T/K  ■ 

whicii  lati  r  become  the  arteria  centralis  retina-  and  vems;  an  artery 
develops  in  tile  vitreous  (the  hyaloid),  going  to  the  jMJSterior  \m\v 
"I  the  lens.  Then  the  vitreous  becomes  abundantly  supplied  with 
rapillaiies  ( I'late  XL,  A),  which  new  bltHxl  sui)ply  permits  of  increa.sed 
nutrition,  resulting  in  rapid  proliferation  of  the  niesodermic  vitreous 
ind  growth  of  the  lens.  During  the  last  weeks  of  ftetal  life  the  blood- 
■>se!s  of  the  vitreous  and  the  lens  di.sap{K'ar,  lejiving  a  pa.s,s!ige,  the 


\( 

H.\;iloid  canal.     If  the  hyaloid  artery  does  not  fully  atrophy,  vestiges 
'iKiy  lie  .seen  later  in  life  by  the  ophthalmoscojx>. 
Retina,     The  retina  is  formed  from  the  eye  cup  by  early  (lifTcren- 

:.:n<iti  of  the  outer  and  iniiei'  ?ayers.     Hy  the  time  tlie  infolded  [jor- 
iion  ot  the  vesi(>l(.  has  iM'come  closely  attached    to  the  outer  .segment 

t  has  increased  many  times  in  thickness  (Plate  XI.,  D.  F,  G);  the 


334 


77//;  i:yi:. 


: 


lalttT  tliiiis,  liut  early  iitTUiiiiilatcs  pifimt'iit  cells,  first  at  llie  anterior 
liulc,  wliieli  jir.iiliially  exteiul  t<i  llie  pusteridr  pole,  iiltinia'.ely  Ihtoiii- 
ing  tlie  pifiiiieiited  retinal  e|)itlielitini.  ( I'late  XL,  A.)  The  prolifera- 
tion ol  the  iinier  layer  ri-sults  in  the  formation  of  two  varieties  of 
tissue,  the  nervous  Jind  the  sustentacular  tissue.  The  nervous  hiyer 
ilitTereiitiates  into  the  nerve  cells,  their  outfirowths,  and  the  epitli 
eliuni.  The  latter  eventually  forms  the  outer  midear  layer  and  the 
rods  and  cones,  thes(>  two  coiistif utitij;  the  vision  cells.  ( Fiji.  I'lo.) 
The  sustentacular  tissue  extends  ihroujih  the  thickness  of  the 
retina  and  ft'vcs  support  to  the  nervous  elements  forminf:  the  radial 
tihres  of  Miiller.  besides  this,  there  are  outfjrowths  of  true  connective 
tis.sue  coining  from  the  surrounding  me.^^oderm,  which  accompany 
the  ramifications  of  the  retinal  arterii's:  all  tiiis  portion  forins  the 
pars  optic."  retina-.  Thi'  anterior  marginal  zone  of  the  optic  cup 
becomes  a  thin,  deeply  pigmented  layer  of  epithelium,  covering  the 


MmtMnHtat 


^mtrt{/ittit/f 


mil  <i 


tmirmitmrUfr 


!*,'«#*? 


tvflilt    CH/M 


Ucveloi.mt'iil  ol  the  reiiiia.    Uuiiimi  embryo.  3  n  mm.  long.    (After  Falchi.) 


ciliary  body,  pars  ciliaris  retiiuv,  and  the  posterior  surface  of  the- 
iris,  j)ars  iridica  retina-.  The  anterior  edges  of  the  c\ip  form  into 
ridges,  l)ecoming  the  ora  serrata. 

Optic  Nerve  and  Tracts.  The  anterior  portion  of  tlio  optic  stalk 
becomes  the  optic  nerve,  the  middle  portions  of  either  side  unito 
to  form  the  chiasm,  and  the  posterior  portions  become  the  of)tic  tract.s, 
.\t  hrst  the  optic  stalk  is  a  sliort  tube  between  the  primary  optic 
vesicle  and  the  mid-brain.  (I'late  X.,  A,  H,  (',  D.)  The  invagination 
affecting  the  lower  wall  of  the  optic  vesicle  forming  the  choroidal 
tis.sure  affects  the  optic  .stalk  at  tlie  ocular  end,  allowing  the  entrance 
of  vascular  me.so<lerm,  from  which  arise  tlie  retinal  bloodvessels.  As 
the  lower  wall  of  the  stalk  folds  in,  its  lumen  becomes  obliterated 
by  apposition  of  its  walls  and  thickening  due  to  active  proliferation, 
the  young  optic   nerve  becoming  .solid,  the   imprisoned   mesoilerni 


EMUKYOLOUY  tJt    iUt:  i.Yh. 


•5;{.> 


producing  the  accoiiipaiiyiiiK  bloo.lvcs.scls  ami  th"  n.  .r.fctivc  ti  -iic 
surruuiwlmf;  tliciii.  Tlu-  lu-m'  tilm-.s  arc  .|..v.-l(.p<.(l  Iroi.i  ncun.lh.t^ 
pa.<siii«  tidiu  tiic  retina  toward  tlic  hraiii  and  ..tluTs  .rr.,«ii,!  loni 
till'  l.raui  toward  the  retina.  The  sheaths  of  the  optic  nerve  iu^  the 
septa  are  produced  by  continuation  of  the  niesoilcnii,  which  I'orin-^ 
the  cerehral  dura,  arachnoid,  and  ])ia. 

Uveal  Tract  (Choroid,  Iris,  and  CiUarv  Body).    The  larjte  amount 
ol  vas;'ular  tissue  m  the  iris,  r-iiiary  an.l  choroid  show,  that 

the  tunica  vasculosa  oculi  or  uveal  has  1 n  develope.!  from 

the   mesoderm.     In  the  early  (hftVr,  ..      .  n  of  the  eve  structures 
the  lens  sac  becomes  separated  from  t>.    overlving  ecioderm  bv  a 
thm  stroma  ot  mesodermic  tissue,  which  iKronies  cleft  in  develop- 
ment (I'late  XL,  D),  un<"  j)art  remaining'  over  the  outer  surface  of 
the  lens,  and  the  other  adhering  to  the  inner  surface  of  the  <rtoderm 
Ihe  former  constitutes  the  pupillary  membrane  and  the  latter  the 
substantia  propria  of  the  cornea,   tlu-  space   between   forming  the 
aiiterior  chamber.     The  forward  growth  of  the  thin  double-lavered 
hp  ol  the  optic  cup  beyond  the  edge  of  the  lens  and  over  its  anterior 
Mirtace  lorms  the  ciliary  body  and  the  iris;    extending  backward 
II    h)rins   the  primitive    choroidal   stroma   which  accomi>ani"s   the 
retinal  tissue  in  its  growth  forwanl.     Almost  th<-  whole  of  the  an- 
terior surface  of  the  lens  becomes  covered,  witii  the  exception  of  a 
central  area  corresponding  to  the  pupil,  which  is  closed  Hrst  bv  the 
vascular  pupillary  membrane.     (Figs.  151  an.l  152.)     Further  altenu- 
Mlion  ol  the  epithelial  cells  on  the  edge  of  the  lips  of  the  optic  cup 
I'-nns  the  colunuiar  and  cuboidal  elements  of  the  pars  ciliaris  and 
pars  iri.hca  retina-.     The  pigmentation  of  the  cells  increa.ses  until 
the  anterior  portion  of  both  layers  forms  the  consjucuous  pigment 
ot   the  posterior  surface  of  the  iris  and  the  ciliarv  bodv.     .\bou; 
111''  thml  month  of  f.rtal  life  the  epithelial  cells  surrounding  the 
'■quator  of  the  lens  form  into  a  series  of  radial  folds,  into  which 
i.'lu-ate  processes  of  me.sodermic  tissue  extend,  developing  into  the 
xascular  structures  of  the  ciliary  processes.     The  outer  stroma  of 
'he  |)ars  ciharis  becomes  pigmented,  the  inn;'r  layer  remaining  un- 
coil ired.  •  '^ 

Cornea  and  Sclera.  With  the  exception  of  the  corneal  epithelium, 
'iK'  ('".s  and  tlu-  nervous  tunic  with  its  cerebral  attachments  ail 
"I  which  are  derivinl  from  the  ectoderm,  the  other  parts  of  the  eye- 
liall  are  develo])ed  from  the  mesoderm  surrounding  the  jjrimarv  optic 
vesich;.  At  the  same  time  that  the  many  changes  hitherto  described 
"<  cur  in  the  optic  vesicle  the  surroun<ling  mesotlerm  exhibit.s  marked 
l'i"lih'ration  and  condensation,  resulting  in  the  production  of  a  dLs- 
tiiut  envelope  of  embrj-onic  connective  tissue.  The  posterior  .segment 
"1  tins  mesodermic  cai)sule  difTerentiates  late  in  f.i«tal  lif.>  into  an 
outer  ,|,.n.se  tumc,  which  becomes  the  .sclerotic  coat;  the  anterior- 
l'"iiion  becomes  earlier  differentiated  into  the  sub.stantia  proiuia  of 
'  "•  ••"••■lea  b,.mg  dev(.|oped  from  a  homogeneous  nia.ss  which  fills 
nie  small  cleft  between  the  anterior  pole  of  the  lens  and  the  ectoderm 


lut  A)/;. 


Fia.  IM. 


whicli  forms  tin"  (•..meal  cpitlicliuiii.  Hctwcf-ii  tin-  anterior  surface 
of  tlie  lens  and  this  mass,  niesodennie  eells  ^o  in  and  form  the  endo- 
tiieliuni  of  tiie  cornea.  ( I'iate  XI.,  V,  (ij  The.se  ceJls  tiirow  out 
projections  piercinjr  tlie  ma.ss  and  forming;  the  corneal  corpasdes; 
the  pi/sterior  layer  of  the  hoinojieneous  mass  remains,  forming  the 
lamina  elastica  posterior,  and  the  anterior  portion  forms  the  lamina 
elastica  anterior.  Precorneal  hloodves.sels  develop  later,  but  disap- 
jM'ar  iM'fore  hirth.     (I'late  XI.,  .\.i 

Ocular  Appendages  (Eyelids,  Conjunctiva,  MuscJas,  Glands,  and 
Orbital  Tissues).  The  eyelids  develop  early  a.s  an  ujiper  and  a  lower 
fold  of  the  ectoderm,  which  ftrow  over  the  corneal  surface  until  thev 
meet  and  fu.se,  this  takinj;  place  early  in  the 
third  mcmth  of  fiital  life  in  man.  contunjing 
until  sl.ortly  before  birth,  when  the  iwrmanent 
w'paration  is  effected  by  cleavage  along  the  line 
of  juncture.     (I'late  XI.,  A.) 

The  hairs,  the  irlands,  lym|)haties,  tarsal  and 
bulbar  conjunctiva-,  and  the  anterior  epithelium 
of  the  cornea,  are  developed  from  the  ei  wxlerm. 
The  lacrynial  jKi.-sages  appear  early  as  a  fi.ssure 
(about  the  thirtieth  day),  Ix'ing  develo|X'd,  as 
are  the  tear  glands  and  tear  sacs,  by  infoldings 
of  the  ectoderm.  (Fig.  154.)  The  ocular  mus- 
cles, together  with  Tenon's  capsule,  the  comiec- 
tive  tissue,  and  various  structures  within  the  orbit,  with  the  excep- 
tion of  the  nerves,  are  derived  from  the  mesoderm 


Itetmtt  / 


Human  embryo  (if  thirty 
one  days.  Magnified  5  dl 
ameters.    (After  His.) 


ANAT0M7  AND  PHTSIOLOOT  OF  THE  UVEA. 

If  the  outer  coat  of  the  eyeball,  wiiich  is  composed  of  the  cornea 

and  sclera,  Ix'  removed,  a  grape-like  bodv  is  exposed,  which  is  the 

uvea  or  middle  coat  of  the  eyeball.     The  anterior  portion  is  coiu- 

jjosed  of  the  iris,  which  is    a   diaf)hragm  in  front  of  the  lens  witli 

a  central  opening  forming  the  pupil;  it  extends  to  the  junction  of 

the  cornea  and  sclera,  where  it  is  continued  as  the  ciliary  body: 

this  being  seen  on  cross-section   is   triangular  in    shape,   and   i.«  "a 

circul;.'  organ  about  2  mm.  wide,  which  is  continued  posteriorly  as 

the  clioroid   to  the  opening  in  the  .sclera  wliich  admits  the  optic 

nerve.    The  whole  uv.-a  is  .soft  and  friable,  the  chorcjidii)  portion 

iMMiig  composed  mainly  of  cot     -ti\e  tissue  and  bloodve.s.sels,  whose 

;he  e.s.seritial  parts  of  the  eye.    The 

tat,  and  has,  in  additi(m,  mascular 

(•■impo.se(l  of  nervous,  vascular,  and 

,        .         .  t<»  <1<>  with  secretion,  excretion,  and 

the  luiictiun  of  accommodation. 

Iris.     Macroscopic  Anatomy.     1  he  iris  is  a  membranous  and  mus- 
cular diaphragm  containing  a  central  opening,  the  pupil.     It  extend.-^ 


function  is  to  cover  and  iiouj 
anterior  portion  or  iris  is  ;i  ph(. 
elements:   the  ciliary  body  is 
muscular  elements  which  hav: 


rsTiSRrTJarr 


.^-.JU>L     .UJ 


wmm- 


M.ATK   XII 


<-.'<•/•>  IV- r 


:s^M.\ 


ftutttttt 

rndofhthum    I'^'t-V 
lay,-' 


iUoam 


Pumm 
Cells 


Ktifulof  stroma 


layer        layer 


2    t^m 


Difujiaminnlii'  Sections  of  Choroid. 

A  Mict..~c.iiiic  Sictii'tl  of  Ivisiii  Iritis.  II.  Mitrosi"i>ic  S>ilion  .)f  Nuvlilal  lii-.  C.  »ll)itrficial 
t  rivers  of  the  ll:it  I'ortiiiii  .,f  a  Ciliary  I'roiess  in  McriMianal  Scliun  I)  Mtri>liaiial  Stctimi  uf 
rurtiml  olCiliar\- I'niccss  near  Apex.  K.  All.inolic  K>e  .  no  I'iRnnut  in  IMKint-nt  Cells,  1-.  Tes- 
sellated 1  nil. In-.  I'inintnt  Confine.l  to  Stroma.  C.  Negroid  Hun.lus :  Ueciily  I'iRnienteil  in 
Iwth  Retinal     .lycr  nnd  Stroma.    A    Arteries.     V.  Veins.    P.  Perivascular  I.yiniili  Spaces. 


A  AVI  TOM  y   I M,  I'll  YsittLoa  Y  Of  TIIK  I '  yfA  jp 

frn-n  tl„.  .■..,t,.ri„r  surlac..  of  tl„.  miliary  Ik,.Iv  ..vcr  tl„.  |,.„s   its  ,.,.,„ral 
or  pupillary  l«.r.,.r  li,.  an.l  kII.!,.  up...,  tl...  a..t..ri..r  ,    ps  |..  * 
-s     l.us  ol,annn«  a  finn  support.     Tl...  ..iiiary  hor.li!    ;;,',.; 
."  ir.   ,s  ,nu,v  p,.st..n..r,  .„,  a.Tm.nt  nf  tl,.-  simp.-  ul  t!.r  l.-n.   mu 
thus   t  „.  ms  t,.rms  a  sl.all..«-  trunrat,.!  ,.u,u-:    ts  rilia  v    ^1.1. 

an.l  .  xt..n,ls  u.  a   plaiu-.     I-.t   n„nnal  appcarancT  .,f  tl..  ins,  x.o 

BJlcroscopic  Anatomy.     ()„  s,rti,.n  tlH>  iris  is  .«,.,.„  |„  1„.  ,.o,„„hs,.,1 
of  s.-v,.ra!  .I.s„„,.t  layrrs  fl'lato  Xll..  .Al:  1.  .Vntoriur  .....iutl     i    , 

•nor  huutrntt  layor.     ...  Pipn.nt  lay.-r,  ,.,„npn.s,.,i  ..f',,,,  tl,,.  .,  ,t  t 
layer  „t  pi-iiu.„f,|  p„lyiroiial  cells.  P<>st.,,.,r 


Kio. 


.■cerior  ,H,er»  of  .h.  iri.  o.  an  a,bi„o,„.  „„„.„  eye,    .Minified  30„  u,„^     , „„.  K,c>,m 

The  stronia  „f  the  iris  ct.sists  „f  nurneroas  l)I(K,dvessels  enclose,! 

to    le  pup,  lary  „.arsu,s.  ...n-l  are  surroun.l.nl  by  a  lo...se  „.esl."      k 
of  'ranchcl  and  |)iKn,ente(l  cells      There  is  •.   H.,t   l....„i     ''    '"     , 
.--.ular  h,,n.s  iL,  .,,...  ,.  „.e  pl-slc^ii.^  ^u/Jt'     '  ,;'irr;;    | 
'«■:      'h.'  pupillary  inargin,  which  composes  the  .sphincter  ,„iscl,r 
cuns,r,<,or  pupilhe.     On  .he  ante.ior  sirface  is  a  T,   e  "v  "o  tl 
the  an  er,or  en.lothehuin.  and  nex,   to  this  a  honioK,.ne.n,.    1.    '  ' 
both  o»  win,  I,  have  crypts  or  openinir    lea-lini^  into  The  in  ,.ri  J^'f 
he  ms  ti.s.su,-    thus  placing  its  spa,.,  in  fre,.'  co.nmu  i,-  ti    ,    vi 
he  cavity  of  the  anterior  chainlxT  and  allowing  of  rlid  ch  ng^i 
oluine.     The  p,)sterior  surface  is  covTcl  by  the  ,K..ster  o  ■  I  mi  ing 
nembrane  and  the  pign,ent  layer.     The  fornu-r  contains  vev  even 
1  se  fibres  cxteiuling    n  a  radial  direction  from  the  ciliary 'to    he 
pupillary  margin,  an.l  is  reg,„,l,.,l  as  a  dilator  pupilhe-   as  no  „, us! 
cular  hbres  have  been  demonstrated  here,  its  ksiue  probaHv  acts 

22 


Ill 


am 


Tilt:  t.YK. 


!)>•  clasiic  iniriinii.  'l'||,.  |,ij;iiiciii  iiiyci-.ovcriiiK  the  |)o.-t«Ti..r  .-^lirlafc 
fxtfiids  tu  the  impillaty  •ii.ii«iii,  ami  turns  luuml  t«>  apix-ar  a  liMlc 
on  the  aiit.Tior  surface,  iMroiiiinft  easily  visihle  where  (he  hi  -  is 
cataraetiius.     (Fi^s.  (>.  loo,  and  l.'>«),) 

Till-  (-..lor  of  the  iris  is  .let.'riiiined  liy  \\^,^  anionnl  of  pinnunt, 
'-.'  k.ids  of  which  exist,  the  one  lyiiiK  in  the  hranch.  d  cells  oi  -he 
strotn.i,  and  (he  other  (ilhnu  u|.  the  e|)iiheliii|  ,ells  uf  the  posteri  r 
pigment  layer,  p;.rs  iridii^a  retinav  W  iih  the  I'xception  of  jdhitmiic 
eyes  ({'iu.  I.mI,  the  retinal  layer  always  ahounds  in  |.iKnient.  while  that 
of  the  stroma  varies,  so  th.it  Nvhen  the  latter  contains  little  iiijrtnent 
that  of  the  epithelial  cells  shows  throu>;h.  the  thin  iris  appearing  hhii'. 
If  the  ,-troni.i  Ik' deficient  in  jiijiment  hut  thick,  the  iris  appears  gray: 
and  if  there  Ik-  a  K^eat  atnoiini  of  pigment  in  the  strom.i,  lirown,  the 
depth  of  color  varyinj;  with  the  amount.  Isolated  patches  of  pij;nieiit 
are  found  iu  the  struma  a-  na'vi  or  .s|)ots  on  a  lirown,  ^rav,  or  hhie 
iris.  The  pigment  may  Ik-  dee|)er  in  one  part  than  anothei  Thi' 
color  of  the  iris  changes  iu  the  early  years  of  life,  at  lirst  the 
stroma  containuiR  hut  little  pi>;inent  anil  hemj,'  very  thin.  Witii 
increa.sinK  ap-  the  stroma  iH'cotnes  thicker,  and  if  th«'  pi^imentation 
does  not  iiii'rease,  the  iris  becomes  light  blue  or  gray;  if  it  incrc;,  -s, 
the  color  becomes  brown. 

Cibary  Body.  Macroscopic  Anatomy.  The  ciliary  body  is  the 
middle  .segment  of  the  uyea.  ext(>nding  from  the  .scleroc-irnVal  junc- 
ture in  front  to  the  ora  serrata  lM'liin<l.  It  is  a  circular  organ,  but 
when  the  eye  is  bisected  the  region  appears  as  a  triangle,  the  dinger 
and  outer  side  lying  next  to  the  sclera,  the  short  anterior  .side  against 
the  jxTtinate  ligament,  anil  the  inner  margin  in  apjiositioi!  with  the 
pars  cili;«ris  retina-.  It  has  three  distinct  subdivisions:  i.  -  ciliary 
ring,  the  processes,  and  the  mosclo.  Th-  muscular  portioi,  larger 
in  hyperopic  tli'in  m  emmetropic  eyes,  i.iid  is  smaller  in  myopic  eyes. 

Microscopic  Anatomy.  I'roceeding  from  without  n\\\  ml.  we  find 
the  ciliary  muscle,  which  consists  .ii  an  external  portio  i  containing 

t!ie  longitudinal  or  meridianal  fibn-s  which  arise  from  tl xterrial 

tunic  of  the  eye  at  the  boundary  iH-twcen  the  (.rnea  and  .sclera, 
and  run  straight  backward  until  they  are  lost  in  the  external  layers 
of  the  choroid:  the  fibres  here  radiate  and  are  transposed  into'cir- 
cul;ii  filires.     (Fig.  i.jt;.)    The  ciliary  jirocesses  (Plate  XII.,  (',  I))  are 


stroma  containing  a  large  iiumlK-r  of  bloodvessels 
t)r;tiiched  Digiiient   cells  placed  upon  the  ciliary  muscle.     The 


a  connective-tisMii 
and  bninched 

layer  next  t(.  the  vitreous  is  a  single  stratum  of'iion-pigmented 
cylindrical  cells.  I'nder  this  is  a  layer  of  pigmented  ells,  the  pig- 
mented epithelium:  these  two  form  the  pars  ciliaris  retina'.  VuCv 
these  is  a  homogeneous  membrane,  the  hvaline  lamella  of  the  ciliarv 
body. 

The  iris  and  ciliary  body  are  attached  to  the  .sclera  a  little  back 
•.=f  the  eorne.wfjrrai  liUirdn  bv  eon.-ic.-tive  li.ssue.  which  i.>  caiied  tiie 


lig;imeiitu!n  pectinatum.     (Fig.  1,")7.)     This  forms 


111  angle  with  the 


iris  and  cornea,  forming  the  sinus  of  the  anterior  chamber,  aiul  where 


.I.V.I7o.l/r  .i.\/*  I'llYsHl.ooY  OF  TIIK  IVi:.[ 


:J39 


a.t..|lMMl  t..  th-  M.|,.ra  .l,..n.  i>  .,„      un.lar  lyn,|,l.  s,.a,t.  f..n,.a.g  the 
caiwl  ol  >d,|,.ihih:   tins  ,M,rfi..n  i,      ulr.  U,,.  dliary  ring. 


Kl.,       * 


Merl.llan.l  «^tlon  through  .nterior  r«rt  of  the  eye.  ,h.,wl„g  .b.-  cllUry  hodv  .nd  Irt,    with 
n...«,„n„«  .r„c„m.,      (•   ,„r„ea.    .v.  s,-...™.     ,.  ^hleinn,  .«„.,.     i    Limb™  «„,  m'c.Tv" 

M.h  friTTornL  t.  'j-^r'^""""/"""""""-  -^  '■^•'"" '"  '•'-""»  "''"oMrr  ;:: 
5r :  r  ,'■->  "f=" -"■''«.  ■=■■  «''..s=:'.,=".T» 

>ir.Hia.    ,h.  (  hon,l.l.    r.  Flbpw  of  r^niiU-  ,.f  ZInn.    r,.  Krif  ,«,rllon  of  lonuU     /  Cn.!  nf  i-Pti? 
.'    Ua..    *.  Nuclei  of  len..     M.gnliicl  14  tlm«     (Arter  K,.,i,."       "' """'•■    '  «•"*'  »'  '""■ 

•  •      ;■  •<Ti.,r  chainlHT  of  the  pyo  is  formed  in  front  bv  the  cornea 
'"1,1    ,      '"■  ins,  in  the  region  of  til..  ..npil  by  the  anterior  capsuit' 


Fio.  v.-. 


Su.-f 


view  of 


te  !iL-an;i-::!-.!m  jvt.-  tinsS'im. 


'i'l  His  an,!  at  its  margins  by  the  ligamentum  i)ectinatum.  behind 
"  ''  '"•  '1"  <'aMai  of  Sehlemm  and  tiie  anterior 


region  of  tiio  ciliary 


;mo 


rUE  EYE. 


body.  Tlic  il('|)tli  111'  tiic  aiitcriur  cliaiiilxT  is  infiucnt'cd  l)y  accoiu- 
iiiodatidii,  \»m^  .sliallowcr  <luriii);  tlio  act  fmiii  |)r(itrusi()ii  of  tin* 
anterior  .surface  of  the  lens;  it  i.s  greatest  in  younj?  persons  ami 
siudlower  in  'ild  aj;e:  niyo|)ic  ejcs  iiave  a  deep  anterior  clianiher, 
iiyperopic  ey(  s  a  siiailow  one.  Where  tiie  tension  of  tiie  i-ye  is 
increased,  the  anterior  ciianilM'r  U'conies  shallower. 

The  posterior  cliand)er  is  an  annular  s])aci'  at  the  edge  of  the  lens, 
heiiiff  jiroduced  by  the  iris  coming  in  contact  oidy  at  its  pupillary 
inarj;in  with  the  anterior  capsule  of  the  len.s.  It  is  bounded  in  front 
by  the  iris,  to  the  outer  .side  by  the  ciliary  body,  its  inner  and  ])o.s- 
terior  wall  bei.ig  formed  by  the  lens  and  the  zonuli-  of  Zinii,  th(  latter 
approachiii}!;  from  the  inner  space  between  the  lens  and  the  ciliary 
body.  The  two  chanil.-ers  coniinunicate  only  by  means  of  the  pupil, 
and  both  are  tilled  with  the  aqueou.s  humor. 

Choroid.  Macroscopic  Anatomy.  On  o|H'nin^  the  eyeball  and 
removing  the  vitreous  and  retina,  the  inner  .surface  of  the  uvea  is 
e.\])ose(l;  *'.ie  choroid  extends  fr mi  the  ora  .s;'rrata  to  the  ojitic  nerve, 
appearinji  as  a  smooth  brown  ineiiibrane.  On  removing  this  from 
the  underlying  .sclera,  it  is  found  to  be  attached  more  firmly  at  .some 
.s|)ots  than  others,  more  ])articularly  at  the  optic  nerve,  at  the  en- 
trance of  the  ciliary  arteries  and  nerves,  and  at  the  ecjuutor  in  the 
region  of  its  hirge  veins,  the  vena-  vortico.sa".  Thus  the  outer  ])ortioii 
appears  to  Ik?  .shaggy,  on  account  of  adiierent  shreds  of  membrane. 

BCcroscopic  Anatomy.  The  thickness  of  the  choroid  varies  from 
O.OS  mm.  at  the  optic  apertmc  to  0.05  mm.  at  the  ora  .serrata.  It 
has  five  outer  layers  ( I'lat(!XII.,  1',  F,  (.i),  being  from  without  inward: 
(I)  the  sui)rachoroid,  which  i.s  a  richly  pigmented  layer  of  fibrous 
tissue;  (2)  the  layer  of  large  ves.sels,  which  are  mainly  veins,  the 
intervasculai  s|)aces  being  richly  supplied  with  pigment  cells;  (;<)  the 
layer  of  medium-sized  ves.seU,  which  is  but  slightiy  pigmented; 
(4)  the  laj-er  of  capillaries,  which  is  non-pigmented.  Tlie.se  caj)!!- 
laries  have  a  very  wide  bore  and  are  packed  closely  together,  with 
their  interspaces  narrower  than  the  capillaries  themselves:  (5)  the 
lamina  vitrea,  which  is  a  homogeneous  membrane  lining  the  inner 
surface  of  the  choroid.  I'pon  tliis  lies  a  .single  layer  of  cells  which 
lunc  l)een  de\-eloped  from  the  retinal  mesoderm,  whicii  are  deeply 
pigmented  ami  belong  to  the  retina,  the  pigmented  t  pithelium  of 
the  retina. 

The  choroidal  stroma  consists  of  a  ground  substance  of  loosely 
interwoven  connective-ti.ssue  lamella'  containing  bloodves.sels,  white 
fibres,  and  elastic  tissue  with  stellat(   pigmente>l  cells. 

Ophthalmo3copic  Appearance  of  the  Choroid.  This  membrane  gives 
the  chiiracli'ristic  color  to  the  fundus,  and  the  amount  of  pigment 
therein  is  responsible  for  inu<'li  of  the  variations  f()un<l  in  normal 
and  diseased  conditions.  The  pigment  is  contained:  (1)  in  the 
pigment  epithelium  of  the  retina  ( l"ig.  loS):  (2)  in  the  stroma  of 
the  choroid  (Fig.  I")i»\  If  the  pigment  be  wanting  in  both  of  these 
structures,  we  have  the  albinotic  fundus  (Plate  XII.,  K),  which  is 


.i.v.iroj/1-  AM)  piirswLOdv  of  the  vvea. 


.'J41 


li>:lil  red.  tlic  oiitirc  liirpor  circulatioii  of  tlic  retina  and  choroid  being 
visil.le:  on  account  of  the  overlyinR  capillary  vascular  layer  of  the 
choroid  the  intervascular  spaces  between  'the  larger  bloodvessels 
show  as  pink.  Where  the  pigment  is  wanting  entirely,  or  there  is  but 
little  in  the  pigmented  eiuthelial  cells  of  the  retinad'late  ,\II.,  V), 
while  that  of  the  choroidal  stroma  is  more  or  less  normal  in  amount^ 
the  tessellated  fundus  is  observed,  in  which  the  inter^-ascular  spaces 
appear  as  dark  pla(iues.  Where  the  pigment  epilheiium  and  the 
stroma  are  heavily  stained  (Plate  XII.,  G)  the  choroidal  circulation 
is  not  visible,  an<l  the  fundus  is  of  a  dark  hue.  This  tyf)*"  of  fundus 
exists  in  the  dark  races,  varjing  from  a  dark  brown  in  the  China- 
nian.  Indian,  and  .Malay,  to  a  .slaty  hue  in  the  negro.  Occasional 
bizarre  effects  are  seen,  as  in  the  fundus  flavus.  The  o))hthalnio- 
scopic  appearance  of  the  normal  average  fundus  lies  between  these 


Fig.  IM. 


Fi<!.  V«. 


m  ® 


@ 


Fio.  1'*.— HexDKoiial  iilumeiit  cells  ipf  the  retina. 
Flo.  l.'>9,— Pigment  ctnima  cells  of  the  choroid. 

ixtriMiies.  Ill  the  blonde  more  of  the  choroiihd  circulation  is  obsorv- 
aiile  than  in  the  Iirui-ette,  and  in  the  latter  the  intervascular  spaces 
arc  seen  more   iistinctly. 

Bloodvessels  of  the  Eye.  The  liloodvessels  of  tin-  eye  belong  for 
the  most  part  t(.  the  uvea,  which  is  made  up  for  the  greater  part  of 
vascular  ti.-;sue,  and.  hence,  is  very  liable  to  become  inflametl.  Fuchs 
ilcscribes  the  ocular  va.scular  system  as  follows:  Three  .'systems  of 
bliMMlvtwels  exi.st  in  the  eye:  that  of  the  conjunctiva,  that  of  the 
retina,  and  that  of  the  uvea  (ciliary  system  of  ves.><els).  The  arteries 
111  this  system  are:  I.  The  posterior  ciliary  arteries :  these  ari.se  from 
ilie  oiihthalmic  artery  and  enter  the  interior  of  the  eve  through  the 
MJcra  in  the  region  of  the  posterior  pole.  Tlit  majority  of  them 
|i:iss  !it  once  into  the  choroid  (.short  posterior  ( ''Mry  arteries).  (Fig. 
Hill,  r,  c)    Two  of  them,  however  (the  long  posterior  ciliary  arteries) 

I  iK.  It'iO,  (/),  run,  one  on  the  outer  side,  the  other  on  the  inner  side, 
l"iween  the  choroid  and  .sch'ra  anil    as  far  forward  as  the  ciliarj' 

""-•'■      Hire  each  divides  into  two  branches,  which  nm  in  a  direc- 


iiiii 


342 


THE  EYE. 


tion  concentric  with  the  margin  of  the  cornea,  and  unite  with  the 
brandies  of  the  artery  of  the  opposite  siile  to  form  an  arterial  circle, 
the  circulus  arteriosus  iridis  major.  (Fin.  liiO.  h,  and  Fig.  150,  a.) 
This  giv.'s  off  the  arteries  for  the  iris,  which  extend  radially  from 
its  ciliary  to  its  pupillary  margin.    (Fig.  KiO,  i.)    Shortly  before  they 

FIH.  160. 


lllo<xlv«.self  ..f  Die  eve;  hohenmlle.  The  reliiml  system  of  vcMels  In  rtcrtvcd  from  the  central 
ttrt«r>-  a.  «■'-!  O"^  "nt™!  vein  <■„  "f  the  ,>i.tie  nerve,  wbi.h  Rive  oil  the  rotin,.l  «rlerie«  h,  hu.1  the 
retinal  vein.  h,.  Th.*e  el.J  ..t  th.-  ..r«  serrala  '/r  The  system  of  <ili«ry  vessels  is  fed  by  Ihe  ,«,slenor 
shert  ciliary  arteries  r  f ,  the  ,K*l.rior  1o„k  ciliary  arteri.s  ,(.  aii.i  .he  amerior  ciliary  arteries  f 
From  these  arise  t,i"  v.iscnlar  nelivork  of  the  ehoroDal  e>ipill..ries/,  an.i  of  Ihe  .•lllary  l««lv  <h  and 
the  cireulus  arl.rMsus  .riiiis  major  h.     From  the  last  s^riiiK  th.  »rl.-,le,  oJ  the  iri.  .,  which  »l  the 

smaller  (inneri  eir.oinr.reiiee  of  the  latter  form  the  eireulus  iri^lis  minor  k.  The  vei I  the  ins  ,„ 

of  the  ciliary  hortv  a^d  ..f  ilie  choroid  are  collecie<l  Inio  the  venffi  vorticisie  I:  those  veins.  h,.«- 
th»t  come  t"ro„i  the  ciU.irv  muscle  m,  leave  the  eye  as  anterior  ciliary  veins  .,     With  Ihe 
canal  «  forms  aiiashnnoses.    The  system  of  cmijoiicllval  vessels  consists  of  ihe 
Thc-c  commi.iicate  wilh  those  bniii<lii-s  of  Ihe  anleiior 


ever, 

latter.  Schlcmm's  c 

i«sterior  conjunctival  veswls  o  and  ■  ,  ,  ■  , 

Is  which  run  to  meet  '.liem-Ihat  is.  with  Ih'-  anterior  conjunctival  vcwels  ;,-iind  form 

/;   ll|>lic  nerve     s    lis  sheath.    .Kc.  S<'lera.    .4.  I'ho- 

R    Internal  rectus     /(.Conjunctiva     i  .Xfler  l.KBER.  fnun 


ciliiiry  vessi 

wilh  these  Ihemalijinal  lc«n>sof  the  cornea  t;. 
rohl      -V.  Ke-ina.    L.  I.eus.     //.  lornea. 
Fl'ciis  I 


reach  ihe  latter  they  form  by  ana.s^toiiiosis  a  second,  siuailer  vasciilai- 
circle,  the  cifiiius  arteriosus  iritlis  minor,  or  the  small  circle  (>f  the 
iris.  I'ig.  IfiO,  ^.)  -'■  'l"l><'  anteriov  ciliary  artei'es  conie  frtiin  in 
front,  arising  from  the  arteries  of  the  four  recti  muscles.  (Fig.  IfiO,  c.i 
They' perforate  the  sclna  near  the  margin  of  the  cornea,  and  a.ssist 


AXATOMY  ASD  PHYSIOLOGY  OF  THE  UVEA. 


•M:\ 


in  forming  tiio  circulus  artrriosus  iridis  major.  The  siiort  oosterior 
ciliiiry  arteries  are  theref(,re  det^ignod  inaiily  for  the  choroid,  the 
loiifl  posterior  ciliary  arteries  and  the  anterior  ciliary  arteries  for  th? 
ciliary  body  and  iris. 

The  arrangement  of  the  veins  is  essentially  different  from  that  of 
the  arteries.  In  the  choroid  the  capillary  network  of  the  chorio- 
capillaris  (Fig.  160,  /)  is  fed  by  the  arteries.  The  blood  from  this 
Hows  off  through  a  gn-at  number  of  veins  that  unite  to  form  larger 
and  larger  trunks.  A  nund)er  of  these  trunks  simultaneously  con- 
verge to  a  common  centre,  where,  con.sequently,  a  sort  of  whorl  or 
\ortex  is  produced  by  veins  coming  together  from  ail  sides.  These 
vortices,  the  numlier  of  which  amounts  to  four  at  least,  usually 
more,  lie  somewhat  behind  the  ecjuator  of  the  eye;  from  them  are 
given  off  the  vena'  vorticosa-,  which,  perforating  the  sclera  in  a  very 
obli'iue  direction,  carry  the  blood  to  the  outside.     (Fig.  160,  /.) 

In  the  ciliary  processes  the  arteries  break  up  into  a  greater  number 
of  twigs,  which  pass  over  into  thin-walled  veins.  (Fig.  160,  g.)  These 
cniistilute  the  greater  part  of  the  ciliary  process,  which,  accord- 
ingly, consists  mainly  of  vessels.  The  larger  veins,  which  are  fonned 
by  the  union  of  these  vessels,  and  also  most  of  the  veins  of  the 
ciliary  nuisde,  pass  backward  to  the  vena'  vorticosa".  The  veins 
that  come  from  the  iris  (Fig.  160,  /,)  likewis"  pass  to  the  vena'  vor- 
ticoste.  Hence,  almost  all  the  venous  blood  of  the  uvea  empties 
into  the  latter.  A  portion  of  the  veins  coming  from  the  ciliary 
iniiscle  (Fig.  160,  ?«),  however,  take  another  course,  as  they  pas.s  out 
directly  through  the  sclera,  and  thus  come  into  view  Ix'neath  the 
(■iiiijuiictiva  near  the  margin  of  the  cornea  (ante-ior  ciliary  veins, 
I'ig.  ItK),  c,).  In  their  course  these  correspond  to  the  anterior  ciliary 
arteries:  they  constitute  princi|)ally  the  violet-colored  ves.sels  which 
are  setn  running  backward  beneath  the  conjunctiva  in  ciliary  injec- 
lion  or  in  sta.sis  within  the  ey<'ball  (glaucoma).  The  anterior  ciliary 
veins  aiiiistomose  with  the  coiijunctiv.'d  veins  and  also  with  Schlemms 
canal  The  latter  is  a  venous  sinus  running  alonjr  tli.'  sclerocorneal 
juni'tioii.     (Fig.  160,  n.  and  Fig.  l.')6,  a.) 

Nerves  of  the  Uvea.  The  nerAcs  of  the  iris  are  derived  from  the 
ciliary  plexus.  They  are  at  first  me(hillated  and  (|uickly  reiniite  within 
till'  <iiiary  zone  to  form  the  iridian  plexus,  which  becomes  denser 
i~  it  ai)proaches  the  sphincter.  Three  kinds  of  fibres  arise  from  this 
I'li'xns:  (li  non-medullated  fibres  Ix'longing  t<i  the  .sympathetic  pa.ss 
I'i'IsuanI  toward  the  dilatator  iridis;  (2)  me<lullated  fibres.  a)«imr- 
'Nily  sensitive,  pass  to  the  anterior  .surf.'ice;  (.3)  mediiiiaie.i  lihns 
I'a-s  ii>  the  sphincter  and  give  if  tnotor  influence.  Certain  va.'^omotor 
tiiiic-  pass  tu  the  coats  of  the  vessels.  There  are  no  ganglion  cells 
ni  the  iris.  Its  tactile  sensibility  is  not  great,  and  ojM'iations  are 
'"■'  very  jiainfnl  if  tr.action  im'  avoided.  Inflammation,  however,  is 
iIIiihIciI  with  great  pain. 

\\\<-  nliarij  mrrcK  supply  the  ciliary  muscle  and  processes.  The 
!"!ij:  nerves  are  .sensitive,  being  derived  from  the  na.sil  branch  of 


;i44 


Tilt:  KYi:. 


tlic  ophthiilinic:  tli(>  latter  aiv  from  tlic  ciliary  piiiplinii.  and  are 
doubtless  of  a  mixed  cliaraeter.  The  eiliaiy  nerves  penetrate  the 
selera  near  the  tiptie  disk,  runninji;  forward  in  the  su|iraehoroidal  spaee, 
enter  the  eiliary  niusele,  and  unite  to  form  the  ciliary  i)lexus,  which 
contains  a  few"  nerve  cells.     Fibres  are  fiiven  olT  from  this  plexus 


which  pass  to  the  cornea,  iri 


and  ciliarv  muscle.     Tliese  nerves  end 


foHows:  (')  vasomotor  endinps  in  the  wa  is  wf  the  ciliary  ves.sels; 
(2)  motor  endiufts  in  the  ciliary  mascle;  (."i)  extremely  tine  reticu- 
lations of  grarmlar  nerve  fil)res,  which  jjrobably  minister  to  ordinary 
sensation:  (4)  terminal  arborcscences.  which  are  believed  to  lr;ve 
to  do  with  the  nmscular  sense  which  is  particularly  develoi)ed  in  the 
•le.     The  sensorv  nerves  of  the  ciliary  body  are  abundant, 


ciliarv  nius( 
d  1 


iHamniation  of  tliis  structure  is  attended  with  pain. 


and  lience  u _. 

The  larrvs  of  the  clmroid  are  derived  from  twigs  given  off  from 
th(>  long  and  short  ciliary  nerves  as  tliey  pa.ss  iM'tweeu  the  fibres  and 
v:iscular  tunic.-^  in  their  course  to  the  ciliary  Ijody.  The  si)ocial 
Inanches  destined  f'>r  the  ehoroiil  form  a  wide-meshed  plexus  of  both 
medullated  anil  non-medullated  fibres  within  the  lamina  sui)racho- 
roidea.  (ianglion  ceils,  isolated  or  in  limited  groups,  are  found  in 
this  plexus  and  al.so  along  the  ves.-<eis;  the  nervous  supply  of  the 
choroid  is  distributed  especially  to  the  muscular  tissue  of  the  bUxul- 
vessels.  and  belongs  to  the  vasoii.otor  sy.stem.  The  choroid  C(mtains 
no  sensory  nerves,  and  inflammation  oi  thi?  membrane  runs  its  course 
without  |)ain. 

L3rmph  Passages.  There  arc  no  true  lymph  ves.sels  in  the  eye, 
except  in  the  conjunctiva:  there  are,  however,  large  lymph  channels 
and  spaces  (Fuchs): 

1.  Anterior  l.iimph  Posmges.  The  lymfih  of  the  anterior  section 
of  the  eve  is  collected  into  two  large  lymph  spaces,  namely,  the 
anterior  and  posterior  chambers,  which  communicate  by  means  of 
the  ]iupil.  The  outHow  of  lymph  from  these  spaces  takes  place  by 
its  discharge  from  the  jxislcrisir  chamber  through  the  pupil  into  the 
anterior  chamber:  tlicnce  it  filters  throiigli  the  meshwork  of  the  liga- 
ni(>ntum  pectinatiim  into  the  subjacent  Schlemms  canal  (Fig.  1(»1,  .>•■), 
and  from  there  g<'ls  into  the  anterior  ciliary  veins  (r),  with  which 
Sclilemm's  canal  is  in  dirr-ct  communication. 

•2.  I'dslcrior  Lijinph  I'nssiif/cs  The.se  ari'  iis  follows:  (a)  The  hyaloid 
canal,  or  central  can.il  of  tiie  vitreous  i  I'ig.  Kil,  /(),  whicli  extends 
from  the  point  of  entrance  of  llw  optic  ik  rve  f..rwar<l  as  far  as  the 
posterior  pole  of  the  lens.  During  the  developiiunt  of  the  eye  this 
cinal  lodges  the  hyaloid  artery,  which  in  the  fully  formed  eye  dis- 
ajipears,  while  the  canal  remains.  It  has  its  outlet  in  the  lynij)!!  j^paces 
of  the  optic  nerve.  /')  The  perichoroidal  spaee  i  Fig.  Kil.  /i)  is  the 
space  between  the  choroid  and  sclera.  It  is  continued  ;ilong  the  ves- 
.sels which  pass  through  the  .sclera,  especially  the  ven;e  vorticosa' 
(Fig.  Ifil,  >■),  and  thus  coimnunicates  with  the  anterior  ciliary  veins 
(I'ig.  Kil,  c).  Tenon's  .space  (Fig.  Kil,  /.  /),  which  lies  between  the 
.sclera  and  Tenons  capsule.     The  outflow  of  lymph  from  all  these 


AXArOMY  .I.VX»  PHYSIOLOGY  OF  THE  UVEA. 


345 


spaces  takes  place  into  the  lynipli  j)assages  wliich  sjiread  out  along 
tlic  optic  nerve.  Tliese  latter  are  (/;)  the  intervafjinal  spice,  which 
IS  found  iK'tween  the  sheaths  of  the  optic  ner\'e  ( Fi^.  1(11 ,  i),  and 
I  A')  the  supravaginal  space  (Fift.  Ifil,  ,s),  whicli  surrounds  the  sheaths 
of  the  optic  nerve. 

H\-  far  the  greatest  amount  of  lymph  leaves  the  eye  through  the 
antf^rior  lymph  passages.  The.se,  therefore,  are  the  more  imi)ortant. 
Thiir  imj)ermeal)ility  leads  to  serious  changes  in  the  eye  (glaucoma), 
while  up  to  the  present  time  nothing  certain  is  know"n  in  regard  to 
disturhances  of  the  function  of  the  i)osterior  lymph  passages. 

Fia.  161. 


1„  1  Z  ,    ?7?H       ?'!'  ""'"™""'      "■  Schlo,«ms™i..l.    ..  Anterior  cill.r,- vein-.    A.  Hya- 
Ion      L^,  r'         T?'  """"  '"">""""""-  by  mean,  or  ,he  ven,P  vortico.*  ,•.  «m, 

-'.a  »I«>"tl>cl..„,|„,„„r,„o.HMlariDU«-lM,Utemllnv.gln„li„n.    Hfter  Fuchs.) 

Nutrition  of  the  Eye.  The  nf>urishment  of  the  e-ve  comes  mainlv 
'  uni.^ri,  ,i„,  „v,,,l  vessels;  the  secretion  of  th..  flui.ls  of  the  eve  i's 
il^o  nuhrectiy  elicited  l.y  the  uvea.  Th.-  a<iueous  humor  is  the 
■■niv  secvhon  of  th.-  evehall  pro|KT.  It  is  a  limpid  li.p.id  containing 
■'  ^iiKill  aUMMinf  of  all.uiiiin.  secreted  mainlv  l)v  the  ciliarv  proces.ses 
i""if:  poured  first  into  the  posterior  ehamher.  thence  pa.s.s'ing  through 
I'"  I '"I'll  '"to  the  anterior  ehamher,  leaving  i  he  eve  through  Schlemm's 
'"■'1  ;"id  tne  hgamei-Mim  |.ectinatum.     It  is  secreted  and  e.xcreted 


:yu 


rui:  EYE. 


rapidly  in  health,  and  is  n'stored  quickly  after  evacuation  of  the  ante- 
rior chanilxT  by  operation,  sooner  in  youtli  than  in  old  age.  The 
flui<l  that  accumulates  in  the  anterior  chaniln'r  after  evacuation  of 
the  aqueous  contains  more  albumin  than  the  normal  a<iueous. 

The  cornea  is  nourished  by  the  marginal  loops  of  bloodvessels  at 
the  limbus,  and  somewhat  by  the  aijueous  humor  which  diffuses  into 
its  tissue.  The  lens  and  the  vitreous  obtain  nourishment  mainly 
from  the  ciliary  body  and  the  anterior  .section  of  the  ciioroid;  hence, 
in  disciuses  of  these  structures  the  lens  and  vitreous  l)ecome  clouded, 
and  may  undergo  degeneration.  The  internal  layers  of  the  n'tma 
are  nourishe<l  by  the  retinal  vessels,  the  outer  layers  being  deix'ndent 
ui)on  the  choroiil;  the  regeneration  of  the  visual  purple  is  accom- 
l)li.shed  through  nourLshment  from  the  choriocapillaris. 

The  intra-ocular  |)ressure  is  dependent  upon  the  relation  of  the 
capacity  of  the  ocular  envelojx's  to  the  contents.  It  Ls  discussed 
in  the  chapter  on  tJlaucoma. 

For  the  participation  of  tlie  uvea  in  the  visual  act,  see  page  65; 
the  reaction  of  the  pupil  to  light  and  acconnnodation,  see  i)age  ."«): 
HMiction  of  the  pupil  to  jioi.sous,  mydriatics,  and  myotics,  see  page 
112;  reaction  of  the  ciliary  body  to  cycloplegics,  see  page  112. 


DISEASES  or  THE  lEIS  AMD  CILIAItT  BODY.    CONGENITAL 

ANOMALIES. 


II  > 


M    I 


Variations  in  the  Color  of  the  Iris.  Then>  may  be  irregularities 
in  the  amount  and  distributi(m  of  the  iris  ])igment,  which  may  Iw 
mas.sed  into  little  heaps  in  the  stroma,  giving  rise  to  a  numlK-r  of 
brown  or  black  spots  upon  a  lighter  colored  iris  or  patch  upon  its 
surface.     (Plate  XI 11.) 

Sometimes  one  iris  differs  in  color  from  the  other;  this  is  ealleil 
ht'lrrochromia.  When  one  eye  is  decidedly  brown  and  the  other  a 
uniform  blue  or  gray,  indicating  al)s<>nce  of  pignient,  the  latter  may 
have  been  the  site  of  previous  tlisea.se,  or  it  is  liable  to  Im"  affected 
later  by  cataract,  while  the  dark  eve  may  remani  normal.  In  inflam- 
matory conditions  the  color  of  the  iris  always  is  changed.  In  albinism 
the  iris  usually  has  a  pink  appearance,  which  is  due  to  the  shining 
of  the  fundus  reflex  through  the  iris  stroma. 

Membrana  Pupillaris  Perseverans.  As  has  been  noted  in  the 
chapter  on  tiie  d<'velo])incnt  of  the  eye,  a  va.scular  membrane  fills 
the  pupillary  area  which  nourishes  tiie  lens.  It  is  of  comparatively 
frei|ueiit  oecurrence  in  newborn  infants,  but,  as  a  rule,  is  resorlK'<l, 
entirely  before  birth  or  shortly  afterward.  In  a  few  cases  complete 
resorption  iI(K's  not  take  place,  and  a  gray  or  brown  tissue  lies  upon 
the  anterior  capsule  of  the  lens,  arising  from  the  circulus  minor  iridis; 
in  the  centre  it  is  attached  to  a  small  round  white  capsular  opacity. 
When  of  such  a  degree  as  shown  mi  I'late  XI II.,  Fig.  12,  it  inter- 
feres seriously  with  visual  acuity.    Many  cases,  however,  display  only 


PLATE   Xlll. 


Anomalies  nn 


d   Diseases  Affecting  Uie  Ifis  and   Pupil. 


Z)/AA-1>AVV  OF  TUE  IKIH  ASD  CILIMIY  liUOY. 


Ml 


..lie  or  two  tilaiiicKts  Iroiu  one  portion  of  tin-  pupillary  nvAT^m  lo  lh<- 
opiiciiy,  or  from  the  iris  to  the  capsule  of  tin-  lens,  or  in  other  fas(> 
only  a  Uw  l)ro\v!i  dots  n-niain  u|)on  the  lens  capsule.  If  tlie  |)Ui>il 
Im>  .lilate.i  liy  atropine,  it  oih'Ii.-  fully,  a.n  the  filires  are  .-ery  exteii- 
>il)le.  It  is'otheiwise  the  c!,se  in  postt'rior  synechia',  for  here  the 
characteri.stic  clover-leaf  formation  of  the  pupil  is  observed  as  it 
becomes  enlarged.     (Plate  XIII.,  Tig.  9.) 


DESCRIPTION  OF  I'L.VTK  XIII. 


Kiii.  1.— Myimlsfrojiesu  Ine;  direct  lllnminatton.  showlnK  the  full  eitetit  of  the  maikinirtof  the 
Inn ;  Mie  puiiilUrj'  iwrtioii  ^l^l  IcbeJ  ty  cimtmctioii  ul  the  circular  Hbr>.-« ;  the  pupil  Ik  ntvcr  prr- 
fcctiy  r'l'im}  aiiJ  is  usually  situated  'lowiiward  uud  InuHnl. 

Kiii  2-V,-tlrwfs  ir.  in  Hlropluu  ;  ophthalmonopic  illiimlnatloii :  fullent  exranrioii  of  thepopi! 
I,y  comnictjoii  oi  ihe  null.il  li'jiwi;  the  dlsilncllve  iniirkiiiKS  ou  tb«  Irinare  nearly  obli'cr.ted;  the 
Ifii-  klur  shows  Indistinctly. 

Ho  o  -Corcctopia.  dl»pla.cmem  of  Ihe  pupil ;  direct  lllumluaUon.  In  thU condition  ibe  pupil 
is  usually  sotnewhat  Irrvitular,  snuU.  and  displaced  u>  one  rtde  of  Ihe  Iris,  mually  downward  and 
Itiwanl-  In  congenital  forms  bcinc somttlmes a».«oriaud  with  co'.ohoma of  the  choroid. 

V\v..  4.-(ilaucoma,  ths  irlf  structure  being  111  delincd  fr.,ra  swelllnit ;  the  pupil  irregular.  dllaUH), 
and  having  a  greenisn  reflex.  ,  ,   _ 

K...  .'.-Iridectomy  for  glaneoma:  oph-halm.  wopic  mumlr.atloii.  Ihe  edge,  of  the  coloboma 
..,vu  and  the  whole  pupil  tpelng  tlie  shape  of  an  inverted  ke>  hole ;  the  urp<"r  edge  of  the  leiw  and 
the  cillarv  prooemies  are  seen.  ,^,  , 

Fiu.  R.  llmiwrfwt  hdlcg  In  Iridectomy  f.>r  gla.icoina ;  anterior  synechia  cau.e.1  by  incan-erailon 
of  one  edge  o'  the  coloboma  in  the  corneal  wound  :  direct  lltuniinallon 

Fio  7-Ot,iUal  iridei'tomy  for  Icucnma  of  the  cornea;  di.cct  illumination.  The  coloboma  is 
usually  made  downward  and  inwaid  on  the  bact  of  the  clearest  i«.rti»n  ..f  the  cornea  ;  small 
iriilecloniv   which  d<«»  not  reach  to  llie  root  of  the  Iris 

Fi„  s  -I  ouKeuitul  colol)oma  of  the  cornea :  direct  Illumination.  Wlicn  the  eolol«raa  rcachea  to 
Ihc  f(«t  of  the  iris  it  is  usually  accompanli-d  by  cohitama  of  the  ihon.ld.  ,    ,,    .  , 

¥v.  .J -irHis  with  iH>»t"ior  synechu.  ;  ophthalmoscopic  illuuiiuution.  The  markings  of  the  Iris 
«r.>  not  well  dcHned  ■  the  synechia  show  dark,  forming  Ibe  characterlsilc  cloverlcaf  pupil. 

Kl.  1.1  -Exclusion  of  the  pupil  or  total  ixelerlor  syuechiu  from  chronic  Iritis  ;  ophthalmoscopic 
ill.unination'  The  »h..lc  e<l^e  of  the  iris  and  snmetlmei  the  entire  p..stcrh,r  surface  of  the  Iris 
arc  Ismnd  down  by  adhesions  to  the  atilerlor  cai*ule  of  the  lens;  this  cmdilion  and  the  f..Ilow- 
iiiL'iFiu  11 1  arc  imiie  to  ;,'lTe  rise  to  secondary  glaucom.i. 

K,„  11  -Occlusion  of  the  pupil  from  lrldo,yclitls  ;  o'-lique  illuminailon.  The  pupillary  area  is 
lillc.!  ttltb  orguulzed  exudation  ;  the  pupillary  margin  of  11-  Lis  Inking  l«>und  down  to  the  anterior 
,u|wilc..f  the  Icus,  the  centre"  ..f  the  Iris  being  bulged  forwarl,  causing  the  condition  known  as 

Klc  ■  •  -eerslsliug  pupillary  memhniuc  :  diicct  Illumination.  A  few  strands  mich  fr<mi  oyer  the 
,  .Ige  of  The  pupillary  margin  to  the  centra  of  the  lens.  This  condiliou  is  frequently  associated  « iili 
IsrsisUtiK  hyaloid  artery-.  ,   .    ,       .1. 

liu.  n-lridodialysis  (ophthaliui«coplc  illumlnatlmi),  lonning  two  pupils  and  asKielatw'  with 
.l.iuble  vl-ion     This  coudltion  and  that  of  the  next  are  of  traumatic  .Tigln. 

l-i..  H  --Cohcoria;  ophthalm<»e<.pic  illumination.  In  this  i«licnt  there  were  three  pupils  and 
triple  vision  ;  the  clge  of  the  lens  au.l  ciliary  i.nKvssis  could  lie  distinctly  8.*n. 

Kio  1.-,  -  Foaigu  bo<lv  111  iris  and  lens,  binding  the  iris  down  h.  the  lens ;  this  l*lng  a.sepllc  was 
„„i  asMKiated  with  Inllamimuon-  ch.mgw,  and  w„s  retaiucsl  in  the  eye  ten  .lays  before  extnuMi.m  by 
'..■mUEucti  hutsl.ghlopacityof  thBlenscap«Ml.  r..;io«Ld.    Direct  Illumination. 

Ki..  Id  -Traumatic  hcmorriiagic  Iritis  with  hvph.Trai:.  siuinlaiiiig  iiyiH)pyon.   IHrect  lllumlimtlon. 

li.i  IT. -Anterior  synechia  with  hernia  .if  the  iris  from  in-  ircerutlon  In  corneal  woun.l.  Direct 
liluininatiou. 

1 10.  is— Sarcoma  of  the  Iris;  oblique  illiiminnthn.    This  was  attended  by  IritLs  and  i>»u;rli.r 

viicchia. 

Vt,.  Y)  —Syphilitic  irllla  ;  direct  Illumination.    Gumma  of  the  iris. 

V\n.  JO  -Acute  .■hor.>iditis,  direct  illumlnaliou  In  .his  comlilion  the  exudation  in  the  vitreous 
-■  ves  rise  to  a  yellowlsb-ureen  reflex  lr»ni  the  pupil. 


h% 


fTr.?r«««^.£*x*sis. 


(if  vision ;  iuit  if 
iliviiinl   l>y  tlK- 


:UH  niKEYE. 

Treatment.     As  m  rule,  tlx'tv  ,-  lull.-  .li.tuil.aiuT 
tlu    iMCMl.ranr  U-  v-iy   tl.irk.  th-  sIra.i.U  ...ay  1. 

Ooloboina  Iridis.     ('....Knutal  r,.l..lH.i>.a  of  th.-  ins  is  al^va^^  Mt- 

!'..'.,....,  ,n..L'.-  nti,.uuusly  ..a,-n.vv..r.  t  ..■  .,.1..,.,...  hi....,  t ho 
„„,,jin  uf  th-  pu,,.!  ;u.  :.!.<..  the  .■ul..lM,...a  as  far  as  .;-  .\>vs.  .  1  tat  • 
V  n  FiL'  s  '  1"  the  ...ajority  -f  rasrs  a  s...aii  n...  ol  .r.s  ...ay  Ik 
:1s 'nV,!  a.  .!..•  In-ttn...  of  th.-  ,.„i..l,.m.a      It  .^  t..  1..-  .hst.nmi.sh.-.l 

...  ,h H.  ...a,lr  i.v  i...l.T......y:   i..    th..   btt.T   tl...    s,,h....-t..r  .s 

.   .,.« i..  11..-  .•oh.i.o,,,:,.  a...i  it  ...ay  iH-  ..M  t..  0...I  -'  •' f ;'n'  -  P; 

„   ,1,0  .livi.h..K  li..o  lH't«-..'n    th.-   l.ui..i  a.Hl  tho  ,-..lul,....  a.     (I  at. 

\ni     l-itr-    -)   0   7.)     li   th.'  o..l..l.<.i..a  1..-  ac.n.„pai..o.l  l.ya  shjjht 
;hl.-t'  „f  tho  Vhor..!.!.  thoro  ...ay  iii<owiso  oxist  a  .l.-tioio;.oy  ...tho 
.'iliarv  IhmIv;  sn,„oti...os  onl.,lH....a  or  ....loi.tat.o..  ...  tho  o-ifrr  ..t  tho 

l,.„s  aooo..;,.a..i.'>.     Th.T.-  an- ....  >I.ooial  sy...l.to..,s  a...l  ....  tnat....... 

Aniridia  vel  Irideramia.    Th.-  iris  ...ay  !«■  .-..t.n-ly  al.s..,.t  ..r  hut 
,  small  rosi.hia!  ,.or,io,.  .-.■...ai.. ;  this.i.-lVot  .s  a,T.....i.an.o.!  Ko...-rally 

1  V      ..L'o..ital  o,.ao,.ios  i.,  tho  lo..s  a...l  con.oa  a...l  nthor  ah..on..al.t.cs. 
K...  th.   ;,.oial  ......l.tio...  .lark  ^lassos  ..r  tho  sto....|..o.o  l.olo  i..ay  be 

""Kpla  PupiUa  vel  Corectopia.    Nonnailv  .ho  puj-il  is  ....t  pro- 

,•,"  V  m  .ho  o...tr.-.  h..t  is  usually  a  littl.-  1h-1...  a.u  f.    ho  s..lo.    I  h.s 

I  s    ao.-...o„t  is  so,n.-ti...os  so  p.oat  that  .t  .s  not.ooa  -lo    <-s,K-o.ally 

,„:        (IMato  XIII..  Ki«.  1.)     It  ...ay  ov,.„  ho  s.tuato.l  oc-c-o n- 

i,..llv   ...   th.-    .>.-inhlM.rh....l  ..f  tho   o...-.,oal   ...a.-p.n   (I'iato  MIL, 

.'  ,;  •      .  „.l  is  so,„.Mi....-s  oo,.,plioato,l  with  .r.slo,.at.o..  of  tho  l.-..s. 

PoUcoria  ..r  ...ultiph-  pupils  havo  Ih-o..  .losorih.-.!  as  <>';;'""-"'ff  <';;"- 
jr,.,.itally,  l.ut  as  a  nilo  such  ciuUtions  aro  .luo  to  ti-auu.at.s.n.    (i  late 

'""lilflaliiSato^' Diseases.    IuHanu..ati...i  ..f  th.-  his  is  h.ti...atoly 
,,  ".  o™  vith  il.a,  ..f  tho  .-itiary  ho,ly  as  hoth  an-  s..pp l.o.l  by  tho 
:      ;  W    uivossols,  a...l  tho  iris  spri.,,s  .lin-.tly  fro,.,  tho  o.l.ary  bo.  y^ 
f     .  i„g  ;.  .•o...i..uous  ti.ssuo.     It  sh....Kl  hkow.s.-  Ih-  n-..,o...bon-.l  that 

;!      5-oi.l  is  a  i.ortio,.  of  th.-  uv,-a,  a...l  is  us.ially  ...oro  or  loss  afToo  .-.I 

:      fl  .n.aa.inas  of  tho  a,.tori..r  portio..s.  pa.-t.oularly  whoro    ho 

Hi-  rv  b...iv  is  .,.v..lvo,l.     Thus,  vvl.iio  wo  sp.-ak  o,  au  .nt.s,  a  oyol  t.s. 

.     -horoiaitis,  a,.  i..Ha.,....atio,.  of  th.-so  tis-uos  .s  u.on-  pn-porlv  a 

;. ,        Th.-  aisoaso  ...av.  l.ow.-vor,  bo  so  pn  ,l.,......a..t  ...  t ho  ,ns  o 

.  1  .    V  l,o,lv  .hat  tho  atTootio..  ...ay  bo  .•lass.-.l  .-.s  .r.t.s  or  .•yol.t.s,  an.l 

f,  ;  ,';a!....'a^  purposes  tho  sy,..i.to...s  of  tho  pn..lo......a„t  ios,o..s  .uay 

'"■^;;;;^i:i;f  Xiris.     (-.....osti....  is  th.-  .irst  sta.o  ..f  i,^a.n.na- 

U^!^.nA  onhor  ...ay  , t..  rosolut.o..  or  to  lato,-  -^  ^f- "^    'f     ; 

,„.„io„      i:vo,-v  iritis  is  pn-o.-.l.-a  by  hyp.-ra-„.,a,  but  .-..sos  an    ...  t 
•i,       hat  .lo  not   pn,n-.-l  fur.ho.    tsan  this  stage.     It  =..ay  also  1k- 
IIm  with  ,.r  bo  a  sy„  ,  'om  ,;•  i..(ia>..,..ation  -]  ^^^^^ 
„f  tlu-  uveal  t.-act  or  th.-  ..oi^rhl^nuig  ooular  tissues;  thu>  .t  iucum 


1)Isi-:a.si:s  or  iiii-:  mis  ami  cilimiy  iioity. 


•Mt 


|i!inii'«  iiiHiiiiitiiiitory  cliiiiip's  in  fhi'  riliary  ImmIv  and  iiculf,  «'Vrri! 
I'iiiii'iiiilitis,  also  ulcer  of  tlif  cornea  and  .iclcrilis. 

Iiy|H'rainia  of  the  iris  is  cliaractcrizcd  l)y  clianfje  in  its  color,  so 
liiat  a  liliu'  or  Rray  iris  iM'ciinifs  greenish  and  a  hrown  iris  yellowish 
red  ;  in  dark  eyes  the  discoloration  is  not  s<»  marked  as  in  lilonde  eyes. 
<  ine  of  the  lirst  symptoms  is  ix-ricorneai  congestion,  a  characteristic 
(if  affections  of  the  uvea  and  cornea,  coiisistiii);  of  erdiirKcmenl  of  the 
line  vessels  situated  in  the  episcleral  tissue  railiatinjt  from  the  corneal 
margin.  (I'ijr.  UV2.)  The  pupil  is  sluKgish  and  d(K's  not  respond 
freely  or  (|uickly  to  lifiht,  accommodation,  or  mydriatics:  as  there 
is  III"  exudate,  posterior  synechia'  <lo  not  form.  In  acute  cases  coin- 
plele  resolution  takes  place  as  IIh'  cause  ceasi's.  In  ciiroiiic  hy))<'ra'miji 
the  iris  Iwcoines  di.scoloreil  from  chaiifres  in  the  pigment  cells,  anil  the 
pigment  at  the  pupillary  border  disapiM-ars,  the  edjie  U'cominn  raided 
and  notched.  S<'nile  changes  in  the  iris  caus<'  hieacliing  of  a  similar 
nature. 

Hyperemia  of  the  Giliary  Body.  Simple  hy])era'mia  of  the  ciliary 
ImmIv  is  accompanieil  usually  hy  changes  in  the  choroid  of  a  conp»'stive 
nr  inll.inrmatory  ty|M'.  The  ciliary  region  hecoines  easily  congested 
liy  u>e  of  the  eyes  or  by  irritation,  and  there  is  ciliary  pain  following 
close  Work. 

Etiology.  IlyjM-ra'inia  being  tlu>  first  stage  of  iidlanunation.  the 
cuise  of  congestion  of  the  iris  or  cilrary  body  may  be  looked  for  in 
eyestrain,  injuries  and  inflainma- 
liipiis  of  the  cornea,  sclera,  choroid. 
;nid  in  disturbances  of  general 
nutrition. 

Treatment.  Rest,  dark  glas.ses, 
instillation  of  atropine,  removal 
of  the  general  or  local  cau.s<'  of  the 
congestion,  regulation  of  eyework, 
,ind  correction  of  refractive  errors. 

Iritis.  In  addition  to  the  sym|)- 
lonis  of  hyjiera-mia,  true  iritis  is 
attended  by  exuilatiou  into  the 
-tionia  of  the  iris  and  the  anierior 
iiid  posteiior  chamUTs. 

1.  K.rii(hili(m  i)ito  the  strnmn  of 
!hc  iris  is  attended  by  infiltration 
with  roinid  cells w'lich  ihi'-keiis.iiid 
-wells  the  membr.ine.  (Plate  XII. 
|.!oiiouMced  than  in  h\  iM-raniia,  the  distinctness  of  the  markings  on 
iie  anterior  .surface  iSecoming  obscured:  the  rigid  and  swollen  iris 
ivacts  but  little  to  light  and  accommodation,  the  i)U))il  being  greatly 
•MMifacted.     fFig.  lt)2.) 

1.  E.rii(hition  into  the  nnterinr  chamher  is  manifested  by  turbidity 
■f  the  ai|Ui'ous  from  susjjcnsion  therein  of  cells:  the  jniiiil  looks  gray 
iiMead  of    black:  the    exudate    floating  in  the   aiiueous  sinks  into 


Fin.  ir.-.'. 


Iritis.    Tilt'  pupil  In  lrreK"l"»"ly  t'onirnoteil.  and 
eircumcornatl  congentlon  l«  iiiarke<l. 

H.)     The  di.spoloration  is  more 


MICROCOPY    RESOIUTION    TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No,  2l 


1.0 

i^  1^     12.2 

I.I 

t  1^     — 

11  1.8 

1.25 

1.4 

III  '•' 

^  >^PPLIEa  IM^GE     Inc 

^Pl  bbi  £a?t   Wo-   S!rM( 

7.^  ''ocnesttf,    Ne*   'ori.  U609       uSA 

'-^  t?i6)    *82  -  050O  -  f^hote 


350 


TUE  EYE. 


the  bottom  of  the  chamber,  producing  hypopyon  With  Rreat  hyper- 
Lmia  exudation  of  blood  may  take  place,  winch  ^nks  to  the  bottom 
onli:  anterior  duunber-hyplnenna  (Plate  XIII,  'S-  ^•)  Jhere 
is  considerable  exudate  upon  the  surfaces  ot  the  iris  (Plate  XII.,  B) 
nd  u  ^n  the  walls  of  the  anterior  ch:unber;  hence  the  cor.iea  and  lens 
aupear  cloudy  on  accunt  of  the  deposit  of  numerous  round  cells  upon 
th'ir  endothdiu>n.  These  may  even  coalesce  and  1m>  dep..s.t^d  .n  sjK,  s, 
hut  this  conditi<.n  is  more  con.mon  where  tlie  cmary  body  is  mvoh  . 
If  these  exudates  become  organized,  a  membrane  is  formed,  connected 
with  the  pupillary  margin,  which  closes  the  pupil,  causing  the  condi- 
lioi.  cane!l  IcdaXm  of  the  pupil  (Plate  XIII.,  Fig.  H)  I  this  results  m 
great  impairment  of  vision.  i:„„„fi„ 

:i    Exudation  into  the  posterior  chamber  cannot   be  seen  directly 
on  account  of  the  iris  being  closely  applied  to  the  capsule  ot  the  lens 
it  gums  down  the  iris,  forming  adhesions  at  the  pupil  ary  ■na-gin  or 
,in«r.s7«cc/u,r.    (PlateXIII.,  Figs.  9, 10.)     t  is  the  layer  of  retina 
L,nent  that  becomes  adh..rent,  ami  as  this  <lepos.t  is  formed  when 
S  iritis  is  at  its  height  ami  the  pupil  contracted  when  he  pupil  tends 
to  resume  its  normal  size,  or  if  atropme  be  instilled,  it  is  founc   Uiat 
the  iris  retracts  strongly  at  its  unattached  portions,  forming  clo^er- 
leaf  a.lhesions.     The  tags  jutting  into  the  pupil  appear  dark  brown 
or  black,  and  there  a«'  isolated  spots  on  the  lens  capsule,  .aovMng 
where  the  retinal  pigment  has  been  attached  and  torn  away.     Dilata- 
tion of  the  pupil  by  atropine  at  this  time  may  release  some  or  all  of 
the  adh.-sions,  but  the  pigment  remains  permanently,  giving  eyulenee 
during  the  whole  lifetime  of  t'     patient  that  iritis  once  existe.l 

If  adhesion  of  the  iris  to  the  capsule  of  the  ens  exist  around  the 
^vhole  extent  of  the  pupillary  margin,  it  is  called  annular  poM 
Tchia;  this  results  in  shutting  off  the  anterior  from  the  posterio 
chamber  exclusion  of  the  pupil  (Plate  XIII.,  Fig  10)  which  does  not 
i  self  n..cessarily  affect  the  sight  if  the  pupil  be  free  from  membrane, 
but  subseciuentlv  causes  increase  of  tension  and  glaucoma,  resultmg 
iu  blindneis.  This  condition  fretjuently  is  associated  vvith  occlus  on 
of  the  pupil,  and  as  the  latter  rarely  occurs  without  closure  of  the 
anterior  and  posteri<.r  chambers,  it  is  subject  to  the  same  dangers. 

Cyclitis.     Most  writers  describe  cyclitis  under  the  name  of     serous 
iriti;.-     Inflammation  of  the  ciliary  body  i^^^ittende.l  alwav^  ^s^h 
Lypera.mia  or  with  inflammation  in  the  ins.     Simple  cycht.s,  with  but 
i  tie  inflammation  of  or  even  with  but  slight  hypera>mia  m  the  n^ 
ay  oc<-ur  in  a  chronic  form,  the   inflammatory  symptoms  being 
S.t.  the  pupils  generally  .somewhat    dilated,  the  f^^  -^^^^^ 
of  obscuration  of  vision  being  due  to  the  presence  of  deposits  on  the 
,     ..ior  .urfa..e  of  the  cornea  (Fig.  l(14),an<  opacities  m   he  y.treou. 
'    S^-vere  cvclitis  mav  occur  without  mark.-d  syn.i)toms  being  set  up 
i„  the   ri.iic  tissue,  which  only  becomes  hypera-mic.     hxudat.on  into 
te  an  e  ior  chami,er  is  not  usually   pronounced,,  ami  while  the  ins 
n' acls  slowly  lo  light,  accommodation,  an,l  mydriatics,  synechia,  do 
not  tend  to  form. 


DISEASES  OF  THE  'RIS  ASD  CILIARY  BODY. 


351 


Exudation  from  the  ciliary  body  takes  place  into  the  anterior  and 
liostcrior  chambers  and  into  the  vitreous. 

1.  Exudation  into  the  (interior  chamber  passes  either  directly  from  the 
aiiterior  portion  of  the  ciliary  body  throufjh  the  ligamentum  ix>ctina- 
tuiii  at  the  sinus  of  the  anterior  chamber,  or,  beirg  deposited  directly 
in  the  posterior  chamber,  is  carried  with  the  aqueous  through  the 
|)Upil  into  the  anterior  chamber.  In  con.secjuence  of  this,  e.>*pecially  in 
the  chronic  fonns  of  inflammation,   conglomerations  of  cells  aggluti- 

FlQ.  163. 


Deposit  upon  posterior  lurface  of  cornea  In  cyclills.    The  endothelium  la  Intact  except  where  the 
deposit  Is  thickest.    (Afler  Fuchs.) 

iKited  into  masses  by  fibrinous  exudate  (Fig.  163)  are  thrown  against 
the  jjosterior  surface  of  the  cornea  by  the  centrifugal  force  of  the  eye 
movements,  and  adhere  in  a  triangular  shape  to  the  endothelium,  the 
larger  exudates  being  at  the  bottom,  while  the  smaller  are  at  the  upper 
portion  of  the  triangle.  (Fig.  164,  A  and  B.)  These  deposits  are  light 
gray  or  brownish,  varying  from  a  very  small  size  to  that  of  a  pin's 
head,  and  formerly  were  supposed  to  be  located  in  Descemets  layer 
(descemitis),  but  are  readily  distinguishable  from  macular  deposits 


Flo.  164. 


A  B 

T>epcsits  on  posterior  surface  of  cornea  In  cycUtls.    ^4.  Larger  deposits.    £.  Smaller. 

in  the  cornea  (keratitis  punctata)  by  oblique  illumination,  by  their 

'liar  outline  and  brownish  color,  and  by  the  fact  that  they  are 

ill  <iii  the  same  plane  on  the  posterior  surface,  and  not  in  different 

•'ipllis  of  the  cornea.     If  the  cornea  be  incised  and  the  acjueous 

iinwed  to  escape,  some  of  the  deposits  are  carried  away.     Pigment 

M'posit  on  the  .surface  of  the  lens  as  well  as  the  posterior  surface  of 

lie  cornea  has  been  seen  following  or  during  the  course  of  cyclitis. 

:  till"  exudate  from  the  ciliary  bo('y  into  the  anterior  chamber  l)e 

ly  great,  it  may  be  deposited  in  the  form  of  hypopyon;  but  if  this 


352 


Till:  EYE. 


occurs,  Rrayish    sp-.n^n-  masses  will  be  foun.l  projecting  around  the 
niicrlc^  of  the  aiiteritir  ('liaiiil)er.  ,        .      .  •     ^u 

T  T le  S-.    ter  n.assof  exu.late  in  cyclitis  i.  .le,.os,te.l  ,n  the  /.> - 
U^iorcLnhrr,  and  if  extensive  lea.ls  to  a.lhes.on  of  the  whole  poste   or 
Sice       the  iris  to  the  capsule  of  the  hu.-total  ,>osterwr  s„mrhm. 
a"h  ^.;Lk;  thisexudatio^  draws  tl.e  iris  everywhere  to  the  a,Ueno 
surface  of  the  l.-ns,  so  that  the  posterior  chamlH-r  ,s  obliterate    an 

he  1ite4.r  chainber  becoineM.roportionately  deeper    espenal  yd 

t  e      rii.herv    where  the  iris  is  .lisplaced  fartluT  backward.     (H|:. 
1(^.!tos  occasions  the  sa.no  danger  of  glaucoma  a.  spoken  ot  ui 

exclusion  of  the  pupil.  i  •  i   :f  ,.f  Urcm  siyc 

'.i.  ExudntUm  into  the  rilreou.  causes  opacity   winch  if  "f   '^^p    m/- 
an.l  ia  the  antc>rior  portion  causes  g'-eat  chminution  of  vision.     If  thi 


Fia.  165. 


Iridocyclitis  after  perforating  injury.    MagnlLcJ  50  time..    (After  Fuchs.) 

„,e.liabe  sufficiently  clear,  they  may  be  seen  im.ler  lateral  illumna- 
tio.i  as  a  srav  mass  behiii.l  the  lens,  causing  the  con.htion  km.v  n  a 
p^nidoglioma^.     (Plate  XV.,  C,  aiul  Fig.  U.S.)     The  sight  ,s  lost  and 
•itniDliv  of  the  eyeball  occurs.  ,  •     r^      ;„ 

iff  L-.s/.n  of  the  eve,  which  in  iritis  usually  is  unchange.1,  oft-n  - 
elevate.!  in  the  beginning  of  cyclitis,  so  much  that  ^^'■'■"V;^^^; 
in  and  blindn.'ss  speedilv  be  pro.hiced.     In  the  later  stage     cjchtis 
Im  account  of  the  shrinking  of  the  exudates,  tliminution  of  the  ocular 
nre«>;iire  is  more  conimon.  .  ,  f         ,„ 

^TCsnlnectire  s.nnpt.nn.  of  both  iritis  an.l  cyclitis  are  those  .>f  .sev  re 
inflammation,  consisting  of  lacrymation,  phoi..phobm,   and  .w^ 
pl'ii.    The  pain  and  tend.-rness  are  situate.l  not  only  m  the  eyeball,  but 


1*'.- 


OF  THE  IRIS  AND  CILIARY  liODY. 


353 


also  in  the  surn-iiidinfi  parts,  especially  the  region  of  tiie  eyebrows. 
In  tlie  acute  '  ^es  the  pain  is  intense,  while  chronic  cases  occur  in 
which  inflammatory  symptoms  are  almost  entirely  wanting.  In  severe 
iriilocyditisthe  pain  is  intolerable,  particularly  at  night,  and  is  accom- 
panied by  hy[)erpyrexia  and  sometimes  vomiting.  \'isioii  is  always 
more  or  less  diminished.  On  account  of  the  inereaseil  refractive 
index  of  the  a(|ueous  in  iritis,  a  p.seudomyopia  i-  Icveloped  in  the 
Cdur.se  of  the  disease,  which  disappears  after  reso.  j.ion  takes  place. 

Tiie  following  signs  show  jmsitive  eridince  of  inrnhevuat  of  the 
ciliurji  hiidy:  1.  When  the  inflammatory  symptoi.is  are  very  severe, 
especially  if  associated  with  ttvlema  of  the  upiK>r  lid.  2.  AViien  the 
ciliary  region  is  painful.  3.  When  deposits  occur  on  the  cornea. 
4.  When  the  anterior  chamber  becomes  very  deei)  from  gumming 
down  of  the  ciliary  margin  of  the  iris.  5.  \\'hen  the  visual  pcuity 
is  greatly  lowered,  which  is  due  to  involvetnent  of  the  vitieous.  6. 
When  the  tension  either  is  lowered  or  elevatetl. 

Course  and  Sequelae  of  Iritis  and  Gyclitis.  Course  Acute  ca.^es 
associated  with  marketl  inflammation  run  a  severe  course,  the  average 
case  of  iritis  lasting  from  one  to  two  months,  the  first  signs  of  improve- 
ment being  decrease  of  the  congestion  and  pain  and  i)ronipt  action 
of  atro[)ine.  Chronic  cases  show  l)ut  slight  .symptoms  of  inflanmiation: 
an  iridocyclitis  or  iridochoroiditis  may  last  a  number  of  years. 
[{lapses  of  inflanmiation  in  the  iris  and  ciliary  body  are  common, 
licing  due  to  renewal  of  the  exciting  cause  rather  than  to  the  mechani- 
cal effect  of  the  adhesions  wliich  may  have  formed.  Formerly  it  was 
supposed  that  posterior  synechia'  were  particularly  dangerous,  and 
many  o|)('rat  ions  were  devised  for  cutting  the  iris  loo.seat  its  periphery. 
I'nlcss  the  adhesions  have  cau.sed  exclusion  or  occlusion  of  the  pupil, 
tlK'V  should  be  left  alone. 

('iiiii|)let(>  resolution  may  take  place  in  mild  cases,  if  seen  sufficiently 
rally  and  the  pupil  kept  dilated  by  atropine.  Even  if  posterior 
■i.lliesion  of  the  iris  has  taken  place,  the  pupil  may  fully  dilate,  leaving, 
linwever,  pigment  spots  upon  the  anterior  capsule  of  the  lens,  which 
■  !'i  nut  l)(>come  absorbed  and  may  later  i)e  .seen  during  the  entire  life- 
linic  of  the  j)atient  by  obli(|ue  illumination  or  the  ophthalmoscope; 
•  hi  y  are  likewise  sulijectively  evident  as  floating  specks  before  the 
■\  ts.  IIy])opyon,  hypha'inia,  exudates  into  the  anterior  cha  'iber,  and 
-lijriit  opacities  f>f  the  vitreous  may  disappear  completely  by  resorption. 

Sequelae.  In  most  ca.ses  |j<'rmanent  se(|upla'  remain  after  iritis 
•!i;d  cycliiis;  1.  The  most  conunon  se(iuela'  of  iritks  are  posterior 

"irliia :  these  are  evident  by  circumscribed  adhesions  of  the  iridic 
!•  riiieiit  r.t  tiie  pupillary  margin  to  thi'  anterior  capsule  of  the  lens, 
"  '  !(U|)il  being  irregularand  responding  to  mydriatics  incompletely  in 

■'over-leaf  form.  (Plate  XIII.,  Fig.  9.)  Complete  adhesion  of  "the 
liillary  margin  causes  exclu.sion  of  the  pupil,  the  body  of  the  iris 

'  irpiishcil  forward,  producing  the  condition  known  as  irisbomhf 
!i-  .Mil.,  Figs.  10,  11):  the  pupil  being  represented  us  a  crater; 
iris  being  greatly  stretched  becomes  atrophic,  elevation  of  intra- 

23 


:{54 


THE  '■:ye. 


ocular  proswurc  occurs,  ami  the  !<yniptonis  of   gocoiulary  plaucoina 
set  in.     On  account  of  the  increase  of  tension,  the  sclera  may  give 
way  in  j)laces,  forininj;  ectasia-.     2.  Atropht/  of  the  irix,  especially  of 
its  pigment,  appears  as  the  result  of  rei)eate(l  recurrences  or  chronic 
inflammation;  the  delicate  markings  of   the  anterior  surface  disap- 
pear, the  pui)illary  margin  is  thiimed  down,  and  dilated  vessels  may 
often  i)e  distinguished.     The  iris  pigment,  particularly  of  the  retinal 
layer.  In-comes  ahsorl)ed  and  a  black  ring  at  the  edge  of  the  pupil  is 
no  longer  seen,  the  edge   of  the  iris  Icjoking  frayed  and    its  tissue 
lighter  in  color.  The  atrophic  iris  is  very  friable  and  makes  perform- 
ance of  iridectomy  very  diiticult.     'S.  Ocduxio  pupilhr  u  c.iused  by 
organization  of  the  exutlate  forming  a   pupillary  membrane  which 
diminishes  the  vision  in  proportion  to  its  thickness.     4.  Exudates  be- 
hind the  iris :  total  posterior  synechia'  has  been  described.     In  severe 
cases  the  fil)rous  mass  completely  envelops  the  lens,  and,  as  resolution 
goes  on,  has  a  tendency  to  shrink,  causing  the  anterior  chamber  to 
become  deeper  from  shrinking  of  the  vitreous,  and  direct  contraction 
causing  detachment  of  the  vitreous  and  retina.     5.  Atrophy  of  tlie 
e^c6«//  follows,  which,   on    account  of  the  diminished  tension    from 
the  effect  of  the  extra-ocular  nmscles  j)ulling  upon  the  ball,  becomes 
of  a  quadrangular  .shape,  being   grooved    at   the    insertion  of  the 
recti.    The  cornea  becomes  smaller,  opacjue,  and  flattened,  at  times 
remaining   transparent,  and  becoming   abnormally  protuberant    or 
thrown  into  folds.     The  lens  and  remaining  vitreous  become  ojiaque 
and    the    eye    blind.     The    eye    Ijccomes    sensitive    to    touch,   and 
secondary  attacks  of  pain  occur,  especially  if  the  eye   harbors   a 
foreign  body,  or  deposits  of  bone  or  calcareous  tissue  develop.  The 
atroi)hy  pursues  a  course  of  months  or  years,  and  pain  usually  dis- 
ap])ears   when   complete   shrinkage    occurs;    the   condition  then   is 
kn(nvn  as  phthisis  bnlbi.     6.  Opacity  of  the  lens  occurs  on  account  of 
disturbed  nutrition,  particularly  in  cyclitis,  as  the  iris  and  ciliary 
body  become  attached  by  exudates  to  the  lens.    Such  a  cataract  is 
known    by  the   name  cntanida    accreta.     In   atrophic   eyeballs  the 
lens  is  alw;    s  ojjaque  and  shrunken. 

Etiolog:  of  Iritis  and  Cyclitis.  Iritis  and  cyclitis  may  arise  as  a 
primary  j'rocess,  the  original  site  of  the  inflanunation  being  in  the 
iris  or  cil.ary  body.  It  is  caused  in  the  majority  of  cases  by  dys- 
crasia-  and  (jcneral  diseases.  In  such  cases  both  eyes  usually  arc 
affected,  altjiough  not  always  at  the  same  time.  The  inflammation 
may  likewise  arise  as  a  local  affection,  under  which  heading  we  put 
traumatism  and  those  idiopathic  cases  in  which  we  can  discover  m> 
delinab'e  cause;  here  the  disease  usually  affects  but  one  eye.  Tr 
♦his  subdivision  belongs  also  sympathetic  inflammation.  Iritis  aii': 
cyclitis  may  likewise  arise  as  secondary  affections  from  inflammati<m 
transmitted  from  the  neighboring  structures.  In  classifying  inflain 
mations  of  the  iris  and  ciliary  body  according  to  the  above  schenir 
we  call  the, II  iritis  or  cyclitis  or  iridocyclitis  accorihng  to  the  struc; 
ure  principally  involved. 


/j'AAViA£vs  OF  TH£  mia  Asj)  CILIA ny  body.  .{;-,-, 

Primary  Iritis  and  OycUtis.    Syphilitic  hiti..    Svihilisis  n. spon- 
sible tor  at  least  oiie-liaif  (,f  the  cases  f,f  iritis.     It  is  an  early  secoiularv 
symptom,  appearmg  shortly  after  t!.e  first  macular  eruj)tioii,  uiui 
occurs  u.  5  jHT  cent,  of  ti.e  ca.s,.s  of  syphilis.     The  inflammation  has 
acharacteiistic  apj)earance  in  that  no.hiles  of  a  yellowish-red  color 
"t  tlie  size  ot  a  pui's  head  or  l.-.rger,  form  either  on  the  ciliary  or 
I.upillary  mar-ui  of  the  iris,  W.    never  between.     In  the  majority  of 
cases  thes(«  notlules  disappc:;r,  .caving  broad  and  solid  svnechia- and 
atrophy  ot  the  uxs  tissue.     In  some  cases  no  distinct  "no.lules  are 
"n.ied,  but  the  pupillary  margin  is  swollen  ui  places,  and  un.i.^uallv 
broad  .synechia-  torm  which  do  not  vield  to  atropine      Irit  s  niav 
occur  in  the  later  stages  of  .syphilis  without  the  formation  of  nt.dules 
but  fiummata  (iritis  gummatosa)  (Plate  XIII.,  Fig.  19)  may  develop 
m  tlie  iiLs  and  ci  lary  body,  and,  attaining  great  dimensions,  nreak 
tlirough  the  envelojx's  of  the  eye,  bringing  about  its  destruction 

Iritis  likewise  occurs  in  hereditary  xyphilix,  although  not  so  fre- 
■  lueiit.y,  be:ng  usually  associated  with  interstitial  keratitis,  occurring 
early  in  childhood,  while  actjuired  .syphilis  -isually  is  ob.ser\-ed  in 
adults. 

Inflammation  of  the  choroid  i.s  as.sociated  with  mor-  than  half  of  the 
cas.s  ot  .syphilitic  iritis  and  cyditis;  the  retina  ami  optic  ner^■e  are 
liv.,ucntly  involved.  There  i.s  a  tendencv  to  recurrence  The  actual 
diagiiosis  can  be  e  abli.shed  only  by  demonstration  of  the  pre.«-nce 
ot  .sypliili.s  or  the  favorable  action  of  antisvphilitic  remedies 

/,v//,v  Scrofulosu.  Iritis  scrofulosa  bears  a  resemblance  to  the  iritis 
ot  liereditary  .syphilis,  occurs  in  ana-nic  and  sen  fulous  chil.lren 
aiul  youths,  and  often  is  characterized  by  lardaceous-lor.king  dei>osits 
wliich  appear  to  come  from  the  angle  of  the  anterior  chamber 

lr,lis  Tuhcrcido.a.    Tubercular  ( h'po.sits  mav  occur  primarily  in  the 
ins  and  ciliary  bf.dy  from  wound  infection,  or,  secondarily  "in  con- 
nection with  general  di.sea.se.     They  may  take  tlie  form  of  miliary 
siiowtlis,  with  con.s(>(,uent  inflammation,  or  may  form  laige  tumors' 
'  lif;s.  1,S7  and  ISS.) 

Irllls  Rheiiwnlicn.     Iritis  rheumatica  appears  in   persons  of   the 

I  I'tiniatic.  arthritic,  or  uric-acid  diathesis,   is  characterized  by  in- 
llammation  with  little  exudation,  and  has  a  marked  tendencv  to  recur 

r>t,s  Conorrhmca.  Iritis  gonorrhn-ica  develops  where  general' 
liit.rtinii  has  arisen  from  gonorrlura.  It  is  a.s.sociated  usually  with 
'iuiioiTlu,,il  rheumatism,  arising  after  the  outbreak  in  the  larger'iouits 

II  ''Mnhits  recurrences  fre(,uently  associated   with  renewal   of  the 
'intiir;,!  (hscharge  or  of  the  joint-affection. 

liitis  has  been  seen  in  relapsing  fever  and  variola.     Iritis  occurs 
'II  >li<ihi'tirs.  a.ssociated  with  hypopyon. 

/n//.v  hiiopathica.     Idiopathic  iritis  is  the  form  in  which  the  cau.se 

'•'Hams  obscure,  being  usually  attriimt^-d  to  col,l.     The  acute  form  is 

-'■neially  unilateral;   the  chronic  form  generally  appears  with  svnuv 

■"•s  ot  ,.y,. htis  and  choroiditis,  with  light  iiiflanuiiatorv  .sympionis 

■'■'I  niiis  a  long  cour.se.     This  has  already  been  described  under  the 


3.">(j 


TllK  KYK. 


hcadiiiK  (Vclitis.  It  lias  Ik'cii  railed  iritis  sorosa.  Winn  it  occurs 
in  iH-rsons  of  advanced  ajic  tlic  cause  seems  to  he  dei'ectixc  nutrition, 
and  it  slowly  i)ro;:resses  until  blindness  sets  in. 

hill's  Tnnotiiitlai.  The  causes  of  traumatism  of  all  kin<ls,  espe- 
cially perforation  of  the  eyeball,  traumatic  iritis,  and  iridocyclitis, 
are  described  under  their  respective  iieadings. 

Iridiiri/rlilis  SijiiiiMilhi'liai.  Sympathetic  inflammation  is  discussed 
on  i)age  ;j'JU. 

Secondary  Iritis  and  Iridocyclitis.  Inflammation  of  the  iris  and 
the  ciliary  body  may  develop  by  transmission  from  neifthborinp  struct- 
ures, more  es}K'c'ally  suppurativ;-  keratitis  and  the  deeper  forms  of 
scleritis;  more  rarely  it  is  caused  by  severe  conjunctivitis.  Inflam- 
mations sometimes  pass  forwani  from  the  j)osterior  section  of  the 
eye,  from  choroiditis,  intra-ocular  tumors,  cysticercus,  and  swelling 
of  the  lens.  Cysticercus  and  filaria  have  been  observed  in  the  anterior 
chamber  and  iris  by  Continental  writers,  and  have  been  successfully 
removed. 

Treatment  of  Iritis  and  Cyclitis.  Most  cases  of  iritis  and  cyclitis 
demand  both  local  and  general  treatment. 

Lor.vi,  MK.vsrKKs.      1.  The    nuidc   of    life    nqnires    m<tdij\c(ili<m  ; 

physical  exertion  should  be  avoided,  and,  in  severe  cases,  resi  in  ImscI 

is  iin|M'rative.     B<'cause  light  excites  the  \ni\)\\  to  contraction,  and  on 

account  of  photophobia,  both  ci/cx  Klniuld  he  praleeted  by  the  patient 

being  made  to  wear  dark  glasses  and  an  eye-shade,  and,  as  a  rule, 

being  kept  in  a  moderately  darkened  room.     (This  is  one  of  the  few 

eye  diseases  in  which  a  dark   room   is   demanded.     Confinement  of 

eye   patients   to   the   necessarily   poorly   ventilated   darkened   room 

fre(|uently  does  more  harm,  as  regards  recuiwration,  than  the  good 

tbat  may  be  obtained  from  the  ab.^ence  of  irritation  from  light;  thus 

the  dark  room,  except  for  the  treatment  for  iritis  and  .some  cases 

''  foi  junctivitis,  has  almost  disappeared  from  modern  ophthalmic 

;■     '        "I     The  luallhi/  eye  should  not  he  strained  by  reading,  and, 

,  it  should  be  put  in  a  splint  by  the  use  of  atropine,  as  the' 

.^"'|ic  action  of  the  pupils  to  light  and  accommodation  is  dele- 

tiTlOUS. 

2.  With  the  exception  of  traumatic  cases  (when  during  the  first 
twenty-four  hours  iced  applications  may  be  used),  hot  compresxinq 
is  indicated  in  all  ciises  of  iritis  and  cyclitis.  The  moist  heat  gives 
relief  from  pain  and  favors  metabolism,  thus  hastening  recovery. 
Moist  heat  may  be  a]ii)l!ed  by  cloths  wrung  out  of  hot  water,  over 
which  Hannel  may  be  laid  to  conserve  the  heat,  the  compresses  being 
changeil  every  two  mimitcs.  Several  ingenious  forms  of  applying 
heat  by  siphon  or  electric  ajjparatus,  vnnler  which  moist  cloths  are 
kept,  may  be  used. 

.'i  Extensive  hlood-leltiiu)  by  the  Ileurteloup  artificial  leech  (Fig. 
iriii)  api)re(I  to  the  temple  once  f)r  twice,  and  repeated  later, 
if  necessary,  may  greatly  diminish  the  inflammatory  symptoms 
Frefpiently  after  such  a  j)rocedure  the  pupi!  yields   or  the  first  time 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 


3.-)7 


Fio    I6«. 


to  tlif  action  of  atroj)ino.  Natural  leechea  may  be  used,  of  which 
six  or  eight  may  be  applic<l,  hut  they  are  o.'ten  unobtainable,  are 
difficult  of  application,  and  are  disgusting  to  the  patient. 

Mkdicinai,  Tkkatmknt.  Atropine  is  the  most  nnjiortant  remedy 
in  iritis,  as  it  dilates  the  pupil,  diminishes  the  amount  of  blood  n  the 
vessels,  and  counteracts  the  hyi«'ra'mia;  by  paralyzing  the  sphincter 
it  |)Uts  the  inflamed  organ  at  rest;  by  enlarging  the  pui)il  it  ruptures 
recent  posterior  synechia-,  as  when  the  iris  is  ful  y  contracted  its  edge 
is  not  against  the  lens,  and  it  prevents  the  formation  of  adhesions. 
Tiic  amount  of  atrojnne  ufc  d  should  be  carefully  n>gulated  according 
to  the  intensity  of  the  inflammation.  As  during  the  period  of  ncrease 
of  inflammation,  sp;usm  of  the  .sphincter  exists,  it  is  usually  difficult 
to  dilate  the  pupil,  and  atropine  should  be  used  in  strong  solutions 
(I  percent,  to  5  per  cent,  every 
three  or  four  hours;  or,  if  the  pupil 
does  not  dilate,  place  a  granule  of 
atropine  in  the  conjunctival  sac, 
taking  care  to  close  the  lacrymai 
puncta  for  a  few  minutes  by 
stretching  the  .skin  over  them  with 
the  finger-tip).  By  the  simultane- 
ous employment  of  cocaine  (3  per 
cent.)  or  holocaine  (1  per  cent.), 
the  action  of  atroj)ine  may  be 
heightened.  On  account  of  sys- 
temic symptoms,  strong  solutions 
cannot  Ix*  used  more  than  a  few  times  in  succession,  and  may 
have  to  be  combated  by  the  administraiion  of  morphine  inter- 
nally. Atn)i)ine  catarrh,  from  the  continuous  instillation  of  the  ilrug, 
may  occur  ;  and  if  so,  the  mydriatic  should  be  changed  to  .scojjo- 
laniine  (0.1  per  cent,  to  0.5  jxt  cent.)  or  duboisine  (1  per  cent.). 
If  the  inHamination  be  very  severe,  instillation  of  1  :  KXK)  adrenalin 
dilnride  tends  to  reduce  the  congestion,  not  onlv  in  the  external 
Micmhranes  of  the  eye,  but  also  in  the  iris  and  ciliarv  bodv.  Dionin, 
in  10  per  cent,  solution,  instilled  .several  times  a  day,  isof  marked 
\:ilue  as  a  lasting  local  aniesthetic  in  cases  of  iritis  as" well  as  corneal 
ulcer. 

In  cases  of  iridncyclitir  in  which  the  impHcation  of  the  ciliary 
'""ly  is  particularly  prominent,  and  also  in  pure  cyclitis,  atropine  is 

t  well  borne.  If  pain  is  cau.sed  by  its  instillation,  or  there  is 
'  vation  of  tension  atropine  should  be  stopped,  and  dionin  and 
I'lfualin  chloride  alone  u.sed. 

<  iKNEiiAL  .Mkasirks.  1.  In  all  cases  it  is  important  to  keep  the  ali- 
'''■ntaiy  tract  in  order  by  regulation  of  fk  liet,  which  should  be 
iiiited  to  simple  nourishing  food,  and  conxtipation  combated,  prefer- 

Iv  by  saline  cathartics, 

-'.  The  etiological  factors  should  be  considered,  the  majority  of 

■  <  demanding  general  medical  treatment.    Syphilitic  iritis  offers 


Ueurteloup  artjfiiial  leech. 


.•{.■).S 


THE  KYE. 


the  most  fiivorahl*'  proKno-i-',  as  it  gciHTally  n'spond.s  to  ciHTRctic 
Iri'atiiiiMit.  As  the  rt-iiicii^  slicmld  act  promptly,  mercury  is  nivcu 
ill  the  lorm  of  imiiK'lion  \  nm.  of  hint-  oiiitiiiciil  or  of  tin-  olcalc 
ruMx'il  into  tlic  arms  ami  tliij^iis  twice  a  <lay,  or  tiie  s'lme  ([uantity 
smeared  on  the  soles  of  the  feet),  and  is  continued  until  the  diseased 
eve  is  no  longer  inHamed,  or  until  symptoms  of  i)tyalism  occur, 
and  then  iodide  of  potassium  or  sodium  is  administered  in  ;;radually 
increasin)!;  dos(>s  ( 1  to  lO^m.,  three  time- daily).  The  other  aiteratives. 
especially  arsenic  and  K"'*'.  either  siufjly  or  in  comhiiuitioa  willi 
ir.  n-nry,  are  of  henefit  (auri,  arseni.  et  hydrargyri  bromidi,  aa  t).()01 
to  0  002  gm.,  three  times  (hiiiy). 

The  general  treatment  after  the  iritis  has  passed  away  is  tliat  laid 
down  for  syi)liilis  in  general. 

In  hrreifilnrj)  sifiiliilis  the  treatmi'nt  should  he  tonic  as  well  as 
siK-citic:  syrup  of  the  iodide  of  iron  (1  to  2  c.c,  three  times  daily), 
together  with  cod-liver  oil  (4  to  Ifi  c.c,  ihree  times  daily),  .syrup  of 
hydriodic  acid  (2  to  4  c.c,  three  times  daily).  If  guinmata  form  and 
are  not  relieved  by  six'citic  remedi(>s,  perforation  of  tlu;  eye  may  take 
|)lace,  and  enucleation  may  have  to  be  done.  Other  operations  in 
the  height  of  specific  iritis  are  usu:illy  contraindieated. 

In  (V(7(.-i  rhfiimaticn  and  ipnorrbaicn,  sodium  salicylate  (1  to  2  gni.. 
three  times  daily)  or  the  oil  of  gaultheria  (0.3  to  0.6  c.c.)  are  indi- 
cated, and  give  relief  in  about  the  same  proportion  of  cases  as  in  other 
rheumatic  lesions.  In  irititi  (linbdicn,  arsenic  sihmiis  to  be  of  .service. 
I iu/()»/// subjects  the  causes  of  t(ie  defective  uric-acid  elimination  and 
such  lesions  as  iritis  are  fre(|uently  a.ssisted  to  disappear  by  cystogen 
or  urotropin  (O.-"?  to  0.5  gm.,  three  times  daily  iM-tween  meals),  to- 
gether with  ai)i)ro])riate  diet  and  lithia  waters. 

Treatment  of  the  Sequelae  of  Iritis  and  Iridocyclitis.  Narrow  and 
isolated  pn^tcrior  syncrhiw  may  often  be  rui)t'n-ed  l)y  the  employment 
of  atroi)ine  (1  to  5  ])er  cent.)  by  itself,  or  in  combinat'on  \vi  h  holo- 
caine  (1  iier  cent.)  or  coc;une  (5  |K>r  cent.).  As  a  ver\'  <'nergetic 
action  is  desired,  it  is  secured  most  certainly  by  placing  the  pure 
drug  direct  in  the  conjunctival  sac:  the  alternate  use  of  myotics  and 
mydriatics,  the  i)upil  being  first  contracted  with  <>serine  (0.2  per 
cent.),  and  then  energetici'ly  <riated  '  th  atropine,  is  even  more 
elTective,  but  such  jirocedures  should  not  be  made  until  some  time 
after  the  iritis  has  been  sulxlued.  Hroad  synechiir  cannot  be  divided 
by  such  means,  and  were  formerly  operatecl  upon  (corelysis).  a.;  it  wa.- 
bl'lieved  that  the  acticm  of  the  iris  in  the  opening  and  closing  of  the 
pupil  caused  ir  itation  which  set  uj)  recurrence  of  ilie  iritis;  but  it 
is  now  recognized  that  in  such  cases  the  original  caus;d  factor  again 
acteil.  and.  hence,  ^    ch  operations  are  now  seldom  jiractised. 

Aiunilar   p(>!<trriit,    sinicrhin.    villi    cjrliisio    piipilla    in    addition, 
lemands  iridectomv  in  order  to  restore  comiiumication  between  the 


haiti';i-rs,  for,  if  allowrd  to  re!r,air!,  sec<.n< 


larv 


(lemands 

ant(Tior  and  posterior 

glaucoma  surely  sets  in.     The  operation  is  often  difhcult,  on  account 

of   the  shallowness  of  the  chambers,  due  to  protrusion  of  the  iris 


DISKASES  OF  THE  IHI.S  A.\'D  CILIARY  BODY. 


.'WO 


(iris  homhv,  riatc  Mil.,  Figs.  H),  11),  and  ii\sn  (  n  aroount  ot  atrophy 
of  tlic  tissue.  Tims  a  pood-lookiiiR  cololMima  i,>  seldom  the  n'siilt  in 
siicli  cases,  and  we  must  he  eontented  if  a  [HTmanent  o|)eniiiu'  n-- 
maiiis,  for  the  anterior  eliamher,  in  conseiiuenee  of  restoration  of  the 
coiuiectioh  hetweeii  the  two  ehainliiTs,  rejiains  its  normal  dej)th,  and 
a  secondary  operation  may  he  performed  later. 

Tdldl  iHixlfTior  ■•<!)iitrliifi  i\U<)  re(|uires  iridectomy,  wiiich  is  fre<|uenlly 
unsuccessful,  as.  on  account  of  the  ;i(lhesion  of  the  iris  hy  its  whole 
posterior  surface  to  the  lens  it  is  fre<|ueiitly  impossihie  fo  excise  a 
suthciently  larjfe  sej;merii.  In  such  cases  the  lens  may  he  removed, 
toi^etliiT  with  more  or  less  of  the  iris,  or,  if  ubnent",  iridotomy  is 
indicated. 

Neoplasmata  of  the  Iris  and  Ciliary  Body.  Haiinv  Tumnrs.  a. 
(  y.v/.x  ()/  Me  ,'nx.  Sirous  ny.v/.s-  may  de  .up  within  the  stro?na  of  the 
■iris  after  penetrating  wounds  of  the  exehall,  growing  gradually  until 
they  reach  the  posterior  surface  of  the  cornea,  and  fill  all  or  a  portion 
of  the  anterior  chamber.  Their  walls  are  formed  hy  thiiuied  iris  tis.sue. 
They  produce  elevation  of  tension,  and  from  this  glaucoma  re.sults. 

Ii.  Dcnmiid  liiwiirs  have  been  reported  (Fig.  Hi"),  being  caused  by 
lienetrating  injuries  by  which  epithdial  cells  are  carried  within, 
starting  u{)  tumor  growth.  The.se  may  even  grow  one  or  two  hairs, 
as  is  the  case  with  dermoids  elsewhere. 

Treatment.  As  such  tumors  are  not  benign  when  arising  within 
the  eye.  they  should  be  removed  early  by  ojjeration,  by  incising  the 
cornea  at  a  point  corresponding 
with  the  growth,  entering  the  for- 
cej)s,  withdrawing,  and  cutting 
out  the  tumor  with  the  adjoining 
iris. 

Mchniotnnla  are  rare  forms  of 
real  benign  gi  "ths  arising  fro--' 
proliiirationof  »'  piirmeiit  sironut 
cells  i."  wing  into  the  iiterior 
cliaml  They      :u-Hy        ''ome 

of    I      -e(|ur'ncc     ,iiid 
di-iwijiuished     fn  rn     sai 
jrrowths    by    theii     -lc\ 
-rn.'iil  size,  :in<l  ;d)M  '!• 
rii:itory  syni[)toiTis.     Tl 
ti'flecti<in   upon   the  ,ii 
pupil  may  [)ro'ifirate  ;. 
iiecoine  se)i;tr,-ite(l  from 
lerior  chamber,  but  tliey  > 
■linl  are  of  very  sKjw  growl 

Miilinmnit  Tutiiorx.    Sai-r, 

tion  with  the  ciliary  b.nlx 

:n-  trniw  very  slowly  at  first. 
:in!(lly  iilliiig  the  anterior  cb 'ml 


Klo.  167. 


,,     l:.r 
atous 

iur.se, 

fhUH- 

rnient   i 


fiermoid  tumor  of  the  lri«. 


'Is  of   the  retinal  layer  at  its 

•     e  of  the  iris  at  the  edge  of   the 

into  the  pupil;    they  gone     ines 

■  iry  margin,  dropping  into  •       an- 

vcome  larger  than  a  grain  o'      heat, 


I  of  the  iris  mav  arise  alone  or  in  con- 

f'lat     X'TTI..  Fig   IS.)    Those  of  the 

"ariuf.   IS  j)ignientc'd  brown  tumors, 

hey  I L      gri  \\  '  ack  into  the  ciliary 


3(M) 


riih:  /.If.-. 


rpftion  and  fill  t'lc  interior  of  tho  eye,  hn'akir.R  thrituRli  the  orular 
wivcloiM's,  ami  cxIfiiiiiiiK  their  Kntwtli  externally.  Sareoniata  i<\  llii- 
ciliary  Inxly,  like  those  of  the  iri!4  and  choroid,  at  (irst  jfive  ri.'e  t«> 
but  little  inconvenience,  hut,  finally,  from  ai-ir  size,  cause  jm-ssure 
syni|)toins,  following  the  siune  course  in;  those  of  the  iris  and 
choroid. 

These  .-irc  nore  particularly  doMcrilx'd  in  the  ch.ipter  on  Neoplan- 
inata  of  the  Choroid. 

Treatment.  .Malifjnant  Rrowths  of  the  iris  when  very  small  may 
jierhaps  l)e  excised,  but  it  is  .safer  for  the  lite  of  ♦•»>  patient  where 
they  an*  of  any  size,  and  in  those  involving  l"  cili-iry  body,  to 
remove  the  eyeball  as  .soon  as  the  diagnosis  is  ..     .e 

TulKicular  tumor.-  usually  occur  in  children  :d  young  adults. 
They  generally  Ix-gin  us  a  tuU'rcular  iritis,  bu.  when  the  nmlules 


rill.  18" 


ria.  i«. 


Flo.  168.— Tnberculnsii  of  rilisry  body  BDd  Iris  cauntng  cyclitls,  fho  v[i,f  iici-lu>  .1  .>f  pupil  with 
retraction  i)f  iris  and  deep  anterior  chamber.  Tnlal  iKBtmnrnyni-ohla.  .'hoii  .;r»ph  fnmi  speoimeii  ) 

Fill.  169  —Tuherctilar  tumor <if  iris,  anterior  i-hamhershailnw  from  Iv  <iil-..)i>«t  tilled  by  neoplasm, 
winch  tills  lower  [lart  o(  posterior  chambe'.    (Photograph  from  ipec'!-!.-!  i 


enlarge  and  form  tumors,  their  com.  i  .s  much  the  t-ame  as  that  of 
nialignant  growths,  and  they  are  amenable  to  the  same  treatment— 
i.  p.,  enucleation. 

Gummata  of  the  iris  and  ciliary  body  form  as  yellowish  tumors 
of  somewhat  rapid  growth,  occurring  during  the  course  of  actiuiretl 
01^  inherited  syphilis  as  one  of  the  later  manifestations.  (Plate  Xlli., 
Fig.  1!».)  They  .seem  to  be  nipidly  reuorfx'd  on  exhibition  of  mer- 
curial inunctions  and  large  do.ses  of  iodide  of  pota.ssium. 

Very  rare  forms  of  iridic  tumors,  such  as  vasculomata,  myomata, 
and  myo.-arroniata  fniin  tlic  cili.uy  luusclc,  carcinoma  from  the  pars 
ciliaris  retina',  and  lepra  nodules,  have  been  reporteil. 


orsKASKS  OF  TUB  //lis  Ay/j  CiUARY  no/n.  ;),ji 

Injuries  of  the  Iri.  and  Ciliary  Body.    Wound,  avd  Fnreufn  Bodi.. 
I  autmt,,,,,  ir„uu,s  „j  /„■  ,r,s  .•  re  cnM,,,!!,,.!..!   l.y  w..un.'l.  „f   ,1..: 
.■..rn.-a    aii.l  u.s,..all>    .v.tli  tl.at  .,f  tl..-  lens  ai.!  ■  iliarv  I- .Iv      If  tli,. 
.■ihary  l»Hly  U-  ,„jur,..l,  the  .-..njunciva,  th.- .scl,.ra.Vhnr..i,i    rHii-, 
aii.l  vitrc.us.  as  wWI  as  tlir  iris,  are  usually  iffected.     If  tli.'        „. 
t-atmu   ,n, iy  ,..  clean    i..f,.cti....  .Lh-s  ,u,t  take  ,.lac...  there  is  usuallj 

'It  IM  le  ,1,.  ..Ims.  .,..1  l.eahng  n-suits,  with  .iarna^re  .le,K.,Hl,.nt  u.k. n 
tu;  ,.xt.-nt  .,  tne  injury.  If  a  vv„un.l  of  the  iris  Ik-  a.r..,np«nie<l  hy 
"iKrtinn,  infla.nmat;(.h  n-sulls  which  nmy  exten.l  to  the  ciliary  ImhIv 
.injl  .  l,or.M.I.  u-.th  resultant  intis  an.l  iri.l..eh.,r..i.|itis.  Synmatln  tic 
"Phthaltmt.s  may  ans,-  fr,„n  infecteil  iris  injuries,  but  is  UHually 
•  liie  to  tliose  of  the  ciliary  region. 
ror,l,,n   Ii,HU,s  in  llu' his.     Non-infectious  foreign   iMHJies  niav 

Jinan,  in  the  anterior  chanilM-r,  or  1k>  enca,,.sulate.l  in  the  ti.ssue  oV 
the  iris  lor  a  long  tune  without  giving  ri.se  to  inflammation.  They 
may  Ik.  removed  In  corneal  incision  an.l  the  iris  .orcens,  with  ..r 
williout  .se.ti.,n  iMiiig  made  .)f  the  iris.  (I'hite  XIII  Fig  15  1  The 
extniction  of  ,,„r.-s  .,f  ste<.|  „r  iron  fn.ni  the  anteri..r  chamh-  .bv  th.. 
«■  V<'tn.maj;n,.t  otT.Ts  the  m.,st  promising  pn.giujsis  f..r  the  ..i.Tation 
(  I.S..  _;u  .ject.H  are  n.or..  s,H.eifiea.  y  .lescrilx'.!  in  the  chajifr  on 
Miiipatli.'tic  Infiammntion.)  ' 

Traumatic  Changes  in  the  Iris.  iMceratiom  of  the  iris  usually 
start  Iron,  the  j.upil  an.l  may  exten.l  t..  the  ciliary  margin,  s.,  that 
iH'  imp.l  ap,,..ars  t<.  !«>  jx-ar-shap...!.  As  a  rul.-,  th.- pupillary  niarg 
IS  torn  hut  httl..  an,l  t.u  gaping  can  only  Ik-  .li.scvemi  by  car.>ful 
.■vmiumtion.  .V.ich  lac.'rati.,ns  are  the  ni...Ht  frcpi.-nt  cau.se  of  ,lila- 
t.ition  ol  the  pupil,  ..ccurring  after  contusions,  as  they  caus..  weik- 
-nrng  .,r  paralysis  .,f  the  sphincter,  due  t..  laceration  .,f  its  film>s 
l.ey  fie.|U..ntly  accompany  simple  cataract  extraction  (with.,ut 
i>i>l..tom^  ),  an.l  are  caused  by  tearing  ,.f  the  iris  in  the  efTorts  to 
-■'■"M.V..  tii,>  cataractous  lens  through  an  unyiel.ling  pupil.  The' iri.s 
■'M.l  ...iiary  mu.scle  inay  also  Ix-  paralyze.1  by  contusion,  so  that 
.KToinniodation  is  affecte.l.  ■'J  .  ""   mai 

lrif{,Hliali,si,.   Sep;,rati.>n  of  the  iris  from  the  ciliary  bo.lv  is  usually 

■"/•<'nsi.l..rablo  extent,  involving  even  as  much  as  .,ne-half  of  the 

'"""•y  margin;  it  is  usually  single,  but  sometimes  multiple     In  the 

;nner  w..  hnd  two  pupil.s   in  th.-  latter  -.yeral.    (Plate  XIII.,  Fig!!. 

•.      .)     The  portion  of  the  natural  pupil  towar.l  the  .lialysis  is  flat- 

.    ,;.  ,f  7     '  "•"';•' ''•■''y-'"f  we  mn;.  ^r-e  the  e<lge  of  the  lens,  the 

^  mule  of  Zmn,  and  the  e.lges  of  tl„    .iliarv  processes     As  a  rule 

'•  sig  t  Ls  but  little  affect.>,|,  alti,-  ..f.  if  V^  diaS         s.fg'eS 

;  ;.  ,r,     1  •\^''''Y'^-     Monocular  .liplopia  maj    ..ccur,  .,n   acc.unt  of 

nS;  '"'"'.«  i""'"^''  thr..ugh  th..  .several  openings  upon  the  reiina. 

/'     m  >nu,  Traurnahcn.    If  the  iri.Uxlialysis  be  of  such  .^xtent  that 

H      >  l,ecom,.s  torn  in  its  full  extent  from  it«  ciliary  attachment, 

I    >  l.ill  down  in  the  bottom  of  the  anterior  chamber,  an.l  lat<T 

"1^  to  an  iiicoi:.spicuous  gray  mass.    If  rupture  of  the  sclera  in  the 


362 


TUJ-J  KYE. 


tiini',  tlic  iris  iimv  cxtrudo 


ciliary  rcfiioii  he  iinHlucod  at  tiic  saiiic 
i.r  !)(•  expelled  t'roiii  the  eye.  ,  ,      i 

Inrcmoii  of  the  »•(.-  consists  in  its  Ikmiir  pushed  and  turned  biicK 
s()  as  to  lie  upon  the  surface  of  the  ciliary  body,  and  it  looks  as  if 
it  wore  absent;  partial  dislocation  is  more  fn><iuenlly  observed,  ami 
here  the  iris  seems  to  be  wanting,  a  coloboma  appearing  to  exist. 
Total  inversion  is  very  rare. 

UjIplinwKi  or  hcmorrhniiv  into  the  anterior  chomhcr  is  duo  to  and 
Konerally  accompanies  wounds  of  the  iris.  (Plate  XIII.,  Fip.  U>.)  It 
is  particularly  marki'd  in  ci)ntusions  of  the  eyeball  and  m  operations 
on  irides  tha"t  have  been  previously  inflamed.  The  blood  sinks  to 
tlie  bottom  of  the  anterior  chamber,  and  disapi)ears  by  rescjrption 
within  a  few  days,  when  we  may  determine  the  extent  of  the  injury. 
It  is  sometimes  impossible  to  And  a  solution  of  continuity  of  the 
iris  structure.  The  subjective  symptoms  of  hypha'inia  depend  uiion 
its  extent.  If  excessive,  .so  that  the  tension  is  raised,  considerable 
pain  is  complained  of,  and  glaucoma  may  follow. 

Causes  of  Traumatic  Changes  in  the  Iris.     These  are  most  frequently 
non-peiietratiufr   blows  upon  the  eye  in  which  two  factors  cause  the 
iniurv:    1.  The  liattening  of  the  cornea  from  the  contusion,  by  which 
its  circumference  and  al.so  the  insertion  of    the   iris  become  larger. 
If  this  enlargement  takes  place  suddenly,  th<'  iris  doe.s  not  adapt 
itself,  and  tears  away  in  places  from  its  insertion,  so  that  iridodialysis 
is   i)r'oduced.     2.  The  coriuui   being  flattened,   pushes   the  aciueous 
backward  against  the  posterior  wall  of  the  anterior  chamber,  which 
ill  the  area  of  the  pupil  is  formed  by  the  Ions,  and  in  the  rest  of  its 
("Xtent  by  the  iris.     The  latter,  when  pushed  backward,  finds  its 
support  in  the  le-.s,  except  in  the  marginal  portion  of  the  iris,  where 
the  posterior  chamber  is  deepest;    therefore,   the  iierijihery  forms 
the  most  yielding  spot,  and  is  the  first  to  give  way  belore  pressure. 
This  bulgi's  the  iris  back  as  far  as  the  zonula,  or    even    into    tlie 
vitreous.     Thus,  a   blow  upon  the  eye  may   produce:    (n)   marked 
stretching  of  the  vitreous  in  a  radial  direction;  (b)  dilatation  ot  the 
pui)il:  ic)  in  (>xtreme  cases,  rupture  of  tli(^  zonula.     The  first  aff(>c- 
tion  mav  cause  iridodialysis;  the  second,  radiating  lacerations  of  the 
v|.hincte"r,  and,  conse(iuontly,  i)aralysis  of  the  juiiiil:  the  third  afTection 
sublux   lion  or  luxation  of  the  lens,  iridonesis,  or  tremulous  iris.     II 
the  eiljie  of  the  iris  slij)  back  over  the  lens,  it  may  imuluce  inversion 
of  the ''iris,  and  the  lens  may  be  li.xati'd  into  the  anterior  chamber. 
Lacerations  of  ihe  pupillary  "edge  may  be  jji-oduced  during  the  simple 
oi)eratioii  for  cataract— i.  e.,  without  iridectomy  where  the  sphincter 
pupilia'  is  risiid  and  does  not  i)ermit  of  ea.sy  jias.sage.     Iridodialysis 
may  also  be  proiluced  in  opeiatictns  upon  the  iris:   if  the  eye  makes 
a  violent  movement  or  the  iris  be  roughly  grasped  with  the  forceps, 
the  iris  has  been  known  to  have  been  entirely  torn  out  iluring  such 
an  openition.     In  iridectomy  done  for  occ'usion  of  the  jnipil,  the  iris 
may  be  torn  loose  at  its  periphery  if  the  adhesion  at  the  pupillary 
arcii  docs  not   g.vc  way;    hence  the  iris  ought  always  first  to  Ijc 


DI^KiSES  OF  THE  IJilS  AND  CILIARY  BODY.  3(J3 

released  from  the  pupilliiry  memhranp  befnro  it  is  drawn  out  of  the 
wound.  Iridodialy.sis  may  also  be  eaused  by  tumors  of  the  ciliary 
body  pushing  the  iris  away  from  its  insertion. 

Treatment.  Tn-atment  of  the  above-described  hijuries  to  the  iris 
(except  penetrating  wounds  of  the  eye)  (le|)ends  largely  upon  the 
extent  of  the  bleeding  (hypluemia)  within  the  eye.  If  trivial,  the 
injured  eye  may  be  bandaged  for  a  few  days  and  the  patient  kept 
1-1  bed  to  ensui-e  absolute  (|uiet,  so  that  further  bleeding  does  not 
take  place  and  the  deleterious  effect  of  the  contusion  may  not  be 
assisted  l)y  further  detachment  of  the  retina  occasioned  by  ordinary 
movements  of  the  body.  If  the  hypha-mia  be  excessive,  causing 
tension  and  pain,  naracen- 

.      •        f  .,  .      •  ,  Fig.  170. 

tesis  oi  the  anterior  cham- 
ber may  be  necessary. 
Hot  comj)resses  applied  at 

iiit(>rvals,    as   in    the   case 

of  iritis,  assist  in  absorp- 
tion of  the  exuded  blood. 

If  an  iridodialysis  can  be 

made  out,  atropine  should 

be    instilled,    so    that    the 

contracting  sphincter  does 

not  draw  the  iris  farther 

away  from  its  attachment. 

It     is    contraindicated    in 

radiating  lacerations,  as  a 

mydriatic  would  make  the 

Wound  gape  more.     Iritis 

does     not     usually    follow 

iion-penetrating      injuries. 

The  internal  administration 

of  alkaline  jjurges  and  one 

or  two  jjilocarpine  (0.(K).")  to 

H.O!  gni.)  sweats  during  the 

lir-t  f<irty-eight  htmrs  .seem 

inatcrially  to  assist  resorp- 
tion of  blood  in  the  severe 

'■■iscs;  iodide  of  pota.ssium 

iiiay  he  given  later. 
Operations  upon  the  Iris. 

i'ornicHy  a  number  of  ope- 
1 1  ions  were  done  upon  the 

'is.  but  in  modern  practice 

Illy  three  forms  are  resorted  to:  1.  The  removal  of  a  segment  of  the 

•IS  for  enlargement  of  the  jjupil.    2.  Removal  of  a  section  of  the  iris 

'«!  iritic  membrane  wliere  the  pupil  has  been  closed  bvintlamnsatio!). 

Incision  into  the  iris  or  iritic  membrane,  in  order  toniake  a  perma- 

iil  opening  or  pupil.  These  oix;rat  ons  involve  incisions  in  the  cornea, 


Portion  of  niwrator's  lunds  In  flirt  otage  of 
Irldecloniy.    (rz»iiM«K.) 


364 


TUf:  i:ye. 

Fio.  171. 


Von  oraefe  Hnair  knife  (side). 
Fio.  172. 

Von  Gmcfe  linear  knife  (back). 
r  J.  173. 


Struight  keratome. 
FIO.  174. 

livnt  keratume. 
Fio.  175. 

Probe  and  spatula. 
Fl<i.  176. 


Sharp  iris  limik. 
Fio.  177. 

Blunt  Irta  hook. 
Fio.  17«. 


Short  fori-ep*. 
Fio.  179. 


Long,  bent  forcepn. 


i>/.SA'.KS/AV  OF  THE  IRIS  AXJ>  CILIAHY  BODY. 

Fig.  ISO. 


365 


Fio.  181. 


De  Wecket's  Iridoiomy  iicisaora  (front). 
Fio.  183. 


I)e  Weclter's  Iridotomjr  scinon  (side) 


in.trnrat.m.,  used  In  .,r*ratlo,„  on  the  Iris  (slightly  reduced).     ,ther  inrtniment.  rnmired  are 


.m.l  ppnotratuiR  wounds  of  tho  eyeball,  which,  if  aseptic,  Iieal  without 
inlla.imiation;  hut  if  septic  are  attended  hy  all  the  dangers  of  septic 
l-nrtratniK  wounds  of  the  eye.  As  sepsis  occurs  in  the  hands  of 
'■■nefu  oijerators  in  but  0.5  per  cent,  of  cases  involving  opening  the 
<'.\ii)all,  tlie  danger  is  comparatively  small. 

Operations  for  Enlargement  of  the  Pupil.     Ihi  decto.mv  is  t  he  renlo^•al 

-I  .1  segment  of  the  ins  for  the  purpo.se  of  enlarging  the  pupil     The 

"K'thod  of  performing  the  operation  is  as  follows:    The  patient's 

I  ■  Md,  lace,  and  eyes  are  jirepared  for  the  oinration  as  if  for  cataract 

■  xtraction.      In    eyes    with    considerable    tension,    particuiarlv    in 

'  iMinmatory  g'aucoma,  general    ana'sthesia    is   advisable,  as  local 

;i:istlietics  in  these  ca.«es  are  not  sufficientlv  penetrating  to  affect 

Ills;   in  other  cases  local  ana'sthesia  is  obtained  by  1  per  cent 

■'"•ame  solution  or  10  per  c(-nt.  cocaine  solution,  dropped  .several 

^  's  uiM.ii  the  cornea.     The  instruiiu-nts  necessary  are  a  .speculum 

IVsmarres   retractor,  to  keep  the  eyelids  apart   ]\  iWni' 


M   the  ( 

«iiig  de.scripti(m  of  the  ojK-rat 


ye,   and   other  special    inst 


ai)art,  a  h\;iti()n  forcep.s 
riiments  mentioned  in  the 


tion.     (Figs.  171-183.) 


•JGG 


Till-:  i:yt-- 


.pisderal  tissue  with  hxatu.n  forceps,    f ,  / J,',  j,    '  ,  rcun.f.-renee 
linl.usan.l  the  pr.>,.ose,l  meisi....,  ..r  at   tl". '"'■[""  ,'>^,..  ,, f,. 


Uuu-e  knife  ..r  l.v  the  ^''^'^'^■^l'f::J^^Z^,,,,^vyA  .hat 
f.,nuer,  in  the  same  numner  as  "''^  •^•\:  /;7  „/  ,i  ,s  pussihle, 
the  cut  should  be  .na.le  ^'>,  >  "j'^  "  "'  1 ''''  .;  .  '  ,,,,L,,  the 
,,,„l,   hence,   mostly  m  seleral    tissue.     1     n      >  tn  ^^^^^^  ^.^^^ 

knife  is  entered  perpen.  jcu.arly  ""*''/•.".  ;,,  ,,  h,,  parallel 
,,,anl,er;  then  the  handle  -;'<:f-^;^;,;t  war    until  the  wound 

Via.  1«. 


(CZKRMAK) 

•  1      f      «i,lP    SO  that  the  ends  of  the  linear  ineisi-n  on  the  inner 
tk  ■  on   e  c'tu^fve  made  slightly  lar,..-,  ano  so  that  the  UMueous 

u    .d  into  the  anf-rior  dunnher  anu   l^u^he.     onto        •■»'.'' 


DISKAHJ-JH  OF  rUE  IRIS  ASV  CILlAll  Y  JlOl)  Y.  367 

small  section  is  (losircd,  the  forceps  heii.R  Renorally  better  in  glau- 
con.a  o|,eratioiis,  an,|  tl...  iris  hook  in  cataract  or  optical  iri.iecton.v. 
liie  ends  of  the  woun.i  are  freed  from  tlie  iris,  and  tiie  spatul;, 
hei.iK  introduced  int.,  tiie  wound  puts  hack  into  the  anterior  chanilMT 
any  ins  tissue  and  riears  away  the  blood  and  debris.  At  the  com- 
p.'tion  ()t  the  opera! ion  the  ,)upil  and  the  coloboma  have  the  sbnw 
ol  a  keyhole.  ' 

The  eye  op,.rated  upon,  and  usually  its  fellow   should  be  light  Iv 

baiK  aged,  the  dressings  behig  a  semilunar  jHece  of  adhesiv..  pla-^«tT 

on  the  upp,  r  eye  id,  to  act  as  a  splint,  sterilised  vas<.|ine  to  lashes 

.()  prevent  them  from  gumming  together,  small  patch  of  lintine  or 

clu-.-se-cloth  to  protect  the  eye  from  tiie  dry  ab.sorbf  nt  cotton,  which 

IS  p  aced  over  tl...  eye  and  orbit,  and  over  all  a  wire  mask  nuule  to 

It  the  face,  or  a  light  roller-bandage.    The  first  dressing    need  not 

"■  made   for   forty-eight   hours,  when   the   evelids  are  washed  wnh 

...lie  aci.l  solution  and  a  light  roller-bandage  applied  t<.  the  e  ? 

that  has  been  ofierated  upon,  the  other  being  protected  by  a  reading 


PlO.  186. 


Iridectomy,    a,  PeripUcml  haision,  as  la  glancm..    6.  Wide  Iridectomy,    c.  Narrow  or  opUcal 
Iridectomy.    (Czbiimak.) 


^liM.le.     Atropine  solution  is  usually  dn.ppe.l  in  at  this  and  the  sub- 
■'■'','';;.'.'    ^T  'r, ■'"■?:  •'•■''■■^•^"p.  which  are  made  a.  twentv-four-hour 
I  .1  M.ils   t.,  dilate    he  pupil  against  the  po.ssible  occurrence  of  trau- 
matic intis.     (As  there  is  excellent  filtration  ami  hvperten.sion  is  n..t 
l-sMl...  t.,r  a  week  or  more  after  the  corneal  incision,  or  until  the 
^^"un.l  has  fully  heahnl,  atropine  is  not  contraindicat.cl,  <-ven  aft.T 
ilau,.oma   operati.d.s.)     Dark   gla.s.ses   ..hould    be   w..rn    f.,r   .s..veral 
"•'■l.s,  a  1.1  at  the  third  or  fourth   .Ires.sing  absorbent  cott..n  mav 
■'•  P"i«;<' "V'T  the  eye  operate.l  up.m,  and  the  dark  ghus.ses  placed 
v-T  tins.     Incismn  for  glaucoma  is  made  in  scl.Tal  ti.ssue  as  ch.se  to 
-_>■'...    .,t  the  iris  as  j.ossible;    it  should  embrace  ..t  least  <.n<-fifth 
ne  hmbus.     Incismn  for  optical  iri.lectomv  usuallv  is  ma.l.>  in 
""ill  tissue.     Ihe  section  for  glauc.ma  and  cataract  extraction 
'■Hl.y  IS  ma. le  upward;  that  for  optical  purpo.ses  .lownwanl  and 
;""•  «.i;  m  the  region  nf  least  opacity.     (Pl.-ite  XIII..  Figs. .',  (]  7  J 
'yhrnl,ons   /or    IridecUmnj.     1.  The    most    important    iiui.cati..n 
iM.lectomy  is  mcrease  of  tension  in  primary  glaucoma  an.l  in  s.-c- 


mm 


MH 


THE  EYE. 


ondary  jtlaucoiiia  resulting  from  txclusio  pupilla',  ectasia  of  the  cornea, 
or  scierochoroiditis  or  iridoclioroiditis.  The  earlier  the  ofx-ration  is 
|)erfornuMl,  the  better  the  suceei.s.  Vet  in  some  eases,  in  order  to 
reliev;"  pain  and  t'urtlier  degeneratic/ii,  in  ectasis  of  the  eyeball  in 
wlii,  ii  |)ereeption  of  light  has  In-en  abolished,  the  operation  may  be 
done.  In  iridectomy  made  after  increase  of  tension  the  section 
sliould  be  made  long,  situated  as  far  back  as  possible  in  th(>  sclera, 
and  the  coloboma  slu-uid  be  broad,  and  extend  to  the  ciliary  margin 
of  the  iris,  for  the  reason  that  the  results  of  iridectomy  for  the  reduc- 
tion of  tension  are  achieved  through  the  establishment  of  filtr.-ition 
through  the  scar  tissue  ius  well  as  by  the  removal  of  a  portion  of  the 
actual  contents  of  the  eye  in  the  portion  of  iris  that  is  excised.  The 
coloboma  is  mtide  upward,  so  a.s  to  be  covereil  partially  by  the  upper 
lid,  and  the  confusion  due  to  dazzling  thus  les.seiied. 

2.  ()))eration  on  account  of  (iiilicnl  ohslruclidiis.  Tlie  formation  of 
an  artificial  pupil  by  iridectomy  may  be  done  in  ca-fcs  where  opacities 
of  the  refractive  media  occupy  the  area  of  the  pupil ;  among  these  arc 
opacities  of  the  cornea,  membrane  in  the  i)upil,  oi)acities  of  the  lens 
lliat  are  non-progressive,  in  shrunken  cataracts,  which  ilo  not  extend 
far  toward  the  peri])hery.  and  in  subluxation  of  the  lens,  where 
tiie  ])U])il  may  be  made  in  front  of  the  |)art  that  contains  no  lens. 
To  obtain  results,  the  following  conditions  nmst  be  ])resent:  (o) 
the  retina  and  optic  nerve  should  be  capable  of  functionating; 
(^))  the  opacity  should  be  stationary;  (c)  the  ojKicity  should  be  so 
dense  that  it  prevents  the  formation  of  distinct  images  u])on  the 
retina.  These  conditions  are  to  be  ascertained  by  proper  obser- 
vation and  examination.  Ci)ntrai»nlicati(ms  to  iridectomy  for  optical 
purposes  are:  (a')  iotal  abst'nce  of  perce[)tion  of  light;  (i/)  stra- 
l)ismus  of  the  eye  affected  by  the  opacit .  when  the  ey(>  is  not 
])ut  in  alignment;  (c')  flattening  of  the  cornea,  which  is  an  evi- 
dence of  iridocyclitis  and  membranous  exudates  upon  the  iris; 
(d')  incarceration  of  the  iris  in  a  cicatrix,  where  the  iris  is  i)rimarily 
attached  to  the  posterior  surface  of  the  cornea.  Iridectomy  for 
ojjtical  coloboma  is  made  preferably  downward  and  inward,  if 
the  media  are  everywhere  e(|ually  transparent,  as  in  t!ie  case  of 
central  cicatr  x  of  the  cornea,  pupillary  membrane,  o:  perinuclear 
cataract,  as  the  visual  axis  cuts  the  cornea  a  little  to  the  inner  sidi 
of  the  apex.  In  other  cases  the  coloboma  should  be  made  at  the 
place  where  the  media  ar<»  most  transparent.  Where  only  the  most 
exterior  marginal  portion  of  the  cornea  remains  transparent,  the 
iridectotny  may  be  made  iiuite  peripheral,  involving  the  root  of  the 
iris;  but.  as  a  rule,  it  is  made  as  n.arrow  as  possible,  and  only  the 
sphincterial  area  of  the  iris  is  excised.     (Plate  XIII.,  Fig.  7.) 

:{.  In  ectatic  cicatrix  of  the  cornea,  iridectomy  is  made  to  cause 
flattening. 

4.  In  recurrent  iritis,  iridectrmiy  made  durinsr  :ui  interval  in  whic!: 
there  is  no  inflammation  sometimes  ])revents  recurrences. 

i).  In  fistula  of  the  cornea,  in  ca.ses  where  some  trace  of  the  anterioi 


DIHiAiiEii  OF  THE  IHLS  ASD  CILIA Ji  K  HOU  V.  y^j, 

0.  In  the  CMS.-  of  foreign  |„„|i,.s  ai„|  .s„uill  tumors  of  tl...  iri.  « l,i  i 

,..';,»";::;;™,.,irS„™;:;':T::^';;,'^;;!r^ ;^ -'i. """■■■ 


.'IIU 
olll 


Klo.  IK7, 


Fio.  188 


oi  nio  wound  to  the  sclerocornea   mare  n;  the  flan  thii<  out  ;= 
";-"•"  out  by  gra..„ing  it  with  tho  iri^  f^rcoL  o    sha" /hooi 

^'  ^i.  P       1  vidlTVh^"-'"  •^r''"'"  Mkmbr.>ck.    [n<^tomv  consists 
"  I'lN,  <ii\  (iing  thp  iris  without  excising  a  piece     Th^  ineisinn 

'  .     '"fl^inSa^l^^t'  "t  ^"^  ^^"^'^  '''-  -  Sucift';^'^ 
instance,  as  an  after-operation  for  cataract  cases  in  which 
24 


370 


THE  FA'K. 


le  pupil  has  bocoinc  closed  by  substniueiit  iriciocyclitis.  The  opcra- 
on  is  (Itiiic  by  passiiij;  the  (Jraefe  knife  iM'riK>mlicuhirly  throujrli 
le  cornea,  rotatiiiR  it  90  degrees,  making  a  liorizontal  incision 
irough  the  iris.    (Fig.  ISO.)     Tlie  edges  of  the  ojx'ning  retract,  leav- 


FlO.  1N9. 


Iridotomy.    a.  eorneal  inclaluu.    e.  Iris  iuciilun.    iri  Wicker.) 

3.  St.\phyi.oto.my  for  oi)ening  a  closed  pupil,  caused  by  incarcera- 
tion of  the  iris  in  a  corneal  cicatrix,  is  done  by  a  sweep  of  the  Graefe 
knife  through  the  anterior  chanilier.     (Fig.  190.) 

Sphinctkkolysis  antkhior  (Fig.  191)  is  done  by  transfixing  the 
ect!i.«iia  by  oneCJraefe  knife,  another  being  pa-ssed  into  the  eyeand  swept 
around,  dividing  the  iris,  and  producing  a  more  or  less  irregular  pupil 


Fia.  190. 


Fia.  1»1. 


Ptapbylotomy.    (AsikDii.) 


Spblncterolysis  anterior.    (Schvlek.) 


Formerly  other  operations  were  practised,  such  as  iridcsis  which 
con.sisted  in  moving  the  pup'.l  to  one  side  by  allowing  the  iris  to 
b(>c()me  incarcerated  in  a  corneal  incision,  and  nirclj/sis  or  division 
of  ])osterior  synechiie:  but,  as  tiieir  results  aio  dangerous,  or  the 
operations  are  uimecessary.  they  have  fallen  into  disrepute.  .•Xs 
operations  done  for  oi)ening  occluded  pupils  are,  as  a  rule,  made 
through  pathological  products  or  diseased  irides,  their  results  arc 
often  only  temporarj-,  the  artificial  openings  closing  later  from 
recurrence  of  inflammation.  Operative  procedures  may  have  to  be 
repeated,  and  often  are  made  in  vain. 

The  after-treatment  of  the  foregoing  operations  is  similar  to  that 
fo!lt)vving  iridectomy. 


PLATE   XIV. 


Anoinalieb^  >>l'  Iho  Clit>roi(l. 

A.  The  Alliiii.lK  I-unilu-.  'Tvi)C  1..  -ve  Plate  MI.,  K' 
II.  The  Tes^ellaleil  Himilu-  ;  iType  II..  >.ee  Phite  .\II..  Hi. 

C.  The  Ne(jroi<l  Fiiiuliis  ;    (Type  III,,  see  Plait  \II.,  <i'. 

D.  The  Yellow  l-iindu-^  .    I  h'nndit-*  l-"Iavus.  Oelleri, 

K    Sarcoma  I' horoide*;  V    -^7--..  (Heniianopic  Hield.  see  IM)!.  I9TI. 
H    CnliilKinia  Chornirte;e  Cenlralis  ;  (Oeller)  ICenlrnl  Siotoma} 


DISEAUBS  OF  THE  CHOROII). 


371 


-'•id  tyjK-        I'late 


lie  ijm> 
})ur    ■< 


ot 
wit! 

'    '  'i-(  i  i 


led 


DISIA818  or  THl  OHOaom.    CONOINITALA    DBIALIIS. 

yariatloM  in  the  Color  of  the  randu.     A.si.le  f,    „  the  three 
tyiK-s  of  funjlas  .lue  f.  variati.,„s  i„  the  pign„.„t  ,.,.||.s r     ,„      ,e 

II  llat.  .\n..  A.  ()„  aeecunt  .,»  the  l,.s..«.ned  contrast  ,  .tweeii  the 
<  .'t  .•  .„  ne  a„,l  .„h..r  part.  „f  the  fu.uh...  the  nerve  h.  "m  nin, 
ol  a  -lark  re,l.|,.sh-gray  e„l,.r;  „..t  only  the  retinal,  hut  »1  tin-  a^ 
ess,.|s  nf  the  ehor.„d  are  n.ulily  s^.-n.  Such  pc-r.,, ns  have  v  h.w  f- 
M..-  flaxen  ha.r  white  ey.bn,w.s  a„,|  lush!;,  and  their'  "e.  are 
l'l"'t..ph..l,u.,  vLsual  acity  Ls  re-ducHl.  an.l  nv.sf,,«n.us  is  c„.:ltan  Iv 
|.res,.„t.  and.  as  a  rule,  there  are  stral.is.nus  ...n-,|  ,■  v,.pi„,  Sn  '  2 
affords  a  deeidt  d  contrast  fron.  that  of  < 
.\I\ .,  C.) 

Treatment.     Correction  of  the  refractioi 

iiiass.'s,   to  protect   the  eye  from   brilliant 

assistance,  such   patients   are   usually   un 

Vocations. 
AccordiiiR  to  the  dispositi(.n  of  the  chor. 

takes  on  more  or  less  color,  as  in  the  sevei 

I'late  .\I\-.,  A.  H.  C.  D.     The  result  of  in 

•III  nicreas<'  m  and  depo.sit  of  the  choroi. 

tnmi   this,  great   changes  in   the   aptx'ai 

MTved. 

Coloboma  of  the  Choroid.    This  anon,  r 
.1  cn-cuniscribed  defect  in  the  choroid  ns, 
"t  the  f(etal  cleft,  usually  in  the  retina,  p 
"ptic  disk.     If  unaccompanied  bv  cololh     .^  , 
"I  the  ins.  It  may  be  of  .-m  ovaj  shaiM-       i  ui 
ii'gii.n  and  of  the  iris,  it  is  that  of  a  Av  v 

toward  the  papilla.  .Such  eyes  have  ,rge  > 
visual  field  m  the  up|.er  (x.rtion.  an.  he  cci 
usually  less  than  normal,  (l-'ig.  HW.  (\AuUn 
.i>s..ciated  usually  with  other  anomalies  of  ,|cv 
with  microphthalmos  and  coloboma  of  the  iri^c  . 
■  ire  hyperopic. 

A  somewhat  rare  form  of  coloboma  is  .-i  dcfe.i 
tlie  region  of  the  macula  lutea  (I'late  XI\-..  F,.  a„      ,„„  -„,.  „, 
IS  generallv,  elect  of  the  retina  at  this  ,,oint,  and  eo..;  en    .e  ',,1 
-toma      All  su,.h  cases  that   I  have  seen  have  Ikh-I,  ."w-c 
optic  n,.rve  atrophy  and  evi.lence  of  prenatal  choroiditi.-   "l„ 


I  lent,    itt-  fun,   ..H 
if  \y]H-»  fW"! -d  in 
latior-  i,-.  Jrequerfth 
igniei     ill  sfMite,  iiitt^ 


.f 


lM;i!. 


villi 


''^  are  i4)- 

■  '  I-  due  to 
'    oi  rfc.sing 

'  liriou  the 

''■   nnd 

.ary 

u!     cted 

ft         the 

y  is 

id  is 

lonly 

I  eyes 

■imroid  at 
'his  tlicre 


with 


I;;;...  f.;rms  of  coiobom.aa  the  .i;;rar;;,i;;;  u- •;;.;•  ;:nd ... 

iK'tily  bonlered  by  pigment.     Th..  bloo.lves.sels  purs,,.,  a  very  rreeu 
lap  course,    the   retinal    yes.sels   usually   avoidiig   the   eoSm^b 
limning  along  its  edges.  Lt>it;.;oma   m 

Treatment     There  is,  of  cour.se,  no  treatment  for  these  defects 
I 'lit  eirors  of  refraction  may  be  neutralized  to  advantage. 


m' 

,SHf 

i 
1 

1 

I 

i 

1 

i 

372 


77/ A  A,rii'. 


Inflammatory  Diieases.  H ilium imti  of  iln  choritnl  it*  i  >it  in  itself 
rrciiniiiziihlc  ;is  :i  lisjoii  <(r  a  >yiiipt()rii :  a.-*  it  in  tiic  fiivr  .wtajjf  ol' 
iiitlaiiiinatinii.  it  iiiiliiiilittMllv  i.n  an  accoinpaiiiini-nt  ul'  tmist  clioriiiii.il 
atTcctiiins. 

Ciinruiiliti;^  iiia>  Iw  rxudativc  or  Mi|ipiitativ«'. 

Choriililitin  I'lxuilittirit.  Acute  cxutlativf  clioroiditi.s  is  cliarac- 
tcrizfd  by  isnlatcil  fori  of  inliatnniation  st-attcn-d  ov»'r  the  fundus, 
apiwariiiK  upon  opiiflialnioscopic  fxaniination  as  iiidist  iictly  out- 
liiM'd  yi'Miiwjsli  s|»>is  lyinj;  iM-ncatli  the  rrlinal  vrsscls  in  tin-  red 
fundus.  I  i'lalc  \\'.,  A.I  Tiii'sc  aif  due  to  intiitration  of  tin-  cho- 
roidal sulistaniT  with  exudation,  hiding  the  ciioroida!  vessels:  the 
overlyinj;  retina  usually  is  involved,  and,  l»einK  clouded,  co\ers  the 
choroiilal  mass  with  a  faint  grayish  veil,  l>olated  heniorrhajjes  may 
appear  in  the  <-horoidal  stron;a  or  under  the  retina.  The  exudates 
may  pa.ss  not  only  into  the  retina,  hut  also  into  the  vitreous:  thus 
opacities  of  the  vitreous  are  ;ilinost  always  constant  accompaniments 
of  choroiilitis,  and  the  di.-:ease  is  really  a  compound  atTecti(Ui, 

Deposits  u|Min  the  posterior  surface  (descemitisj  of  the  cornea  in 
a  larjje  niimlwr  of  cases  of  apparently  simple  exudative  choroiditis 
show  that  the  disease;  is  a  trui'  uveitis,  and  is  not  liiiiited  to  the 
choroid  projier. 

Symptoms.  Suhjectivelv,  the  patient  complains  of  loss  of  visuu! 
acuity  anil  of  floating  spots,  which  are  due  to  complete  or  |)artial 
s<'otomala  from  implication  of  the  retina  and  vitreous,  ;ind  of  flashes 
of  lijih  ,  and  photopholiia,  due  to  irritation  of  the  retina.  .Vs  there 
are  no  sensory  nerves  in  the  choroid,  then-  is  no  |)ain  in  uncompli- 
cated cases. 

The  limitation  of  vision  both  as  rejfards  visual  acuity  and  the 
visual  lield  is  not  .i  prominent  symptom:  itid.'ed,  severe  inflamma- 
tion may  lie  present  without  these  visual  factors  heinj;  apprec'ahly 
alTected,  until  the  chronic  stage  or  that  of  atrophy,  w'  tc  degenera- 
tive spots  and  increa.se  of  pigment  api)ears,  and  the  r<  ;  la  and  optic 
nerve  become  involvi'd;  then  th<'  visual  acuitv  and  field  suffer. 
(Fi«.  KM.) 

Course.  W'hil"  the  course  of  choroiditis  is  es.sentiallv  chronic,  it 
may  be  subdivided  into  an  acute  stage,  marked  by  inllanunatioii  and 
exudation,  which  last  for  s<'veral  weeks  or  months,  and  the  chronic 
sttifji',  or  that  of  atrophy,  whici    "ists  for  months  or  years. 

The  chronic  stage,  or  that  :jf  atro])hy,  pri'sents  a  radically  different 
jiicture:  .\s  the  e\uilat<'s  ix'come  resorbe<|,  the  spots  become  more 
|iromineiit  and  lighter  in  color,  ;.nd  gradually  a  white  spot  is  forme(l 
as  the  choroid.'il  stroma  atrophies,  which  is  due  to  the  white  scleni 
showing  through.  In  some  cases  tlie  remains  of  the  vessels  and  the 
pigment  may  be  recognized  in  the  white  cicatrix.  The  jjigment 
generally  ])roliferat(>s  aiound  the  edges  of  these  scars,  so  that  the 
clioroiditic  iilai|ues  ajipear  lined  with  >lack,  or  covered  with  black 
sjiots.  (Plate  X\".,  li.)  The  visual  acuity  and  the  field  suffer 
gn  .itlv. 


PLATE  XV 


Types  or  Choroitlnl   Diseases 


V.lin.i    , 


'i'  rif], 
■    '  t.na,  s 


rge.    RM>g   bcotoma.    no   ,HTCep.io„    „f    colors.    «,    K„     ,„„       J    R^m  u™ 


■^    ■r*?'.  w....tr. 


PLATE   XVI. 


B 


■■^^£S--SSV2^ 


■';  I, 


Aft 

Of 

At 

4   of    Opi- 

0>l 

Artt     Of 

\ 

Chonaid      . 

\ 

NOBMJL    OPTiC    NERVE    ENTRANCE. 


A.  0.. 

B.  D,. 


POSTERIOR   CHORIOIDAL  STAPHYLOMA 
WITH  SICKLE-SHAPED  CONUS. 

C.     0|.hllMli.v».opi,    .le* 


RING   CONUS 

The  0|)ti<     Nerve  Entfaiioe  ii 


URGE   SEMILUNAR   CONUS 

1  its  Relation  lo  the  Choroid. 


DJS£ASJCS  OF  THE  CHOROID. 


373 


Etiology.  Exudative  choroiditis  is  a  frcqupnt  disease,  and  is  seen 
at  all  ages.  Its  eauses  are  local  irritations  and  disturbances  of  the 
nutrition  of  the  eye,  due  to  eyestrain,  errors  of  refraction,  irritation 
due  to  ex|)osure  to  bright  light,  and  to  general  disturbances  of  imtri- 
tion,  such  as  ana-niia  and  chlorosis.  Thus  it  is  accompanied  by 
general  diseases,  particularly  .sy|)hilis  and  scrofula. 

.Myopia  of  high  degree  is  accompanied  also  bv  changes  in  the 
choroid  Icxs  of  inflammatory  character  than  of  atroi>hic:  these  are 
caused  by  stretching  and  tearing  of  the  choroid  at  the  optic  nerve 
entrance.     (Plate  X\I.j 

In  mode-rate  degrws  of  myopia,  from  —5  D.  to  — «  I).,  as  a  rule, 
only  one  side  of  the  oj)tic  nerve  entrance  is  affected,  forming  a  coims 
(Plate  Xyi.,  V):  in  severe  degrees  the  jiosterior  section  of  the  ,ye- 
bail  i)ulging  backward,  the  choroid  retracting  considerably  with  the 
sclera,  forms  not  only  conus,  but  also  posterior  stajihylonia.  (Plate 
X\'I.,  (".  D,  K,  and  Plate  X\".,  K.)  Such  cases  are  accompanied  bv 
localized  choroiditis  at  the  edges  of  the  coloboma,  with  increase  iii 
the  choro'dal  pigment  ring:  changes  likewi.se  occur  at  the  macula, 
and  the  pigment  granules  of  the  retina  are  more  or  less  absorbed! 
allowing  the  intravascular  pigment  of  the  choroidal  stroma  to  show! 
An  eye  atfect"d  by  choroiditis  of  any  degree  of  severitv  always  lo.ses 
more  or  less  of  its  function,  as  may  be  determined  bv  careful" exami- 
nation (»f  the  visual  acuity  and  of  the  field. 

Treatment.  The  treatment  of  choroiditis  is  that  of  its  cause. 
Eyestrain  shouhl  be  relieved  by  proper  ieiises  and  unhygienic  habits 
corrected:  ))articularly  is  this  the  case  in  myopia,  where  full  correc- 
tion of  the  error  should  be  given  for  distance,  and  the  ciliarv 
muscle  favored  l)y  weaker  lenses  for  the  near.  In  most  cases  the 
glare  of  light  should  be  mitigated  by  the  wearing  of  smoked  glasses. 
In  acut<>  ca.«es  atropine  .solution  of  sufficient  strength  and  often 
enough  to  suspend  accommodation  should  be  in.stilled  into  the  eye. 
Hot  compres,ses  favor  resorption  of  exudates,  and  m:iy  be  u.sed  three 
or  four  times  a  day  for  half  an  hour  at  a  time.  Injection  of  salt 
solution  under  the  conjunctiva  is  used  for  the  same  rea.-*on.  In  acute 
choroiditis,  extraction  of  blood  by  the  natural  or  artificial  leech, 
applied  on  the  mastoid  process  over  Hie  emis.sary  vein  of  Santorini, 
wiiich  comes  from  the  cavernous  sinus,  into  which  the  ophthalmic 
veins  pour  tli(>ir  contents,  is  useful.  In  the  chronic  .stage,  mas.sige 
of  the  eye  with  t'  .•  '-nger-tijis  once  or  twice  a  dav  for  hve  minutes 
at  a  time  stimulate>  meialtolism.  The  general  treatment  .should  be 
directed  against  the  exciting  cau.se.  disturbance  of  nutrition  from 
ana'mia, should  be  met  by  exhibition  of  iron  and  arsenic.  pro|>er  diet, 
and  regimen.  Wlien  the  disea.se  is  accomjianied  by  the  rheumatic 
•  ir  uric  acid  diathesis,  administration  of  sodium  .saJicylate  (()..")()  to 
0.1  gm.  three  times  daily),  or  oil  of  wintergreen  (().;«)  "to  ()..')()  c.c.)  is 
indic'Ued.  (V«togpn  or  urntro})in  ;().:50  gm.  three  (ime.s  daiiv)  rapidly 
relieves  the  .sy.stem  of  uric  acid.  When  the  patient  is  scrofulous, 
alteratives,  tonics— j.  c,  mercury,  gold,  arsenic,  and  iodide  of  iroii 


374 


THE  r.YE 


with  cod-liver  nil — should  Im-  cxhibitod.  If  t!ic  local  lesion  !«■  a 
symptom  of  sy])hilis  in  the  acute  stage,  luercurial  iiiunctitms  will 
often  produce  a  ((uick  effect;  the  salts  of  mercury,  Rold,  and  arsenic 
stem  to  be  s{)ecifics  for  this  affection;  iodide  of  potassium  is  ])ar- 
tieularly  serviceabh,"  in  rcsorhing  exudates  in  the  retina  and  vitreous. 
Diaphoresis  by  vapor  baths  and  pilocarpine  are  of  use  when  properly 
carricil  out. 


Fig.  192. 


Fio.  198. 


Fig.  192." Central  absolute  arnl  relative  scutomft  due  to  hemnrrhage  in  syphilitic  chorioretini'.is 
irlateXIV.,  E) ;  also  trpical  dI'  ehorolditii^  centralis  senilis  iIMa'e  XIV.,  <'!,  {Visus  ^  objects  in 
periphery  of  field  ;  nt)  fentrai  vision.) 

Flo.  193.— Seetunil  eoiitnietion  due  to  choroidal  cololtonm.  a:id  enlarged  blintl  sjKit  IVoin  iM»<teri'ir 
siaphylcuuii.     iVisn.s    -  »>  x.xiv.) 


Fill.  194. 


Fiu.  195. 


V/7 


Fit!.    194.— I'ttracentral    and    [lericentral   scutftniata  in  chnroiditis   disseminata   chronica  (PliUt 
XIV.,  Hi.    (Vi.-u.-   -i;i.\.i 

F:o.  19.').— Ahsolutc  and  relative  riuK  scotomata  in  chorioretinill^  dilTiisa  syphilitica.    (Flate  XIV. 
III.    (Visus  =  6i..\.) 


VISEAHES  OF  THE  CUOIWID. 

^^-  '*•  fta  197. 


375 


*,-»• 


Klii. 
KlG. 


I'Jti.— Great  con'ractlon  in  ihorinretinitis  plgui.^iuosa.    (VigiM  =  6'xn.) 

liir.-Stttnml  contraction  simulating  vertical  hemlanopla  in  sarc'iina  of  chomld  in  first 

iVisns  -=  ti  xxxvi.) 


Vdrictie.t  of  Exudntire  Chmiidilis.  Aside  from  tho  distiiictioii  of 
ivcciit  and  old  clioroiilids,  certain  well-defined  forms  are  to  be  dif- 
ferentiated: 

1.  Choroiditis  centralis  is  characterized  by  changes  occurring  in 
the  icfrion  f)f  the  macula  lutea,  causing  disturbance  of  central 
vision  from  central  scotoma,  with  resultant  diminished  visual  acuity. 
(Fig.  192.)  The  most  common  ftjrm  is  that  occurring  in  old  jjeople 
Mtrecti'ig  both  eyes  about  e(iually,  and  is  referable  to  .senile  changes 
due  to  sclerosis  of  the  central  ve.s.sels.  In  young  j)eople  srlerosis  of 
the  vessels  is  not  .seen.  In  some  cases  there  is  considerable  deposit 
"1  i-iginent  as  well  as  atrophy  of  the  choroid.     (Plate  X\.,  C.) 

2.  Clioroiditis  Areolaris.  The;  fiist  foci  develops  in  the  vicinity  of 
the  fovea,  while  sub.seciuent  ones  make  Uunr  a[)j)earance  at  con- 
stantly mcreasing  distances  from  the  latter.  The  most  recent  spots 
•lie  entirely  black,  and  afterward  slowlv  enlarge,  at  the  same  time 
iMcniiimg  decolorized  in  the  centre,  at  la.st  iM'coiiiing  almost  entirely 
uliite.  One  or  two  isolated  .spots  may  be  seen  in  other  portions 
til  tiie  fundus.  This  is  ])e'-haps  a  variety  of  the  dis.seminated  form. 
Myopia  ()f  high  degree  is  accomi)anied  usually  bv  changes  in  the 
hivea.  The  acute  form  of  macular  choroiditis  "is  found  most  often 
HI  syi)hilis:  this  subsefpiently  degenerates  into  atrophy,  with  increase 
"i  pigment  dei)osit.  Injuries,  such  as  contusions,  entrv  of  fore'gn 
l"'dy  into  the  vitreous,  burning  of  the  i-iacula  from  direct  exposure 
I"  the  sun  s  rays,  as  iti  obser\nng  an  eclipse  and  electric  light  flashes, 
'i<'  liable  to  develop  macular  disease.  The  macular  region  of  the 
iiiiiia  and  of  the  choroid  is  a  vulnerable  spot,  and  is  affected  readily 

•y  :('ea!  or  general  di.sea.ses.     Injurv  to   it   has  a  most  deleterious 
'■"'"•t   upon  the  visual  act,  causing  central  scotoma  and    -i.at  lo.ss 
'  visual  acuity.     (Figs.  192,  194,  and  195.) 


.376 


THE  EYE. 


:i.  Chnroulitis  disseviinntn  is  characterized  l)y  numerous  round  or 
irregular  spots  scattered  over  the  fundus,  composed  of  isohited  iu- 
Hanimatorv  foci  wiiich  at  first  loolv  whitish,  Ix'ing  accomimnied  by 
disease  of"  the  o%eriyinf:  retina.  (IMate  X\'.,  A.)  Home  of  these 
sjiots  progress  to  atropliy,  witii  incrciise  of  tiie  retinal  and  choroithd 
pigment,  whih'  fresh  ones  appear,  so  that  ultimately  the  eyeground 
appears  studded  over  with  the  placjues,  and  in  old  cases  a  large 
portion  of  the  fundus  looks  whitish.  In  the  iM'ginning  tlio  o|)tic  nerve 
and  retina  usually  are  involved  in  the  hypera-mia,  and  the  nerve 
looks  reddish;  ultimately  atrophy  of  both  the  nerve  and  retina  takes 
place.  (Plate  -W'.,  B.I  "  Wlien  many  of  the  spots  In-come  confluent, 
the  whole  background  of  the  eye  may  ai)pear  mottled  and  present 
a  peculiar  picture,  resembling  choroiditis  diffusa.  In  the  acute 
stage  the  visual  acuity  and  the  visual  field  suffer  but  little,  so  that 
nearly  normal  vision"  exist.*,  the  patient  comijlahiing  mostly  of 
dazzling  ami  flashing  of  light,  and  asthenopia.  As  this  is  an  essen- 
tially dironic  disea.-^e,  it  ultimately  progresses  to  amblyopia.  From 
the  "changes  taking  place  in  the  "retina  and  optic  nerve,  there  are 
usually  scotoma  and  contractions  of  the  visual  field,  with  reduction 
of  the  visual  acuity.     (Fig.  194.^ 

4.  Choroiditis  anterior  is  characterized  by  exudation  at  the  [m-- 
riphery  of  the  choroid,  the  fundus  being  here  studded  with  r  nlish 
ink-black  opacities.  It  is  found  in  myojjes  of  high  degree  ano  .some- 
times as  an  accompaniment  of  sy])hilis.  In  old  pe;)i)le  pigmentary 
changes  are  fre(|Uently  found  in  the  anterior  jiortioii  of  the  choroid. 
It  is  sometimes  a  complication  of  retinitis  pigmentosa. 

5.  Choroiditis  Dijfiiso.  In  recent  cases  the  retina  and  vitreous 
appear  cloudy,  and  circumscribed  exudates  are  present  in  the  retina 
and  choroid,  occupying  mainly  the  region  of  the  macula.  Later  on. 
thi'se  appear  as  dirty  light-gray  irregular  patches,  and  in  the  last 
stages  the  general  cloudiness  of  the  media  disapjjears,  being  replaced 
by  atrophy  in  the  retina  and  choroid,  into  which  migration  of  pig- 
nient  takes  i)lac(>.  (Plate  X\'.,  I).)  This  is  a  disease  characteristic 
of  syphilis,  and  has  been  described  under  the  name  of  choroiditis 
syphilitica.  The  visual  acuity  and  field  suffer  greatly,  color  vision 
part'culariy  being  affected.     (Fig.  19.5.) 

(>.  Tuhcrndor  deposits  rarely  occur  in  the  choroid:  they  present  the 
jiicture  of  yellowish-white  plai|ues,  over  which  the  retina  appears 
grayish  and  infiltrated.  (Plate  .W  II.,  A.)  These  ultimately  degen- 
erate into  atro])hy.  pursuing  nuich  the  same  course  as  the  di.ssem- 
inated  form. 

7.  Chomn's  in  the  choroid  hi  nijiopia  consist  («)  in  retraction  of 
the  choroid  and  atro])hy  at  the  bonier  of  the  o])tic  disk.  This  first 
appears  as  a  crescentic  i>atch  at  the  outer  border  of  the  papilla, 
being  caused  by  the  heail  of  the  nerve  being  pulled,  toward  the  temporal 
side.  Later  on,  the  scleral  canal  enclosing  tiie  nerve  is  so  pulled 
and  gets  such  a  slant  that  upon  ophthalmoscopic  examination  it 
comes  into  view  through  the  transparent  tissue  of  the  papilla,  ap- 


PLATE  XVII. 


''•»-»«« 


Diseases  of  the  Choroid  alfectiiig  ihe   Retiiin  nnd   Viireous. 

A       Clu.roiiliiw  TulienuloMi    Milimii- 

B       HyHlilis  ,-1  (,-h,,rimlili^   Sii|ipiiriiti  vn  i  P-.eil.  lo.i  1 1.  mlai 

C      Cl)uru>- i-eiMi  iti^  Ariiut 


.li'-i  fsm 


iJlSKAisKli  OF  THE  CIlOROllK 


377 


|K'ariiij{  a.s  a  \vliit«'  cTcsecnt  cIom'  to  tin-  ttiniioral  lM)nl('r  (Plate  \\'., 
I'.,  and  riatc  -\VI.,  F);  this  is  caiUnl  conus.  At  thi.s  time  a  rcHcx 
may  1m'  seen  in  «)n(e  cases  at  several  disk  diameters  temporally  from 
ilie  nerve  head,  which  is  a  characteristic  symptom  of  progressive 
iiiy(i|)ia,  the  curvilinear  line  of  Weiss.  As  the  myopia  progresses 
till'  ntraction  extends  around  the  nerve,  forming  a  i)and  of  white 
ii>su(—  ring  conus.  (I'late  X\I.,  E.)  If  the  retraction  extends 
lurllier,  intiammatory  changes,  with  con.>ie(|uent  atrophy,  take  place, 
resulting  in  l)ulging  back  of  the  ball  or  postf-rior"  staphyloma. 
I'late  X\l..  V.)  [b)  High  myopia  is  likewise  accfinipanied  by 
intiammatory  changes  about  the  macula,  such  as  have  Iwen  described 
UMiliT  the  heading  of  Choroiditis  Areolaris. 

CompUcationa.  In  mild  ca.-<es  of  choroiilitis,  the  retina  and  optic 
nerve  may  U'come  hy|H'rainic.  When  the  atTection  is  due  to  eye- 
-irain,  tlie  cau.se  may  (|uickly  Ix'  relieved  by  correction  of  the  refrac- 
tiiiii,  and  thus  the  retina  and  o])tic  nerve  ac(|uire  no  pronounced 
defects;  but  if  choroidal  disea.se  exists  for  any  length  of  time,  or  is 
-ivere,  incidental  inflammation  and  sub.se<juent  atrophy  of  the  oi)tic 
iicive  and  retina  occur,  with  subse<|uent  diminution  of  vision.  Thus 
it  is  that  most  cases  of  choroiditis  are  a  chorioretinitis.  (Plate 
-W'll.,  C)  The  clioroid  likewi.se  is  generally  involved  in  cyclitis  and 
iritis,  which  are  accompanied  by  hyjiera'inia  or  ulirnal*'  degenerative 
changes  in  the  choroid.  Iridochoroiditis  has  thus  l>een  de.scrilH'il  as 
,1  speci.il  disease.  The  vitre()us  is  generally  involved  in  exudative 
rhoriiidiiis.  and  the  results  of  choroidal  inflanunation  and  exudation 
,iic  to  be  seen  therein  in  ojiacities  of  tlie  vitreous. 

Choroiditis  Suppurativa.  Suppurative  choroiditis  may  originate 
ill  tlie  clioniid.  being  evident  at  first  by  a  local  exudation  containing 
iiutiicmus  celis  and  j)us  germ.-.  The  inflammation  extends  to  the 
Kiiiia  .-ind  vitreous,  and  at  this  stage  may  be  .seen  through  the  pupil 
.1-  :i  yellowish  mass  in  the  fundus,  or  later  as  a  yellowish  reflex. 
I'hite  .WII..  H.)  The  inflammation  becomes  violent,  implicating 
tlie  cili.iry  body  and  iris,  and,  finally,  all  the  structures  of  the  eje, 
cMiisiiig  panophthalmitis. 

Symptoms.  There  are  but  few  mild  ca.ses,  but  in  tliese  or  in  the 
li'L'itiiiing  of  supi)urative  choroiditis,  although  the  inflammation 
!iin|icr  is  confined  to  the  uvea  it.self,  the  media  become  clomled,  and 
tuiidiis  examination  is  limited  to  the  perception  of  a  yellowish  glim- 
iii'  1.  Tlie  vision  is  greatly  diminished,  there  is  pain.  and.  on  account 
"I  :lie  iritis,  congestion  is  present.  There  may  be  slight  rise  of 
I'liipeiMture.  In  the  graver  ca.ses  the  inflanmiatory  symptoms 
!.i..irr,.<s  t,,  s,.v,,p,>  iinplioation  of  the  ocular  structures,  violent  pain 
'-  I'lisint.  ;iii(l  .sight  is  completely  lost:  hyperpyrexia  likewise  occurs. 

Course.  In  the  lieginning  there  is  hypertension,  owing  to  exu- 
''•iii"ii:  llie  eyeball  softens  late  'ind  finally  atrophies.  In  severe 
■  '-^-^  tlie  riitijunctiva  and  eyelids  .     -oiih'  (edematous,  and  the  con- 

iiictna  often  so  chemosed  "that  it  projects  iK'tween  the  lids,  which 
^^''^''  difficulty  forced  open.     In  violent  cases  the  eveball 


111    be 


378 


TIIK  E\H. 


.K-nirs    tl..-  int..  •\'-'     '''     ''f   ,,,,  i„,,„..,.s,.  until  tl»'  puniU'i.t  .-xu- 
choroid  IroiM  pyop'i.ic  luattcr;  .   .^.^^^^^ 

1.  '^r^;'-;;;'K;;;;S'i^ ..'.'( i:!::;'.";'  ^p..nuiv..  pn- 

the  ..utsulf.    CI  Iduti.nmj,   n  fn'.iu.-iit 

"■'.'r  :,;:■•;•;'.* ,'r;r.: »:  .:a,!;;;l'.;;i «, .,.»,.>. 

:*;u:  '.,wr  ,i  .1,..  t>...™  xLi;-'»!;:,i;i"  :^;^,  i;;;, ::;;;::; 

l^^tt''''-  /    ,•  ,„.,i.-<-     rr7i    Tlir()ii"li    ciiibulisiii    I'niiii 

(it   tllC  llin.imi"-"i""  "  ,.     •..  ..i.:i.l .,■„    .m.  ,  IS  lllirilislicd 


(llll    lllf    in'iii"f^>  •'•    I- •  .  •    1        1 

.,™ai  r,„™.  -r .«.. :;..■  .■.»*  ";;|«™-;:;;;1  -:;,:^«Z:!;;:il 

,,V  ,l„.ir  ,,,m|,anuiv.;ly  ";*'"""';".    ■',:„,     ,|,..  i„ll,„„a,a- 

is  j<>(ipMr.liz.>'l  ,  „f  suiMuinitivc 

Treatment.     No  iiicdii-alioii  (.vn    i'-'"-'    "'  ,,.,,■  „,,'^   siifTcriii<' 

,,.„,„i,,i,is.     1,  is  .-onti,,..,!  to  an...hora,m,    '1'''    I^^'""!.^  ^f  l™- 

If  th.'    .'as.-  piosr."ss,.s    to    panophlhahn.t.s.    tu'.. 


:uiil  narcotic^ 
incision    of    tin 


Un.inishcs    the    tension  hy   allowing 


,,,....   i„    its   anterior   r«.m^^^ 

'  "'        "      u  sh„!t      When  tlu'  eye  beconu-s  shrunken. 

;;;.su;ily  ren.ains  ..uieseent ;  hut  in  ^^^^^  ^:!T^y 
such  as  calcareous  deposits,  occurs,  causui^  iirit.ition  oi 
nerves  ami  synipath..tic  irritatiot,  in  the  oth,-r  eye. 


evacuation  o 

ivss  of  the  ilir-ease  are  <■! 


»f^ 


^ 


■PHI 


DisKAn^a  OF  rut:  ciiunum. 


;i7i> 


Kii^.  I9M. 


U  liilf  an  artilicial  tyc  inijjlit  Ik-  worn  nvcr  the  resultant  stump, 
>till  the  irritation  causi'il  :»y  llit-  .shell  may  give  riw  to  wrundary 
>yni|itonis.  Altlinujfh  it  ha-  Ix'tn  customaiy  to  do  prostlicsis  over  a 
:.|irunk('n  stump,  tiic  ilangcr  iVom  sym|)atln-tic  irritation  should  Ik- 
considcnd.  and  cnucifation  should  Ik-  prai-liscd. 

i:nuii('atiiin  in  the  ht'ijtht  of  panophthalmiti.s  .should  not  usually 
Ih'  done,  cxcfpi  in  ca.scs  where  phh'ftnion  of  the  orhit  is  likewise 
developed  and  where  it  is  neeessary  to  oliiain  thorough  drainajje. 
Su|i|)urative  meninjtitis  hius  Ix-en  reported  as  oeeurrinff  after  enu- 
cle.ilion  for  panophthalmitis,  hut  also  several  cases  have  Ix-en  reported 
111  lalal  nieninjiilis  sueeeedinj;  a  pano|ihthalmitis  in  wl.ieli  emielejition 
was  not  practised.  The  jreneral  treatment  should  !«■  that  adopted 
fnr  sejiiicaMnia  or  pyaniia:  (|uinine.  alcohol,  and  strychnine  are  to  U" 
e\hil>ited,  anil  the  excretory  functicitis  kept  in  normal  condition. 

Sequelc.  The  result  of  .severe  plastic  or  purulent  inllatnmation  <tf 
ihe  uvea  is  shrinking  of  the  eyehjiJI,  due  to  ahsorption  of  its  contents 
and  their  replacement  hy  coiinoetive  ti.ssuo. 
I  uo  forms  are  ohserved  : 

I.  Ali-ojilii)  I  |'i>;.  lOSi.  where  the  .shrinkage 
lakes  place  slowly;  the  diminution  is  usually 
ninderate,  I «'in)i  caused  hy  the  contractinn  exu- 
ilali'.  The  li.ssues  of  Ihe  eye  remain  iiidivid- 
ii.illy  distinct.  The  shrinking  of  the  exudate 
ijraws  tlh'  inlra-ocular  conl<'nls  together,  caus- 
iiiir  repeated  .•iilacksof  inflamm.'ition.  and,  at 
limes,  syinii.athetic  irritation  in  the  fellow  eye. 
riir  cause  of  atrophy  of  the  cyehall  lies  chiefly 
in  pl.i>iic  iridocyclitis.  The  atrophy  goes  on 
Inr  nioiillisor  vears,  and  niav  result  in  phthisis 
l.iilhi. 

■2.  i'hll,isi>  liiilhi  Mere  the  shnnk.age  fol- 
I'lwiiijr  perfor.'itiiig  panoiihthalmitis  is  rapid. 
.■i>  a  rule,  tliccye  becoming  very  small,  shrinking 
i'Vi'n  to  the  size  of  a  hazelnut.  The  ocular 
'•"Mlents  .are  cxtnidi'd  through  the  rujitureor 
■itc  r.'ipiilly  ahsnrlied:  hence  such  eyes  are 
-I Mom  |iaiiifui,  and  do  not  give  rise  to  sym- 
I'Mihetie  irrigation  in  themselves,  hut  the  orig- 
i.ii.ii  inflammation  through  which  they  pas.sed, 
in  many  cases  gives  ri.se  to  sympathetic  inflam- 
'iiaiion. 

ly-snilial  l'l,ll,;si.'<  liidhi  (ophthalmom.-dacia). 
I  (lis  is  a  rare  affection,  suppo.sed  to  !)<■  due  to  a 
•  -ion  of  the  sympathetic.  The  eyeball  becomes  soft,  and  in  mildca.ses 
^!  aciiics  of  the  media  occur.  The  conilition  may  hi't  for  .several 
i  ,v-  or  weeks,  and  fin.nlly  disa])i)ear  without  leaving  traces.  In 
'  \ire  cases  the  tension  i)ecomcs  lowered  and  the  eyeball  perma- 
i^'ntly  diminished  in  size. 


Atrophy  of  the  eyelmll. 
Tin*  I'vuball  is  simtlliT  and  of 
•  I'liKlraD^iilur  sha|x--.  from 
pitlliMK  of  the  recti  mnsfles, 
Hiirl  Rf^iovwl  at  llicir  lnM.T- 
lion  ;  tile  cornea  is  irrcKOlar. 
the  retina  detarhed  from  tlie 
I'horoid.  anil  much  exuda- 
tion in  the  remains  of  the 
vitreous  behind  tlie  leiH  :  tlie 
choroid  remains  attaelieil  at 
tlie  iMtfterior  |iortion  of  the 
Klobe.  t»einK  detaehed  only 
as  far  as  the  ora  scrrata  :  be- 
tween the  clioroid  f*r  \  ttie 
retina  is  a  space  filled  with 
an  albuminous  fluid ;  ttie 
optic  nerve  is  thinner  and 
atntpbio. 


(h.iiicnliu,,  ../  //-.   rhi>rn.,l  ami  n«Milar  f..iitcnts  is  foiin.l  :i..t   iiifn-- 

u,„.||llv  il.  -lllMhk.M  .'V.'S  nf  I..I.K  stMM.Iihj::  U  lllih  sll.'ll  n|  l„mr  Is  f...m.l 

in  ilic"|.-'-"'iinr  i-urliuM.  in  whirl,  then-  is  a  li.ilr  Inr  il.f  upiir  nnvr. 
<'alcar.'uiis  ,lcv.'.'nrraliuii  nf  ih  cuiilr.ils  lii<cwis..  may  ..••ciir.  I  In- 
stniii|.  is  uifii  painful  I..  Iniic:..  ami  may  «ivc  n..'  m  sym|':itli.'tir 

"Treatment.  Almpliic  .•ycballs  .-..iita.iMiMH  luivinn  lM..lirs  ..r  l.avini; 
„„,|..rnnhr  ..sM-uns  ur  .•alra.v.,..s  .Irp.n.Taliun.  a.ul  all  imtal.l.-  ami 
,,,mlul  stnmi-  sIh.uM  Uv  .■nMrlralr,|.  In  hut  IVw  rasi-s  n  «l.irl. 
tl,..,v  an-  small  nnn-irrital.l.'  stumps.  sl.ouM  attitic.al  .ys  I..-  titt.'.l 

witlinut  cnui'iratiiin.  ,        .•     ■  i   .       . 

Neoplasmata  of  the  Choroid.     Nc\v-L'r.>wil.s  ut    the  u%-.al  fact 

■nv  rrhtivrlv  unn.m.mm.  urcuninfi  in  (MU7.-.  U>  (UMMi  p.T  (■.•nt.  ..t 

,,v i<,.s      (»!'  Ilifsc.    sarruma    is    tvlativrly  .•..nniioii,  and    is  s.-<'ii 

m..-t  uflrn  in  tin-  .•l.c,r..i.l.  It  usually  is  pijinK'ntci.  an.l  its  cnirs.- 
i<  Midi  iliai   fnur  aistinct  sta^.'s   may  !).•  nhs.Tvnl.     II    .KTurrmit 


11..  1''.' 


F„i   ,...j  -sarcoma  of. :l.nr,ml.nn.t  stage.    .fh,.t,*rn..lu.,l  fr,m,  H.Tim.n  , 

K,":  V,-S«rr„nm,.f  .■lu.roul;  h.o.   .,1  Mage  :  .....r,ml  a«,-.t..l  c.„u..;nm-.U->et«n. 

■      „,,,   ,,,,„,„i.,.   i„   ,l„.   first    stap-    111.    tmm.r   is  >,nall    "'V    ';«;'• 
' , ,    ,•  „,,,,,-ii.«  awav   from  tl,.'  macular  ivpon,  .Iocs  m-t   a    tus 
:  .,   ,h..  visi.a  a.-uiiy.  but  «ivcs  rise  ...  .idcct  in  t  u;  vi.u:.^  fu  .  1 
,,„„,  ..ircumM-rihcl  d-'lachmciit  ..t  llu'  rctma,    digs.  1!».>-1<><.\    "' 
,"    r,'  lallv  n'adilv  ma.lc  by  the  ..phthalmoscupc,  alt  im.,h 
;^"   V  .V    upon  lirst  examination,  as  it  is  to  be  d.tlcrcutiatc.l  tron, 
,p  tachmeut  of    the  retina.     .\s  the  tutnor  ,n.vs  the   retma 

,;   :;,,...sn.ore  and  n,ore  detached  fn.nniie  choroid   the  space^.^^^^^ 
.  ,  ,,„,  ,.,,„,,,i.i  ,.,,ntainin-a  thickened.  ,|..lly-like  mas.^  uihl  i.iImI 

;,,     .,ive-,i<sue  elen..n,s  and  an,n.boid  cells  Jmt  not  Y 
iV,„e.     The  tun>or  itself  is  Usually  circumsmbed.  the  ^l;;;'--;^       - 
,,i nin.r  in  contact    with  the  sclera  in  its  lull   extent.      lAte.nal  1. 
:.;.".:  still  appears  normal.    (Plate  .\I\  ..  l-'    On  turther  growth. 
,h,.  ev  becoin.'s  blind  and  ophthahnoscopic  exammatio,.  is  m.l-os- 
..ilili.  ;,„  account  of  the  .listurbance  «i  th.«  media.  .      ,-,       , 

„  th.-  secon.l  sta-e  symptoms  of  increased  leuMon  s.;t  m.    he  e>. 
pre   .  11  til '  the  appe^ranVe  of  iuHammatory  ,rh,ucnn,a.  beiijj:  m  lame, 
he;    lull     1-  =n.terior  chamber  shallow,  iris  dis<.olored,  pup.l 


f^mm 


UlUK.USh.s  lit   THE  CUoHullf. 


iHl 


ililitlnl  iiiiil  iiniiioliili',  trii.siiiii  clfvatrd.  Tlic  Icii.s  later  Im'ciiiiic.-, 
cliiinli'il,  Mini,  iM'sidcs  tlic  tiital  Idiiiiliios,  llic  patifiit  >iilTri>  nain. 
A*  tlifsc  an-  till'  syiiiiiliiiii.-*  of  iiiflaiiiiiiatnrv  jflaiicnina,  ami.  a>  maiiv 
cax-  all'  hut  mtii  liy  llir  |)liysii-iaii  until  tlii?«  >taKi'  si'ts  in.  a  (■(nrrct 
.li.iHii(i-i->  uttcii  i.<  inailr  with  ililllnilly.  If  tlii'  cyi-  he  cimcli'ali'd  at 
till-  tiiiii'.  it  may  lie  l<iiin<l  ul  an  inrjrular  sliajx'  tnuii  luilginn  of  tin 


lar  (•nat>  iliii-  tn  jfrnwth  nf  till'  tniiiur.     i  I'ij;.  i.'(K). 
rill'  third  -itaKc  i.-<  that  of  iiriforation  of  thiTv 


rliall  am 


ll'Xt 


ra-ociii 


(Ticwth  of  till'  iiiiiior.  I'rrforatioii  occiir-^  l>y  infiltration  of  the  .sclera 
and  iv|ilai'i'iiiciit  of  its  ti.s.'<iii'  hy  the  neo|ila.-<iii.  The  favored  site  is 
|iosteriorly.  when  the  nodules  of  the  tumor  are  iiivisihle  until  aftei 
emicjealiori.    1  lit    if  anteriorly,    dark    and    hard    proinineni'es    m.iy 


seen  devi'lo|iiii):  ill  the  region    of    the  corneal  limliiis.     .\ 


soon 


-iircoiim  ..I  (.rlji  iMihii|liim',"tall.  ongiimli^.rf  in  ehoroiilul  itrowili;  tlnr'l  -Uue,    iAit  Kig.  Wi.t 


1-  ih"  neo|.l:t.sm  has  hrokeii  tliroiijih  the  envelop.'^  ..;  the  eyehall, 
'lir  i:ie;it  tension  and  eonseijuent  pain  usually  .-eases,  .1:  d  after  this 
III'  imiior  irrows  nipidly.  filliiif;  the  orbit  "with  proje.tiiif;  cauli- 
' 'un-like  excrescences.  (  Fi>;s.  L>()I  and  202.)  I'leeraiion  of  the 
ii|>erticial  portion  with  hemorrhajies  and  foul  di-(har>ie  then 
■rr\\v>.  The  neoplasm  may  extend  directly  into  the  iiei<;hl)oriii>r 
."!'  and  luain.  th<'  patient  dyinfr  of  septica'iiiia,  from  al)sor|)tioii 
'  th"  ne<'rntic  products,  from  hemoriiiajie  or  from  implication  of 
'><■  liraiii. 

I  he  lourtli  stasre  is  that  of  met.'ista.sis  and  jieiioralization  in  the 


i  lial   I  n 


Met 


:ans.  usually  the  liver.     (Figs.  JUA  and  L'()4. 


i-tasis 


hefiins  during  the  second  .'ind  third  st 


iipes.  and  a  diag- 


-I-  "I  internal  disease  cannot  usually  be  made  until  the  visceral 


3«2 


nil-:  KYK. 


,u,„ors  an-  sullici.-ntly  larj;.-  to  ho  anm-nut.-.l  l.y  imlputiun  and 
'"  S';n;!.u'ua  uf  tlu.  c-l.on.i.l  consist  of  eith.-r  nnnul  or  spi.ull..  <-.lls. 
and  usually  contain  niarv  wi.k  l.lo<.dv.;ss.>ls      As  lti«>  '''^\'  '    "  • 


the 

the  same  as  that  ol 


ri'oniuia  o 


FlO.  203. 


Vu;  ■•.»-  -Sart-oma  »f  orWt  inclu.iinR  e>-el«ll.  urmimUiuK  in  cl..,roi,ial 
Kro«lli-  third  si.ii;e.    ,Vu,m  i«tium  Bl.owii  m  l.g.an.i 


,,,,  th.   only   fonns   of   new   pnsvths   that    hav   been   reiu.rted  as 

ncciiirin"'  in  the  ciioroid.  ,  n     i ,  . 

Dui  and  Prognosis.     The  first  and  seeond  sta«..s  usually    a- 
„.n.e  or  four  vears.     Patients  die  in  the  tlnrd  sta«e    n,n,  •'xl';  •> 
:  ':;„.nsion  im.,  ,1.    l-rain.     'Phe  fourth  sta.e  .s  =''->>;;;';;';;'"' 
the  two  latter  >ta-es  usuallv  cuhnn.ate  ni  death  n.  about  a  }(ar. 
"'k      ona  aire..,s^,he  uveal  tra..  and  orbit  h.  .dnmt  -1-    1-   ^  ]. 
tions  of  UKdes  and  feniales.  the  average  a^'  l-u-K  forty-...irht  an^   m. 
al  years.    It  is  ..xtren.ely  rare  in  children,  so  that  a  niahRuant  p  o  v  t 
;.  oping  in  an  eyeball  would,  in  all  i.robab.hty,  U-  roRarded  as  •> 


insEASj-:s  OF  the  viioRoiit.  ^^^ 

-ilioiiia  in  a  child  and  a  sarrntna  in  an  adult.  Rcrurronrc  tal<cs  place 
in  alxint  S.N(>  per  cent.  In  primary  uv<-al  sarcciina  wiicrc  the  cychall 
IS  removed  early  the  priifrnosis  is  more  favorahle  than  when  a'risin.r 
HI  Ihe  orlut,  where  recurrence  takes  place  in  5S.()  per  cent.  Sarcomata 
ot  the  nis  and  ciliary  body  ix'have  in  respect  to  their  course  anil 
iihimate  outcome  like  those  of  the  choroid. 

Treatment,     llarly  enucleation  of  the  oveball,  in  which   the  optic 
nerve  is  cut  a.s  far  hack  a.s  possible,  is  the  treatment  of  the  iirst  stage 
II  the  neoplasm  has  affected  the  orl)it.  complete  exenteration— V  e 
ninoval  of  the  entire  contents  of  the  orbit— tofrcther  with  the  perio.s- 
teum    may    be  done    in    hojx's    to    prolong   life.     Kxposure   of   the 


Kl<i    201. 


Al>i{iminal  coiiir! 


sjirco;im  (»n(,'iimlinj;  in  i  In 


"ici.iiilury  KfiiHth  luick  nf  liver.    (Same  case  as  Fig. 


.  sht)\s  ingeiKjriiiuu.s 


■''"""■'I  .'"-bit  to  tl...  action  of  the  .r-rav  may  then  be  resorted  to  as 
'"  Ji'I'litional   s..eurity  against   recurrence.     Recurrence  and  .leath 

'\\i;\er,  usually  take  j.lace  within  two  vears.  but  a  very  small  i)ro- 
;.""""  "I  cases   being  cured    by  exenteration  and  x-rav  expo.sure 

'"'■   "7" '"    "f    "i''    l'""rtl.   stage,   wluTe   involvemen't    of   other 

";:h!^  h:is  uccnrre.l,  is  siniph-  palliation  of  the  patient's  .sutforing 

iniunes  of  the   Choroid.     I'cirirotin,/  wnumls   of  the   posterior 
"I""  "I  tlie  ey.'ball  involve  the  choroid:    tliev  are  likewise  accom- 

'i'i,.,l  by  injuries  to  tlu>  retina  and  vitreous.     If  clean,  thev  heal  bv 
"'I'l.'i  ti.-..M,e;    li  septic,  inflammatory  changes  result,  producing 

'■'"'■•"""Klilis  aiul  iianophthalmitis. 


it 


.•J84 


riij-:  EYE. 


Huiitiirc  iij  the  (Imroid.  Tliis  is  prnduccd  l)y  a  contusion,  usually 
liy  a  liluiit  iiistiuiiiciit :  sometimes  several,  but  jieiii-rally  only  one 
laeera  m  oecurs.  On  aecount  of  extravasation  of  blood  into  tiie 
vitreous  and  under  the  retina,  this  injury  is  not  usually  recojinizcd 
until  some  time  after  the  aecident,  when  healing  has  already  taken 
Jilaei'.  (I'late  \'II..  li.i  Then,  upon  ophtlialnioseopic  examination, 
a  white  streak  is  obserx'ed  over  which  the  retinal  vessels  run  without 
ch;in};i'  in  their-  Mirse;  theedjres  of  the  rent  are  ()bserve<l  to  be  colored 
by  proliferati'         '  the  pigment,  localized  detachment  or  rupture  of 

the  retina   is  jjenerally  jiresent.     Con- 
'•■"•■-'"■■'■  striction   of  the  visual    field    and    loss 

of  visual  acuity  occur  from  atrojihic 
chanfjes  in  llie  retina  and  o|>tic  nerve. 
Treatment  Treatment  of  this  con- 
dition is  absolute  rest  in  l)ed  for  a 
week  or  more,  to  reduce  the  liability 
of  hemorrhajie  and  retinal  detachment, 
and  instillation  of  atropine  to  quiet 
the  action  of  the  ciliary  muscle  and 
iris.  Imme<liatoly  after  the  accident 
saline  cathartics  may  be  j;iven  as  de- 
rivatives, and  iodide  of  potassium 
later,  to  .aid  in  the  absorption  of  clots 
or  exudates. 
Detachment  of  the  choroid  is  due  to 
subclioroidal  heinorrhase,  which  jjives  symptoms  of  j^laucoma  (one 
ot  the  so-called  forms  of  hemorrluifiic  glaucoma).  It  is  ;d)solutelv 
fatal  U)  vision.  This  is  one  of  the  results  of  sudden  relief  of  intra- 
ocular tension,  and  has  been  observed  as  an  unfortni  accident 
after  iridectomv.  made  in  fj;laucoma,  and  also  after  cat  extrac- 
tion. 

Treatment.      'I'iie  eyeball  usually  has  to  be  removed    in    order  to 
stop  the  henii)rrhaji;e  and  gvi\\{  pain. 


THE  VITREOUS  HUMOR. 

Anatomy  and  Physiology.     Macroscopic  Anatomy.     The  vitrcoii- 
(corpus  vitreum)  is  a  transi)arent,  colorless,  jrelatinoiis  mass  fillinL 
the  posterior  cavity  of  the  eye.     It  is  surrounded  ])osteriorly  an- 
laterally  by  the  optic  nerve  and  retina,  ard  anteriorly  hy  the  cilian 
body  and  ca|)sule  of  the  lens.     On  tin-  anterior  stn-face  there  is 
depression,  the  fossa  palellaris,  in  which  rests  the  posterior  surface  "' 
the  lens.     It  is  traversed  from  liehind  forward  by  the  hyaloid  can.i 
which  is  a  lymph  space  beginninji  at   the  p.apilla  and  exteiidiiifr  ' 
the  posterior  pole  of  the  lens.     DnriTig  fn't.'il  life  the  hva.loid  .'irter 
runs  in   this  can.al,   and  sometimes  persists.     The  vitreous   has  i: 
bloodvessels,  and  depends  for  its  initrition  upon   the  surround! i. 


Severe  siitKliurniiiul  hetnurrhage.  with 
ik-Uu'Iimeiit  iif  ehciroiM  and  retiiiu.  fol- 
liiMUii;  iniieetiHii.v  fur giauconitt.  tlMioto- 
KrHplicti  from  si>eciiueii.) 


THE  VlTIiEOVS  IIVMOR. 


385 


tis>  „..  par..rularly  tl,.-  uvea:  honce.  aff.Ttions  of  the  inner  nu-n.l.ranes 
ot  tlu"  ,>y(N  t!>,M-etn.a,  aiul  the  ehon.i.l  always  i,n,,lic.ate  tl.e  vitmi^ 

Microscopic  Anatomy.  Th,.  vitreou.  k  a  tralK.par.n  re  cX.' 
.-."nmnng  a  c  ear  I,  juid  .uh^tunce,  with  roumi  or  hranche  S 
whieh  are  mostly  h.un.l  in  the  out.-r  hiyer,  an.l  are  .supp,  id  t .  be 
nuftra.e.!  wlnte  blood  eorpaseles.  The  ext..r„al  e.nelo  i  is  ..rn,«l 
l.y  a  structureless  layer,  the  hyaloid  nieinbraiie 

liie  yitn'ous  serves  as  a  ineiiiun.  of  support   to  the  ocular  tunics 
|>resery,ng  the  sph.-ncal  sha,.e  of  the  eyeball,  and  as  a  clemmed    n 
P-.;.HUtu.K  tlu.  jmssafte  of  light  and  focusing  of  objects  u     no 

Diseases  of  tho  Viteeous. 

Congenital  Anomalies.  I'ern,te,H  Hyaloid  Artery.  Th(  hyaloid 
art.;ry  passes  fro„,  the  cei>tral  artery  of  the  retina  to  the  posterio 
>n.tac.j  „l  the  lens  occupying  the  canal  of  Cloquet  in  the  hyaL.id 
'-'■a! .  unng  l.etal  life,  shriyels  and  disappean.  about  the  sixth  month 
..prestation  but  occasionally  persists:  (.,  a  filamentous  stra 
^-  -l-'l  to  he  .hsk  or  to  the  lens,  the  free  end  floating  in  ihe 
Miie.M.s.  (,)  a  strand  passing  across  the  yitreous;  (c)  invgular 
■n..M,„.  bodies  upon  the  surface  of  the  ,lisk.  Its  yestigial  rein  a  ins 
:"<•  accountable  for  posterior  congenital  capsular  cataniet  There 
1--.  ns  a  rule,  no  def.rt  .,f  yision,  ..xcept  it  be  accompanied  by  opacity 
"I  I  lie  lens  or  other  congenital  anomaly.  '  ' 

Tlie  wall.s  of  the  canal  of  (-lo.iu.'t  an.'sometinu.s  sufheiently  o,,ac|ue 
Hniil'v"'''"  "Plithalmoscope  or  to  interfere  with  central  yisual 

Inflammatory  Diseases.     H,/aHHs.    Inflammation  of  the  yitreous 

|_  -M-yr  primary    but  accompanies  an.I  is  the  result  of  inflammation 

"  "'<•  "'I";.'!  Mild  th,.  uyeal  tract,     \ision  is  diminished  from  inter- 

•'•'■■;<•"  -itlj  the  function  of  ti.e  ret.  ,a.  and  also  by  disturbance  of 

'I'"  "i""m  du.>  to  punetat.   .spots  in  the  yitreous,  which  the  patient 

-.■<  as  llo.M ting  specks.     These  are  not  to  be  confoun.le.i  with  musc.T. 

It.    les.  which  are  a  normal  plu-nomenon,  being  due  to  th<.am<eboid 

'      ;',  i  l'"  '";■""■■•  "  '""'i  ""'  '■'''•"'•'>■  ■^*""  <'"t"l'i™llv  by  dosing 

■n    ..\  .1  In     .,.  la  ter  haye  some  error  of  refraction  which  shoul.l  be 

;;;■<;;!  w..l.  suitable  lenses.     A  flne.  dust-like  mist  occurring  in 

se  o.  choroiditLs  part.cuh.rly  of  th..  .syphiHtie  >-ariety,  can  be 

,       .     '  'V     •'"'',?",  \''  ^  '."'.'"'^  •^'"■'■'^^  ""•'  "'^"  ''V  the-ophthal- 

i    :      Vl  "  '"""'''  ''^™  ••',•'  l"""'t»t'i-     J"  another  form  of  the 

;  '    :  ,      '',T  "■''"  •'■•^  '"^"'"-'''^'^  "••  a«  "'">«♦<■  light-colored  spheres, 
'"  HjKi  nyaiitis.  ' 

"l.^niic.  in  (he  Vitreou..    These  are  either  fixed  or  moypble   and 

'   -condary  to  other  aflfections  of  the  ivtina  an.i  choroid.     Large 

"■'".Hies  may  form  as  the  result  of  hemorrhage  or  inflammation, 

2o 


386 


niK  EYE. 


and  arc  rcadilv  seen  bv  llic  oplitlialiiuiscuixv,  iiiipcdiun  visum  di- 
pciidiiifi  upon"  tlicir  hication.  (I'i-;.  -'(Hi.)  Tlic  oplitlialnioscoiM' 
oifcis  a  sure  inctlu.d  of  niakinj,'  tlic  diafiiuisis  it' tlu- nicdia  Ih' dear. 
A  convex  filass  of  from  :>  D.  to  1.")  D.  is  used  to  focus  tiic  various 
depths  of  the  fundus,  and  tlu'  i)aticnt  diivctc.l  to  rotate  tiie  eye.  l)y 
wliich  tiie  opacities  niav  i)e  l)roujil.t  into  view,  and  tiieir  dei>tli  dis- 
covered hv  the  strength  of  the  focusing  fjiass,  and  their  i)arahictic 


KlQ.  JOfi. 


Striii  rvtiiiic  t:  ■.in'iiibmiu-  vilreii'  ei  chomiililis  cxmhuiva. 


nioveineiits.  Ilifiii  defirees  of  inyojiia  predispose  to  (h-generations  <il 
tiie  ocular  contents,  and  usually  are  attende.l  l)y  nieini>ranes  or  opaci- 
ties hi  the  vitreous.  Tiie  several  diath(>ses  and  fteneral  di.seases  ftiviiifr 
rise  to  di.seases  of  the  retina  and  choroid  are  likewise  prone  to  develop 
vitreal  opacities.  .... 

Treatment.  The  treatment  of  hyalitis  and  opacities  m  the  vit- 
reous should  he  that  of  the  cau.se,  if  such  can  be  ascertained.  Altera- 
tives, such  as  mercury  and  potassium  iodide  are  sometimes  us(>tul. 
Irrefiularities  of  tlu-  menstrual  function,  disorders  of  the  liver,  etc.. 
<liould  be  treated:  diaphoresis  with  pilocarpine  (0.01  gm.  liyp(.(lei- 
mically)  once  a  dav,  followed  by  a  hot  fieiieral  bath,  is  somemiH- 
useful!     I'lrrors  of  refracti(m  and"  bad  ocular  or  bodily  habits  should! 

be  corrected.  •  c  ,i 

Hiinliiis  Siippiiriilira.     This    is  an  infective  inflanimation  ot  tii 
vitr  ous  c.HUsed  bv  entr.-uice  of  i)yogenic  micro-organisms.     It  is  -.^ 
ace,  npanimi'iit  of  iridochoroiditis,   and  has  been   described   uiul  r 
that  heading. 


Tilt:  VITHEOVm  Ill'MOR.  3^7 

iWudouliowa.  A  circuiMsciilM.,!  .suppuration  <,r  plastic  inHaiutna- 
tioi.  u  tiu'  vitn...us  may  .ktui-  in  tlu^  p.-npL.Ty  „f  the  d.anii«.r  near 
Uic  ciliaiy  .vfiion,  bcinf;  du.'  to  exudation  from  tlic  ciliarv  bodv  and 
1,.  accompanied  by  loss  of  vision  and  minus  tension.  On  .■.ccount  of 
tli..  yeilowisl,  reHe.x  from  ti.e  pupil,  sud.  cases  have  l.een  n:istaken 
tor  true  lilumiii  of  tlie  retina,  hut  the  evid.'i.ces  of  a  K<-neraI  uveitis 
and  the  decreased  tension  should  ^ive  the  proper  diapiosis 

lih,.„lrcs.scl  Fonnution  i„  l/„-  Vilrc.us.  After  inflan.niati<.n  or 
h|'ninrrhaKe  mto  the  vitreous,  organization  and  develoj.ment  of 
i.lo.,.  ves.seis  may  take  place,  forndnf,'  a  veil  of  freelv  cominunicatuiK 
capillaries  haying  scH^mingly  no  connection  with  the  hloodves.sels  of 
the  ictma.  1  hese  interfere  with  vision,  dei)ending  uj.on  the  .•.mount 
and  their  po.sition. 

Degenerations  of  the  Vitreous.  Sywhms  Corporis  Vitrei  Flmditi, 
n/  thr_  \  ,lm,us.  The  vitreous  being  dependent  upon  tiio  retina  and 
'li'irnid  lor  Its  nutrition,  .luring  the  progress  and  as  t!ie  result  of 
dis..a.ses  ..»  the.s,Mneinbranes,  and  in  high  degrees  of  mvopia,  degen- 
"lalion  ol  ti.e  vitreous  occurs,  ,so  that  its  framework 'is  destioved 
Insing  Its  normal  con.si.stency  and  becc.ming  a  straw-lik<-  li,|uid  There 
air  likewise, h.nmished  teiisioiK hyj.otoiiy  1  and  frequenllva  tri^nulous 
Ills  ini,loi...sis),  an.!  occasionally  a  luxated  lens.  This'  (•< -idition  is 
a  II1..SI  unfavorable  factor  for  restoration  of  vision  by  cataract  ex«rac- 
tUMi.      treatment  is  of  no  avail. 

Sfixchisix  Scinlillans.  Chohsteriu  Crystals  in  the  Vitremis  These 
•in.  api.ar..nt  to  the  pati.-nt  by  fla.shing  sparks  before  the  .-ves 
.•md  t,.  the  ophthalmoscope  by  numerous  gli.stening  crAstals  r.'flectlng 
lie  light  from  the  ophthalino^-coi.e  in  the  for:n  of  a  .shower  of  sparks 
Ih.y  are  compo.s,Ml  of  r  ,te  crystals  of  cholesterin  and  tvrosin,' 
.md  Jh.'  ophthalmoscopic  j.icture  is  very  brilliant  and  interesting  As 
I  us  happens  in  ..yes  that  are  more  or  less  degenerated  in  oth.-r  respects 
til.'  vision  ,s  r..,luce.l.  Th.>  con.lition  d.,es  not  vi.'ld  to  treatment  ' 
I- alt,,  Ikycmratwn  of  the  Vitreous.  In  this  c..nditi..n  there  are 
niiwa.  vohlanles,  an.l  the  ophthalm..scope  shows  numerous  white 
di-t.'iimg  spots  evenly  distributed  through  the  vitreous.  Th<.  vision 
N  -liglitiv  reduc.-.l:  but  as  this  is  an  evi.lence  of  senile  decav  there 
i-  no  m.fication  f.)r  special  treatment  '  ' 

iMarhment  af  the  Vitreous.     The    vitreous    mav  shrink  in  volume 

I'm,  ,|..gen.>rative  c!iang(>s,  an.l  the  n-tina  thus"  lo.sing  its  .support 

':"'">>i<'s  .l.;ta<-h..l.    It  may  arise  from  choroiditis,  hemorrhag..  exten- 

:nv  post.-n<,r  staphyloma,  and  trauma.     If  the  ."ve  does  not  become 

'■'"■I'll..,!,  then;  IS  no  occa.sion  for  treatment.     If  "congestion,  imin   or 

uiil'atlietic  .hsease  set  in,  the  eve  mav  be  enucleated 

In]unes  of  the  Vitreous.    Loss  of  Vitreous.    Prolapse  of  the  vitreous 

"I" -■as  an  unf.)rtunate  occurrence  in  pen(>tratiiig  wounds  of  the 

^'•'.•111.  especially  m  ratar.ict  extraction,  an.l  about  nne-fifth  of  the 

I'pyus  may  be  lost   without  materially  affecting  the  functi..n  of 

|;i"n,  as  the  ..nvelopes  of  the  eye  accommodate  themselves  some- 

'^t  to  their  diinmished  contents. 


388 


THE  EYE. 


Treatment.  If  due  to  penetrating  wounds  of  the  sclera,  the  bead 
of  vitreous  may  Im!  cut  off,  the  wound  stitdied,  and  the  eye  treated 
antiscptically;  if  occurring  during  cataract  extraction,  the  toilet 
of  the  anterior  chamber  eaimot  be  jus  rigidly  made,  and  iris  prolapses 
cannot  always  be  replaced.  The  extruding  vitrcoas  should  be  snipped 
off,  the  eye  closed,  and  disturbed  as  little  as  possible  in  the  dressings. 
The  extruiled  vitreous  retracts  somewhat,  and,  if  it  does  not  become 
infecteil,  the  wound  heals,  but  union  is  delayed. 

Heimrrluu/e  into  the  Vitreous.  This  follows  rujjture  of  the  vessels 
of  the  retina  or  choroid,  most  probably  the  latter,  cau.siiig  loss  of 
vision  depending  upon  the  retinal  and  choroidal  lesion  and  upon 
the  amount  of  bieeding.  Spontaneous  hemorrhage  may  occur  in 
young  adults  who  have  irregularities  of  circulation  and  gout.  As  a 
rule,  these  are  not  entirely  absorbed,  but  leave  opacities  in  the 
vitreous,  damaging  the  vision  if  centrally  located.  If  the  hemorrhage 
be  extensive,  the  sight  is  immediately  lost,  and  fundus  examination 
IS  impossible.  The  blood  becomes  absorbed,  leaving  numerous  fixed 
or  floating  opacities.     (Figs.  207  and  208.) 


Fia.  207. 


Fio.  208. 


no.  207.- Recent  hemorrhage  and  exudation  Into  vttreoun,  following  penetrating  wound  of  clUan- 
region.    (I'hotogmphei'  from  speclruen.) 

Fiu.  208.-Organlzed  eiudation  and  membranes  In  vitreous,  following  iridocyclitlB  from  pene- 
trating wound  of  ciliary  region,    (Photographed  fro.u  specimen.) 


Treatment.  Mercurial  jjreparations,  iodide  of  potassium,  pilocarpine, 
saline  mineral  waters,  ergot,  artificial  leech  on  the  mastoid,  and,  for 
the  first  day  or  two,  cold  applications,  followed  later  by  hot  coni- 
|)ressing. 

Entozoa  in  the  Vitreous.  The  scolex  of  pork  measles,  Cysticercu.x 
cellulosu',  and  of  beef  measles,  cysticercus  of  Tirnia  mediocanellata. 
have  been  occiusionally  found  in  the  eye,  more  fr«iuentlv  in  (iermanv, 
where   it   is    customary  to  eat  unc(K)ked   or  improperly  prepare.! 

To  acquire  this  complaint,  the  patient  must  first  develop  a  tape- 
worm in  the  intestinal  tract ;  the  egg  entering  the  general  circulation. 
IS  carried  to  the  eye,  and  grows  therein  as  a  cysticercus.  It  is  mo.<' 
commonly  recognized  after  it  enters  the  vitreous,  being  usualh 
first  deposited  under  the  retina.    The  Filaria  sanguinis  hominis  an^' 


THE  VITRKOVS  IIVMOR. 


389 


tlio  ochinococcus  (the  youthful  stage  of  the  tapeworm  in  the  dog) 
liav(  likewise  been  found,  hut  arc  of  more  rare  occurrence. 

Treatment.  Propiiyhixis  is  most  important.  Food  should  be  well 
(■(.oked,  and  i)et  animals  not  allowed  to  lick  the  hands.  Attempts 
liave  been  made  to  extract  cysticerci  from  the  vitreous,  but  none  as 
.\-et  have  resulted  in  restoration  of  vision;  enucleation  of  the  eyeball 
is  therefore  indicated. 


CHAPTER    VITI. 


SYMl'ATHhyriC  OPIITIFALMJA. 

Hy  H.  GIKFOHI),  M.l). 

When  an  eye  is  painful  di-  irritated  from  any  cau-  >,  it  is  liable 
to  set  up  a  syinpath(>tic  irritation  in  the  other  eye,  the  symptoms 
consisting  i.i  more  or  less  photophobia  and  lacrymation,  sometimes 
with  slight  ciliary  congestion,  or  shnj)lv  in  an  inability  to  use  the 
eye  steailily  either  for  near  or  distant  vision.  This  sympathetic  irri- 
tation must  be  sharply  distinguished  from  sympathetic  oi)hthalmia. 
It  may,  and  freciuently  does,  exist  for  many  years  without  any  jkt- 
manent  injury  therefrom,  and  it  disappears  promptly  wlien  the 
other  eye  or  the  source  of  irritation  in  it  is  removed.  This  irritation 
IS  simi)ly  a  reHex  from  one  eye  to  the  vasomotors  of  the  other,  and 
although  in  former  yeai-s  it  was  believed  that  such  reflexes  could 
cause  plastic  inflanmiation,  and  a  certain  amount  of  experimental 
evidence  was  produced  in  favor  of  th(>  itlea,  it  is  now  generally  con- 
ceded that  reflex  irntati,.n,  if  it  acts  at  all  in  the  production  of  a 
genuine  inflammation,  c;:>i  ilo  so  only  as  a  i)re(lisp.)sing  cause,  the 
presence  of  some  chemical  irritant,  generally  jjroduced  by  micro- 
orgamsms  of  some  kind,  being  necessarj-  to  comjjlete  the  proces.s. 

Sympathetic  ophthalmia  is  a  plastic  inflammation,  generallv  in- 
volving the  whole  uveal  tract,  occurring  in  the  vast  majoritv  of 
cases  alter  a  penetrating  wound  of  the  other  eve.     It  matters' not 
how   extensive   a   woun.l    may   be.  if   it  heals"  promptly,   without 
symptoms   of  infection,   sympathetic   ophthalmia   rarely  or    never 
r.>sults  from  it.     But  however  slight  the  wound,  if  it  is  followed 
hy  a  lingeriiifr     „igestion  and  irritation,  the  possibility  of  sympa- 
thetic  ophtli.ilmia   must    be   taken   into   account.      On   the  other 
hand    wlHTe  an  eye  is  severely  injured,  without  anv  penetrating 
wound   long-contmued  cong<>stion  is  .,uite  common,  but  svmnathetic 
ophthalmia  ran-ly  n-sults.     A  few  cases  are  on  record  where  it  has 
followe.1  subconjunctival   ruptures  of   »he  sclera,  with  or  ^vithout 
luxation  of  the  lens  under  the  conjunctiva,  also  rarelv  as  the  result 
of  ossihcation  o    the  choroid,  and.  rarest  of  all,   from  traumatic 
detachment  <.    th,.  retma     A  perforating  corneal  ulcer  .sometim.'s 
causes  sympathetic  ophthalmia,  most  commonly  where  a  large  defect 
hii.s  been  pn.duced,  with  subse,,uent  entangl..ment  of  iris  tissue  in 
he  scar.     Tattooing  .such  sc,,rs  has  also  r..,use,l  svmpathetic  o})h- 
thalnua     A  great  number  of  other  cau.s.'s  of  .sym,,athetic  ophthalmia 
which  have  been  described  are    the  result  mainly  of  the  want  of 


arMJ'A  niETiv  oj'jitjialmia. 


391 


iH'twtrn  !syiii|)atliclic   oplitlialriiia   and   syiiipatlictic 


Wiscriniiiiatioii 
irritation. 

licfoic  tiio  role  played  by  iiiicro-ornaiiisms  in  the  pioductioii  of 
inllainMiati(»ii  was  understood,  it  was  natural  that  the  ciliary  nerve 
llieory  of  von  tiraefe,  according  to  which  syin|)ythetic  o[)h'tiialniia 
IS  simply  the  result  of  the  reHex  irritation  from  one  eye  to  the  other, 
should  generally  be  accejjted.     It  was  also  naturaf  that  with  the 
ailvent   of    bacteriology   the  almost  (onstant   connection   between 
sympathetic  ophthalmia  and  pem'trati.ig  wouikis   of  the  eye  should 
.-UKgest  that  micro-organisms  were    the  cause  of   the  disease,  and, 
alter  the  ai)parently  convincing  experiments  of  Deutschmann,  which 
seemed  to  (leincjnstrate  the  easy  i)assage  of  bacteria  from  the  interior 
oi  a  wound.'d  eye  along  the  sheaths  and  lymph  spaces  of  the  optic 
nerve  to  tlu;  chiasm,  and  thence  down  between  the  sheaths  of  the 
other  optic  nerve  to  the  fellow  eye,  this  view  raj)idlv  displacetl  the 
ciliary  nerve  theory.     These  experiments,  however,  did  not  receive 
^'.iieial  conhrmation.     The  great   majority   of  subswjuent   investi- 
jlMtoi-s  failed  to  produce  anything   like   sympathetic  ophthalmia  in 
annuals,  and  it  is  only  i-  excej)tional  cases  that  micro-organisms 
lia\c  been  found  in  eyes  which  have  bwii  enucleated  on  account  of 
causing  sympathetic  ophthalm.a.     Nevertheless,  it  is  commonly  con- 
ceded that  such  well-marked  inflammation  as  that  which  usually 
occurs  in  sympathetic   oi)htlialmia  can  hardly  result  from  anything 
liul  the  growth  of  micro-organisms  which  reach  the  second  eye  from 
!li<'  first,  either  through  the  lymph  or  blood  channels,  the  congestion 
c.cuscd  by  the  symjiathetic  irritation  jjossibly  causing  a  focus  of 
lessened  resistance  in  the  second  eye,  thus  favoring  the  lodgement 
and  growth  of  germs  therein.    The  most  ardent  advocates  of  the 
■.'crm  theory  of  the  di.sea.se  admit,  on  their  part,  that  the  nature  of 
tlie  germ  which  caases  the  disease,  and  the  path  which  it  takes  in 
icMciimg  the  .seconil  eye,  are  as  yet  unknown,  although  the  free 
cnmmiimcation  between   the  eyes  by  way  of  the  lymph  spaces  sur- 
loniHling  the  optic    nerves  suggests  this  as  the  easiest  and  most 
probable  route,  the  main  objection  to  it  being  the  non-occurrence 
ol  serious  brain  symptoms  in  sympathetic  ophthalmia.     These  would 
ii.iiiiraily  be  expected  if  the  germs  have  to  pass  through  the  cranial 
'"ivity  on  the  way  to  the  second  eye.    This  objection  is  met,  to 
-.111.'  ext<-nt,  by  the  suggestion  that  there  is  probably  only  a  very 
-lender  stream  of  germs  passing  from  the  first  eye  to  the  second, 
iiid  that  the.se  may  |)roduce  serious  symptoms  onlv  where  they  accu- 
Miulate  111  the  terminal  lymph  spaces  of  the  .second  eve.    It  has, 
moreover,  been  noted  ihat  quite  severe  headache  is  not  an  infrequent 
"•••"ini'amnient   of  syiiii)athetic  ophthalmia,  and,  in  a  few  cases, 
'he  victims  of  the  disease  have  iK'come  deaf  as  well  as  blind. 

I  li«'  rare  cases    in  which  sympathetic  ophthalmia  has  followed 

'^'Conjunctival  rupture  of  the  sclera,  intra-ocular  tumors,  and  other 

I'liclitions  in  which  the  eyeball  has  apparently  not  been  opened  for 

:  !<•  entrance  of  the  germs,  call  for  some  explanation.     They  all  have 


392 

lliis  in  coininoii, 


Tilt:  EYK. 


tlmt  the  cxcitiiiK  eve,  a 


It  hough  wifht.iit  iipimrontl 


I,  is  the  scat  of  an  activ  iiitlainination,  pro 


l)al.l\ 


of  an  inlVrtious  .•harart-r.  th-  pT.ns  in  th.-  .ascs  of  •^\''''7'J"'';-  ^ 
rupture  prol.al.lv  havinjj  ..l.tainc.l  ."ntran.r  through  nunut,'  ruptuns 
of'tlH.  conjunc-tiva,  while  in  th-  nis.'s  fron.  n,tra-..cular  tun.urs  an. 
ossihcatiot,  of  the  fh..roi,l  the  inf.rtion  ol  the  .rst  .v.-  is  prol.ahlj 
Either  fron,  the  l.lood,  ..r  is  a  vival  of  s...n..  ol.l  u.t.rtion.  n...st  of 
the  ."VOrt  with  ossification  havint;  Iwi-n  u.J'in-'l  inany  yrars  i..'l(.ri. 
\  >infilar  .'Xi.lanati..n  applies  to  the  eases  in  whu-h  a  sightles.  stun.p 
n-uuiin-s  ..uiet  an.l  harmless  f..r  many  years  alter  th.^  oriKU.al  u.jury, 
but  l.ee..n,es  inHamed  an.l  excites  sympathetic  ophthalmia  upon  re- 
c..iving  a  l.ruisc",  or  whet,  the  ,.atient  catches  col.l  or  luu.  some  genera 
inf..cti..n.    Ca8i-8  of  this  kind  have  been  reported  after  n.easl.'s  an.l 

"'Formerly  much  str.^ss  was  lai.l  up..n  the  s,K.cial  ilanger  ..f  w..uni|s 
in  the  ciliary  region,  an.l  this  was  sui.pos.'.!  to  give  «np,.rtant  t.-sti- 
n..ny  in  fav..r  of  the  ciliary  n..rve  th.-ory.  (Irantmg  th<"  prenus«v 
it  .-an  be  explaine.l  in..re  satisfactorily  on  th.>  germ  th.n.'y  .Sucli 
w..unds  are  among  the  c<>nun..nest  ..f  penetrating  mjunes:  th.-y  are 
c.n.plicat.-d  gen.-rally  with  pn.lapsos  of  iris  or  clu.n.ulal  tissue,  which 
■ire  ,vell-recogniz.-d  fact..rs  in  favoring  en.L.cular  mfectu.u,  and, 
Hnallv  they  lea.l  into  the  soft  tissue  of  the  ciliary  b.).ly  which  hits 
be.-n 'found  to  be  an  especially  favorabU-  I  nrding-gniund  for  van..us 

'^*The<lictum  lai.l  <lown  years  ago.  that  .'y<'s  iu  which  panoi.hthal- 
mitis  has  develope.l  never  cause  sympathetic  ophthalmia,  has  been 
slu.wn  t..  be  inc.rrcct,  alth..ugh  it  is  pn.bable  that  symi-ath.-tic 
..nhthalniia  is  less  c..mm..n  after  a  violent  .lestructive  infianimation 
than  aftfr  a  mil.ler  and  more  chn.nic  torm,  this  IxMiig  .hi.'  probably, 
in  part,  to  bl..cking  up  an.l  d.-struction  ..f  the  lymph  chann.'ls 
leading  from  the  ove,  and  possibly,  also,  to  .lestruction  of  the 
hvpoth.-tical  germ  ..f  sympathetic  ophthalmia  by  the  rapi.l  growth 
,.f  the  pus  germs  whicli  an-  generally  toun.l  in  these  ca.ses. 

Rogardiiig  the  length  of  tim.-  which  elapses  between  the  origma 
injury  an.l  the  <.utbr.>ak  ..f  symj-athetic  .,i)hthalmia,  it  may  be  said 
that  the  nu.st  danger.ms  perio.l  is  from  thr.r  to  eight  weeks  after 
the  injurv,  alth..ugh  a  few  .loubtful  cases  liave  been  reporte.l  within 
from  <.iu'"to  two  weeks  after  th.«  injury,  an.l  s..me  well-authenticat.>.l 
on.-s  as  earlv  as  two  w.>eks  th.'reafter.  At  the  othiT  en.l  of  the  seal." 
there  is  n..' time  limit:  ca.ses  have  .iccurre.1  forty  years  after  tl«- 
original  injury,  although  always  in  the  well-authenticated  cases  after 
a  recrudes.-.'nce  of  an  .>ld  inHammati..n. 

Symptoms.  Where  the  patient  is  ol.l  an.l  intelligent  enough  to 
give  ac'urate  testimony,  the  first  symptom  of  synii)athetic  ..ph- 
tlialmia  in  most,  if  n<.t  all  ca.ses,  is  a  slight  failure  of  vi.si.m.  Alm...st 
oinci.lent  with  this  there  occur  very  slight  signs  of  m.-ii.u-nt  inti:^ 
in  th.'  form  of  ciliarv  congestion  (hardly  noticeable  in  s..me  ciisesi, 
with  minute  spot.s  of  dep..8it  ..n  the  p..sterior  suJ-face  of  the  cornea 


T^TaaBT" 


rmsm 


^'siBnn^mfmm^^'^t&M 


SYMI'A  TIIETIC  OVIITUALMIA. 


303 


III  the  aiitcriiir  surfan-  of  tin-  lens,  thcw  latter  Ix-iiiR  lianlly  visihlo 
t\(i|it  l>y  strong  iiiaftiiiticatiori.  Tlicn,  in  tlic  scvcriT  cases,  follow 
i;i|ii(lly  adhesions  Wetween  the  iris  ami  lens  eapsuie,  inerease  of  eiliarv 
coiijjestioii,  turbidity  of  the  a(|ueous,  discoloration  of  the  iri«;  in  short, 
•ill  the  symptoms  of  plastic  iritis,  and,  in  rare  cases,  hypopyon. 
The  indications  of  sympathetic  irritati(m,  photophobia,  and  so  forth, 
which  were  formerly  much  relied  uiM)n  as  warnings  of  the  ajiproach 
of  sympathetic  ophthalmia,  a.  ;;enerally  conspicuous  by  their  absence, 
and  the  pain  is  seldom  j?reat,  except  in  the  later  stapes.  In  the  few 
cases  which  have  been  seen  sufficiently  early  to  jK-rmit  a  careful  exain- 
mation  of  the  fundus,  slight  optic  neuritis  has  often  been  si-en,  and 
ill  some  ciises  the  main  symptom  of  the  ilis«'ase  has  h-en  a  well- 
marked  inflammation  of  the  optic  disk.  H  it  ordinarily  the  vitreous 
hccomes  turbid  so  rapidly  that  the  fundui  is  never  distinctly  seen. 
Ill  a  few  eyes  which  have  cleared  up  after  severe  sympathetic  oph- 
ihalmia,  small  roundish  spots  of  choroidal  atrophy  have  been  noted 
by  different  observers.  All  grades  of  severity  of  the  iiiHanimation 
■  iccur;  in  some  casi>s  it  never  goes  Ix-yc  'd  what  would  be  called  a 
mild  serous  iritis,  and  yielils  readily  tu  appropriate  treatment.  These 
mild  cases  are,  unfortunately,  exceptional;  as  a  rule,  in  sjnte  of  all 
tiviitmeiit,  the  ilis«'ase  progresses  steadily,  the  iris,  in  spite  of  un- 
limited atropine,  becoming  adhen-nt  to  the  lens,  often  not  only  at  the 
|iiipil-margin.  but  over  the  greater  part  of  its  posterior  surface.  The 
I  iliary  congestion  continues  for  months  or  at  intervals  for  years, 
I  lie  nutrition  of  the  lens  Ix'ing  interfered  with  to  such  an  extent 
iliat  it  generally  becomes  opaque;  and,  while  some  eyes  go  through 
a  stage  of  secondary  [glaucoma,  the  end  in  the  majority  is  a  mild 
loriii  of  i)hthisis.  There  is  nothing  about  the  appearance  of  the 
I  ye,  ill  .sympathetic  ophthalmia,  to  distinguish  it  from  any  severe 
iiidocyelitis,  although,  since  we  fjerhaps  see  more  eyes  that  have 
linii  blinded  by  sympathetic  ojjhthaimia  than  by  any  other  form 

it  plastic  uveitis,  the  atroj)hic  di.scolored  iris,  the  shallow  anterior 
iliaiiiber.  and  the  grayi.sh  immovable  j)upil,  which  result  from  any 
>c\(rc  and  long-continued  inflammation  of  the  uveal  tract,  become 
a>sciciat<'d  in  our  minds  with  sympathetic  ophthalmia. 

Pathology.    Comparatively  few  such  eyes  have  l)een  examined  with 
'1h'  microscope,  the  bulk  of  what  has  been  written  about  the  i)ath- 

'I'ljry  of  .sympathetic  ophthalmia  referring  to  t^'>  eye  which  has 
'  aiis<"d  the  inflammation,  and  not  to  the  sympathizmg  eye.  In  those 
\'liich  have  been  recorded,  the  entire  uveal  tract  has  been  found  to 
'"   Mie  seat  of  an  active  inflammation,  with  numerous  accumulations 

■I   li'ucocytes  such  iis,  in  a  progressive  inflammation,  pathologists 

'"  liive  to  indicate  the  pn>sence  of  micro-organisms,  the  same  extend- 

ir  lor  .-iome  distance  back  into  the  optic  nerve  and  its  sheaths.     In 

■   lew  cases  in  which  both  eyes  have  l>een  obtained  from  the  same 

'j-'-?  the   changes  have  been  strikingly  similar  in  each  eye.     One 

iliese  presented  the  unusual  occurrence  of  so  large  a  number  of 

lit  ceils  both  in  the  uveal  tracts  and  in  the  optic  nerves  that 


3i»4 


Tilt:  i:ye. 


(limed.     >''^t    ■'    '".'"r  '      "     1  ..-n        n    „.  ,.„„sul.ml 

..V,.  witl.  svMM-to.ns  of  inf.-ct.oM  wl.ir  .  Im.  _  •        'f  ';';..,  ,„, 

i::r;;r;  "\ ;;  ;;:.l;.t;;:,:;;\:  ;^;n.nt.  it  s..ou.a  '.<• -p.ain..i  ;;^t . 

V    .  i,U  rpl.tiv.-^  tint  tlxTi'  is  some  danp'r  whicii  can  oi  U  Ix 
'v'l'iol'wih  S,    ^  M..^    .Ttainty  ».y  sacrificing  the  injuml  ey.^ 
,;    i^   u        V    in,     .  assume  the  flight  risl<,  the  operation  need  no 
liut  II  in  i>  "1111"^  I  Tl,,.,,  if  flw>  «viiii)tonis  of  nitec- 


■  lij. 


SYMIWTIIETK'  nl'lirilM.MlA. 


a!ir> 


ciihiimic.  Ill  tlic  <'iisi'  ut  l)liiul  t'Vcs  wliicli  arc  entirely  free  fniu 
>\iii|il(iiiis  uf  (|ee|)  iiil'eeliini,  no  interference  is  called  for,  in  my 
opinion,  excepl  for  cosmetic  purposi's:  l)ut  in  the  cjise  of  a  sijrlitless 
eye  wliicli  is  the  seat  of  ri'current  deep-.'^eated  intiammation,  liie 
jiatii-nt  >liould  Iw  warned  of  the  possiliility  of  danger,  and  eviscera- 
liiiM  advised  even  if  the  lilindness  was  lot  originally  caused  iiy  an 
Mijiiry.  In  ailvisinj;  the  |talient  of  the  ilan^er  of  sym|iathetic  oph- 
llialniia,  fjreat  emphasis  shoulil  !«•  laid  upon  the  fact  that  it  comes, 
M>  a  rule,  without  warnin>{,  and  tiiat  aftt-r  it  once  apjK'ars  all 
inaliiieiit  may  Ih-  in  vain;  and  in  watching  for  its  ap|)eai.ince 
physician  and  p;itient  should  pay  .special  attention  to  the  slightest 
iliiniiiuiion  of  sight,  daily  tests  under  uniform  condition.s  of  illumina- 
tion lieing  made.  As  a  purely  prophylactic  measure  I  always  prefer 
evisceration  to  any  other  operati()n. 

Ii  >liould  Ik-  unih-rstood  that  neither  opticociliary  neurectomy,  nor 
evisceration,  nor  enucleation  is  an  absolute  protection  .'igainst  sym- 
p.iihetic  ophthalmia.  The  disea.s<'  has  iK'en  known  to  <iccur  after 
all  (il  these  Operations,  apix'aring  after  a  period  varying  from  one 
III  tifly-four  days  sul)s<'(|uent  to  the  operation.  Some  of  these  after- 
ciM  >  aiv  diliicult  to  explain  u])on  any  theory,  hut  they  arc  prohalily 
due  Id  tlie  infection  having  spread  for  some  distance  bat  I.  ot  the 
rye  before  the  Operation  was  performed.  When  .sympatheiic  oph- 
iliahnia  has  alre.idy  apix'ared,  the  tri'atment  varies  according  to  the 
.iiiiiuuit  of  sight  in  the  other  eye  anil  the  length  of  time  which  has 
il:i|ised  since  tile  first  symptoms.  If  seen  within  a  day  or  two  after 
ilie  iiist  oii.set  of  the  di.sea.se,  I  should  advi.se  immediate  enucleation 
"I  ilie  other  eye,  even  if  it  has  u.seful  sight.  Hut  if  not  .seen  for 
X  vir.il  d.iys  or  weeks  after  the  first  symptoms,  and  the  first  eye 
|"'»ess  fair  sight  or  has  a  prosjx'ct  of  obt.-iining  it  by  a  cataract 
I  \ii;i(t'">n  or  some  other  op^-ration,    it   is   probably   better  not    to 


Mf      it,- 


ilice  it;   but  if  it  have  only  a  little  sight,  and  tin 


re  IS  no  prospect 


■ver  having  more  than  enough  barely  to  allow  the  patient  to 
L'li  amund,  I  should  sacrifice  it,  even  in  the  later  stages  of  the  dis- 
iH',  if  the  second  eye  still  had  the  better  .sight  of  the  two.  In  this 
I  iliitcr  from  the  majority  of  writers,  who  follow  the  rule  never  to 
iiiiiie;;t(>  .iftcr  all  outbie.ik  of  sympathetic  oiilithahnia,  if  the  hrst 
VI'  ||;ivc  (ir  can  have  useful  sight.  My  reason  for  this  is  that  the 
i:ilisti(s  iiiilicate  as  plainly  as  possible  that  the  second  eye  !ia.-.  a 
Iter  chance  when  the  first  is  enucleated,  even  lone  after  the  out- 


Ihe  (1 


isease.     The  case  often  cited  in  which,  where  an  e 


nu- 


iiiiiii  was  recommended  and  refu.sed,  the  coiulemiied  eye  retained 
!iil  >iglit  while  the  other  lu'canie  entirely  blind,  should  have  little 
au.^e  if  the  enucleation   had   !>een  consented  to,  it  might 
I  veil  much  better  sight  in  the  second  eye  than  eventually  was 


I'jiii, 


d  liy  the  first.     The  effect  of 


lueleati 


in!!:'.!! 


d 


s  sometimes  so 
iften  showing  mo'^-t  rs-nrkeii  jinpro'.-c- 
'1'  oil  the  day  following  the  enucleation,  that  it  s«'ems  probalile 
''  tlie  first  eye  exercises  a  constant  influence  on  the  inflammation 


396 

in  the  socoik 

(It  luis  l)et>n  shown 


TJII-:  KYE. 


I  oithor  1)V  roflox  irritation  or  by  the  passapc  of  toxin 


(•(inclusivciv  ni  ral)l)its  that  toxins  re 


iidily  pi! 


from  one  ov(>  t(.  the  oth«'r,  causnin  tnarkc.l  inflannnation  there  witli- 
out  any  (Iwide.!  meningitis  or  general  .hsturbaJice.)  Tins  su(  <len 
improvement  following  emirleation  is,  to  be  sure,  generally  of  short 
duration  in  s<>vere  cases.  l)ut  in  the  long  run  the  comparison  of  a 
series  of  cases  in  which  enucleation  has  been  ]M>rformed  with  another 
in  which  it  has  not,  sjx-aks  plainly  in  favor  of  the  operation.  Knu- 
deation  is  n'conimended  here  in  place  of  any  other  oiwration,  because 
it  takes  out  more  of  the  infected  tissue,  especially  if  the  iK-rve  is 
cut  far  back,  as  it  should  be  in  such  cases.  It  is  not  certain  that 
enucl(>ation  giv(>s  better  results  than  evisceration  would,  but  where 
the  outlook  is  so  bad  at  the  best,  cosmetic  considerations,  which 
are  the  main  argument  in  favor  of  evisceration,  shou'd  have  no 
weight  as  against  even  a  theoretical  argument  in  favor  of  something 

else* 

Treatment  other  than  surgical  should  consist  in  rest,  the  free  use 
of  atroi)ine,  and  large  doses  of  salicylate  of  sodium,  mercury,  lodulo 
of  potassium,  or  (luinine.     I  mention  the    .salicylate  first  Ix'cause  it 
is  the  only  remedy  which  I  have  known  to  exert  a  marked  effect 
upon  a  severe  case"  of  sym{)athetic  ophthalmia.     In  two  very  severe 
cases  in  which  I  have  us(mI  it  normal  vision  was  restored  in  one,  and 
liseful  vision  in  the  other,  while  in  a  third   case,  well  marked  but 
not  so  severe,  normal  vision  was  n-stored.     By  large  doses  I  mean 
10  to  i;i  grains  in  the  course  of  sixteen  to  eighteen    hours  for  each 
ten  pounds  of  the  patient's  weight.    That  is,  a  man  of  150  i)ounds 
would  receive  from  150  to  200  grains  in  the  course  of  the  waking 
hours.     Thes(>  amounts  are  borne  best  when  given  in  brandy,  15 
grains  to  the  teaspoonful,  followed  by  a  cjuarter  of  a  glass  of  water: 
but  if  this  nauseates  the  patient,  it  may  be  given  in  capsules,  brandy 
and  water  being  taken  .separately.    Some  patients  may  not  stand 
such  large  amounts,  and  if  there  is  any  (|uestion  of  heart  trouble, 
one  should  begin  with  smaller  doses.    FuJl  iloscs  can  generally  be  borne 
for  two  (lavs  out  of  three.     In  eases  where  the  stomach  rebels  the 
remedy  may  be  given  l>y  the  rectum.     If  it  has  the  desired  effect,  it 
shoulil  be  coiitiiUKHl,  w'ith  increasing  intervals  of  entire  ab.stinence 
from  it  fa  large  dose  on  two  days  in  a  week  is  better  than  half  the 
amount  on  four  davs),  until  loiig  after  the  last  sign  of  congestion 
has  (Usai)])eared:    aiid  this  rule  applies  to  whatever  form  of  medi- 
cation is  employed,  on  account  of  the  danger  of  relapses. 

Mercury  is  best  given  in  the  form  of  inunctions,  a  piece  the  size 
of  the  patient's  whole  thumb  being  rubbed  in  twice  a  day  for  four 
days  in  succession,  unh-ss  tenderness  of  the  gums  api)ears  sooner: 
tiien  the  same  amount  once  a  ilay  for  the  n-st  of  the  week,  after 
which  an  interval  of  .severtd  days  sliouhl  occur  Ix-fore  the  inunction^ 
are  recommenced.  If  salicylate  or  mercuiy  have  no  marked effect, 
large  doses  of  iodide  of  jwlassium  or  <|uiniiie  >lioiild  be  tried.  ■:: 
they  may  be  used  in  the  intervals  when  the  patient  is  not  \xsiw 


.V  YMl'A  THETie  OPHTHALMIA . 


397 


the  otlicr  roincdios.  If  this  is  done,  it  would  jjrobahly  be  best  to 
avoid  following  salicylate  tvith  (juiiiinc,  on  account  of  the  ctTect  on 
the  cars. 

Asa  rule,  hot  applications  have  a  favorable  effect,  though  in  .some 
of  my  patients,  when  used  in  the  ordinary  way,  they  have  seemed 
to  do  harm,  while  when  emj)loyetl  in  the  fonn  of  thick  soft  poultices, 
chanficd  every  ten  minutes  for  an  hour,  four  times  a  day,  the  effect 
has  been  decidedly  bcneftcial. 

If  other  remedies  fail,  subconjunctival  iujcctions  of  two  or  three 
drops  of  sublimate,  1:I00(),  or  ten  drops  of  2  j>er  cent,  sodium 
chloride  every  third  day  may  be  tried.  If  the  first  e\-e  be  retained, 
it  should  receive  the  same  local  treatment  as  the  other  eye  as  long 
as  signs  of  infection  continue. 

It  goes  without  saying  that  everything  consistent  with  rest  which 
can  be  done  to  kwp  the  general  condition  food  should  be  done.  In 
s|)ito  of  all  treatment,  even  when  the  ca.se  i,  seen  at  the  start,  the 
prognosis  is  bad.  The  iris  generally  a("!'.eres  closely  to  the  lens  in 
s|)itc  of  idl  the  atro|)in(>ihat  can  be  borne,  and,  besides  the  blocking  of 
tiie  pupil  with  exudate,  sight  is  reduced  still  further  by  opacities  in 
die  vitreous  and  lens.  Where  glaucoma  ensues  an  early  operation 
fur  its  relief  may  be  re(juired;  in  these  cases  the  iris  connnonly  bulges 
,it  the  periphen,',  and  a  double  tran.sfixion  of  it  with  a  cataract  knife 
should  be  tried  In^fore  resorting  to  an  iridectomy.  But,  except  in 
I  lie  case  of  glaucoma,  no  operation  should  be  done  for  the  improve- 
iiiciit  of  sight  until  all  signs  of  active  infection  have  been  absent 
lor  a  year.  Even  then  the  results  of  operations  are  apt  to  be  dis- 
ci uiragiiig.  Good  light  sen.se  and  projection  are  retained  surpris- 
iiifljy  long  in  these  eyes,  and  to  a  novice  the  ta.sk  of  restoring  sight 
liy  an  iridectomy  or  extraction  i>\ay  seem  simjjle  enough;  but  when 
an  iridectomy  is  attempted,  it  is  generally  found  that  only  the  anterior 
l.iycrs  of  the  iris  can  Ix'  removed,  the  pigment  layer  remaining  to 
lilock  effectually  the  artificial  pupil.  If  the  lens  is  extracted,  the 
^iirlit  generally  still  remains  poor,  on  account  of  exti'iisive  vitreous 
opacities,  and  any  oju'rative  interference  is  a])t  to  ])roduce  ii  marked 
icactioii,  accom|)anied  bj  the  production  of  exudate  which  occludes 
the  new  pupil,  so  that  repeated  sul)se(|uent  iridotomies  or  excisions 
<i|  ilic  inllamiii.itory  membranes  with  de  Wecker's  scissors  have  to 
111'  resorted  t<i.  All  these  re])eated  attempts  should  be  made  at 
cnnsidtiable  intervals,  and  in  a  fair  proportion  of  ca.ses  patience  will  Ix' 
rewarded  by  a  rea.sonable  amount  of  success, 

III  many  cases  no  chance  for  ojx^rative  interference  is  ever  given, 

liic  iiiflammation  continuing  until  all  sight  is  lost,  while  it  some- 

nii's  hajiiM'ns  that   in  addition  to  blindness  the  jiain  IxTomes  so 

iiiinlciable  that  enucleation  or  evisceration  of  the  second  eye  has  to 

'■■■<   performed. 

Tiie  gloomy  |)icture  hitherto  presented  applies  to  the  severer  ciises, 
I  id  thes*',  up  to  the  present  time,  constitute  a  large  nuijority  of 

ise  liescribed;  but  it  is  evident  that  of  late  more  favorable  reports 


:59.S 


77/ A"  EYE. 


.,r,>  Lciiiir  nTcm.l.     This  is  iKTluips  .luo  loss  f.  in.i.rovon.ents  i» 
m-U    "S     la     to   a   .nun-    wi.U.s,.n.a.l   knovvl.-dp-   a.ul   an   earluT 

,uc'    m  o     1.  disease.     M..n-uv..r,  it  is  prohahl.  that  nn hi  h.r.ns 

V     "it  .■tic  ..phthahnia  an-  .nuch  nu.n-  c-.„.nu....  than  i..nn.-rly 

t^Z^Zd      I  have  known  it  t..  .l-v.-lo,,  an.l  run  .ts  cours.  .n  two 

Inrac  patients  with  so  little  .-onsestion  ..r  subjectiye  .hsturhauc..  of 
mv  kh.  I  that  asthesifiht  wasalrea.ly  ol.scun-.l  by  the  cataracts  t he 
;  i,.  wenAimware  that  any  intla.nn.ation  ha.l  occurred.  Where 
Iv  n  vSietic  ophthaln.ia  has  occurred  after  enudea  .on  or  eviscer- 
S  le  i)U  s,.  h;u-  ahnost  invariably  b.-en  n.il.l  and  ta.r  or  pertect 

ivSs    a  "^"n  obtained.     The  sa.ne  is  true  ...  son.e  extent  o     he 
eases  which  have  occurre.l   in  conn..ction  with  oss.hcation  of  the 

''"■Si''Treatment  of  Penetrating  Wounds  of  the  EyebaU.    Where 
•1  Je-in "ut  peni-tratiiiK  wound  of  the  eye,  w.th.mt  any  prolapse;  o 
irif ;  mr  id'        5   eons  has  occurred  some  days  beh.re  the  patient 
'on      t   ef  te  of  the  eye,  as  far  as  the  infection  is  concerned,  is 
"  ;    "llv   l-H     d  behlreliLd.     If  the  eyeball  shows  little  or  no  c.m- 
S-io      ..X  ept  ill  the  nei«hborhoo.l  of  the  wound    and  no  pa  n    « 
oxn  HenH..l    t  is  Renerallv  safe  to  conclude  that  infection  has  In-en 
'  ;  „      a    i  all  tlKit  is  iinniediately  required  unless  s<.<-oi.dary  Slau- 
M,;     i  '     esent    is  to  protect  the  ey.-.  preferably  v  th  s...ne  lori.i  of 
'  I    K     lai    use  su'tfii-ient  atropine  to  keep  the  ins   n.ni  adhering 
e     'ns,   mid  keep  the  patient  quiet.     Of  course,  if  a  trauma 
■  t  rue    is  present,  it  may  be  extracte.l,  if  there  is  no  increa..e  n.  the 
;!;;."  Kut  if  tlu>re  is.  it  is  l>etter  ,..  put  otT  the  extraction  for  a 
w  rk  or  so   treatiiig  the  lids  with  some  astringent  meanwhile. 

\\\Z'  however,  a  fresh  ,K.iietratiiig  wound  is  seen,  the  treatment 
.Iw.ul.l  b<>Lriii    wherever  possible,  with  a  thorough  irrigation  of  the 
:     i  1  ctii     s^c    .n.l  su/face  of  the  gl..be  with  a  steri^^e,l  0.5  ,K-r 
c         solution  of  salt  or  ^onie  ..th.-r  sterile  non-irritating  solution. 
¥l    n  a    er  the  excision  of  anv  l.rolapse.l  iris  or  vitn-ous,  should  follow 
U  !  pVotecti      of  the  wound- with  a  conjun.tival  flap:  for  it  should 
;,  X'dthat  nearly  every  conjunctival  siic  contains  nu^r.^rro^ 
nt  hogenic  germs  which  .•annot  be  thoroughly  clean-d  out  by    .> 
;  Isun-s   .•luMui.-al  or  mechanical,  which  it  is  safe  to  use:  and  w  ule 
:;,„,e  cases  of   infection  tlie  germs  may  be  present  on  the  offen.ling 
s  ,bs    nee  before  it  rea,.hes  the  eye,  th,.  probability  is  tha    in  nearly 
i   c lis  the  germs  either  are  carried  in  from  the  surtace  of  the  go 
.     ,1,,.  time  of  the  hijnry,  or  they  gain  entrance  from  t he  cnjunctn.  I 
„     ft  r  the  iiijurv  has  be..n  inHicte.1.     To  prevent  this  latter  (;<.n- 
;  ,;  li^v  t  en  is  n.;  protection  ...,ual  t..  that  affonle.l  by  a  conjunctival 
hT     \V lere  th<.  wl.und  is  entirely  in  the  sclera  the  b<>st  plan  is  to 
!x    se         ingular  bit  of  conjunctiva  at  one  side  of  the  wound,  am 
lr.w  .triangular  flap  ..ver  this  raw  surfac-  from  the  opposite  side 
Uie  wound  bv  one  or  more  sutures.     Where  the  wnun.l  extends 
s     rt  way  into  the  cornea  the  simplest  plan  is  t..  d.ss.>c    up  the 
;.,u  u  K-tiv    al  aroun.1  the  cornea  and  draw  it  over  the  whole  cornea 


S YMPA  Tin: TIC  OPIITIf  ILMIA. 


399 


by  !i  piirsc-striiifj  suture  tightly  tied.  A  more  coinpiicat  -d  but  on 
some  accounts  l)ett('r  f)lan — as  it  allows  the  pliysiciaii  to  keep  a 
lictler  \vat<'li  of  the  condition  of  tlie  iris,  and  as  permitting  a  better 
.•iction  of  atropine — is  to  exci.se  a  portion  of  tiie  conjunctiva  at  hotli 
-ides  of  tile  v.'ound,  a.s  inihcated  in  Fig.  209,  a,  and  to  (Iraw  tlie  loosen  1 
ciinjunctiva  over  the.se  raw  surfaces  and  the  woujid  at  the  same  time 
by  two  sutures,  or,  as  in  Fig.  209,  b,  by  a  single  suture.  Where  the 
wound  involves  the  central  [)ortions  of  the  cornea,  it  may  be  that 
the  jmi-se-string  suture  will  offer  a  sufficient  protection,  l)ut  a  more 
(crlain  jjlan  is  to  excise  a  portion  of  the  conjunctiva  all  around  the 
iipposite  half  of  the  cornea,  as  in  Fig.  209.  r,  and  bring  a  conjunctival 
liaj)  from  above  clear  acro.ss  the  cornea.  It  may  be  (|uestioned 
whether  the  use  of  a  protecting  flap  is  neces.sary  in  the  case  of  clean- 
cut  woimds  of  the  cornea:  imt  wliere  the  wound  is  irregulai  or 
ciiiitains  iris  tUsue  or  fragments  of  broken-down  lens  or  vitreous, 
there  can  be  no  tloubt  about  its  advisability.     In  the  case  of  wounds 


Fig.  -IO. 
b 


a       D 


Thi'  shiideil  areas  indicate  the  surface  from  which  the  conjuuctiva  ahnuld  be  excised  ;  the  dotted 
iincs.  the  outlines  of  the  conjunctival  ilaps.  A.  wound  to  be  covered  ;  B,  C,  D,  piiinti  where  luturea 
nrv  Id  be  applied  in  drawing  the  flaps  Into  position. 

that  are  not  above  suspicion  the  edges  should  be  touched  with  the 

^.ilvaiiocautery  or  Paciuelin  cautery,  or,  if  tbese  are  not  at  hand, 

with  a  chemical  caustic,  such  as  carbolic  or  nitric  acid,  applied  with 

I  lie  utmost  care  with  a  very  finely  drawn-out  cotton  swab,  before 

ilr.iwiiig  over  the  flap.     To  be  logical,  one  should  u.se  the  same  line 

"t  treatment  for  operative  wounds  where  vitreous  is  lost  or  iris  tissue 

1-  cauglit  ill  the  wound.     And  it  is  certain  that  if  the  wounds  had 

turn  protected    i)y  a  conjunctival  flap  many  and  probably  all  of 

liic  cases  of  sympathetic  ophthalmia  which  have  been    eported  after 

■■it.iiact  extraction  could  have  l)een  prevented.     The  small  conjunc- 

'ival  Hap.  which  is  often  made  as  the  final  step  in  the  incision  for 

:it,iract  extraction  is  good  as  f:<r  as  it  goes,  but  it  is  .seldom  large 

■iiniigh   to  cover  fully  the  large  prolap.ses  which  sonetinies  occur 

!ir  simple  extraction,  and  if  an  iridectomy  is  made  the  points 

''  which  the  iris  is  most  ajit  to  be  entangled,  nany.-iy,  the  angles  of 

■'•    wound,  are  left   unprotected.     To  make  an  effective  Hup  for 

"itectiiig  an  extraction  or  iridectomy  wound,  the  conjunctiva  should 

-lightly  raised  by  the  injection  under  it  of  a  cocaine  solution  at 


400 


THE  iiYE. 


tho  point  .,f  pu..ctur,.  and  coanter-punr  «ro,  an  1   >«^ j^,^       '^^^^^^^^^^^^^^ 
s..nie  (listauce  out.si.U-  o(  tlu"  fonuvi  an.l  pusso.l  aU.ng  un.loi  '" 
\       tiv'i  S<.re  entoring  ih"  ai.tm.,r  chanibi-r:  tl.cn  .n  niakmg  the 
Cnt^;  pun  tiro      re  should  be  taken  t<.  pass  the  knife  along  beneath 
tSJ     >  junS  as  far  .us  possible  before  piercing  ,t      In  eases  «^.m 
olapi  of  vitreous  is  expected,  two  sutures  shoul.l  be  P"t  "  at  the 
unue    part  of  the  conjunctival  wound,  and  .Irawn  well  out  of  the  «aj 
Ee      e  extraction  is  con.pleted.     This,  it  se<Mns  to  me    is  th 
.^     les   wav  to  protect  con.pletely  an  extraction  woun.l  but  ,t  may 
be  th'u  to  prepare  a  Hap  above  the  cornea  and  bnng  it  .lown  and  hx 
U  in  tt  mannir  indicated  in  Fig.  209  a,  or  even  to  use  a  Purse-Jr  ng 
suture    will   prove  to  be  l)otU'r.     Some  such   form  of  extraction 
Sugl  too  Complicated  to  lx>con>e  popular  at  once  .s  eerta.n  after 
the  tedmique  is  mastered,  to  give  a  l^^'«e>;  guarantet_  o    an  nnme- 
diate  goo.l  result  and  of  safety  from  sympathetic  ophthalm  a 

After  protecting  the  wound  as  well  as  possible  from  infection  a 
^Lul  bandag'e  (both  eyes  being  closed  ^^  ^.J,  ^^  ,f  i;^^^^^^ 
in  severe  injuries),  rest,  and  atropine  are  all  that  will  be  requireu 
no  LiLction  has  tak^n  place.     It  may  be  ^l"-tioned  w^t he.  i 
is  not  best  to  applv  coKl  in  some  form  during  the  hrst  t^^ent^-toul 
ou  s     This  is  rLmmended  by  g..od  authorities,  but  the  chthcdt) 
of  applving  cold  in  anv  etticient  way,  without  danf?>r  of  di.sturbmg 
an     nfecting  the  wound,  is  such  that,  on  the  vs^io  e,  I  J'^l'^e  ;is  good 
nwults  will  be  obtained  without  it.  unless  .lec.ded  pain  indicates  that 
infection  has  taken  place,  in  which  case  the  continued  use  of  ice. 
nreferably  with  a  light  rubber  or  metal  coil  or  a  small  ice-bag  fn- 
I    entlv  HUed  with  tmall  bits  of  ice,  should  be  employe,    until  the 
.!,„l  ot"the  first  twenty-four  hours,  the  eye  being  P'-;'t;'-te«l  hy  a  pad 
of   absorbent   cotton   which    is    kept   wet  with  sublimate    IM 
Later  than  this  1  prefer  the  use  of  hot  applications  for  ha  f  an  1  ou 
to  an  hour  three  ur  four  times  a  day,  where  symptoms  of  mfection 

'"ln'!;irca.ses  where  infection  is  suspected  or  feare.l,  besi.le  the  use 
„f  cold  or  heat  and  rest.  atropin.>  should  b.-  use.l  with  extra  liberal  t  . 
10  to  15  drops  of  a  1  per  cent,  solution  being  inst.lle.l  an.l  alio  ^ .  1 
to  run  ..ut  at  the  outer  angle  ..f  the  eye  tw.)  ..r  three  times  a  .la>. 
an.    1  rge  .l..ses  .,f  so.lium  salicylate  .sh..ul.l  be  given.     Subconjunc- 

al  u.jections  of  1  t..  :i  .Irops  of  subHmate,  1  •  1^^),  or  6  . Irops  . 
cvani.l.-  of  mercurv.  1:2(KM),  ..r  10  .In.ps  of  s.,.lium  chlori.le,  2  m 
c-ent.    mav  be  tri...l  every  secon.l  or  thir.l  .lay.     In  s..me  cases  the. 

elTc't  is  ast..nisl.i.,gly  g..o.l;  in  others.  f''V'^ '^l'''^"'"*- 'T.orfc.'a 
a.,  ....  go...l.  or  even  .U.  ham..     Where  the  ..nfecti.m  is  superhcia  . 
i,    so,... -cataract  woun.ls  or  injuries  of  the  c.,rnea    a  thorough 
application  of  the  galvano  or  Pa.iueli..  cautery  ..ft.-..  c.>ese|xcd^ 
servi<-e.  an.l  if  n.-ither  of  these  is  available,  scraping,  followed  b> 
api.licati..n  of  tincture  ..f  i.-.line  ..r  ..itric  "^  ^f  ^"'l"™'- .^J' ^'T ," 
times  l)e  as  effectual.     '  i  desperate  cases,  where  it  is  evident  that 
pruleiiT  rnflammation  oi  the'  vitreous  ha«  started,  the  endocular 


S YMPA TIIETIC  OPHTHALMIA. 


401 


use  of  11h'  puutcry  has  hccn  reported  to  give  good  results;  the  tij) 
of  tlie  gulvanocautery  having  been  phmged  deeply  into  the  vitreous 
as  near  tlie  focus  of  infection  as  possil)le,  and  tlie  current  turned  on 
whili'  ihe  point  is  moved  slowly  about.  I  have  had  no  experience 
witli  tiiis  method  of  treating  the  vitreous,  but  have  tried  it  in  the 
anterior  chamber  witii  a  ba>;  result.  If  it  is  tried  in  tiie  vitreous, 
tlic  wound  siiould  innnediately  afterward  be  covered  with  a  con- 
junctival flap.  In  treating  prohip-ses  of  the  iris  much  discrimiiuition 
is  necessary  in  the  use  of  the  cautery.  Kxcej)!  in  plainly  infected 
cases,  it  is  best  not  to  use  it  if  the  iris  can  either  be  replaced  or  .seized 
with  the  forcei)s  and  cut  off.  Where  this  is  not  possible,  as  is  fre- 
i|ueiitly  the  case  with  a  prolapse  of  more  than  a  day's  standing,  or 
where  the  prolap.se  i.s  apparently  infected,  it  may  be  u.sed  if  the 
burnt  tissue  be  immediately  scraped  away  and  the  .spct  well  coveretl 
with  a  conjunctival  flaj).  To  burn  a  prolapse,  however,  without 
iiiiniediately  protecting  the  spot  from  .secondary  infection  is.  I  bt^lieve, 
(listinctiy  dangerous.  It  is  often  done  witli  good  results,  but  evidence 
is  constantly  accumulating  to  show  that  it  has  a  decided  iondoncy 
to  favor  the  occuiTence  of  sym])athetic  ophthalmia. 

Where  a  small  prolapse  is  swni  seven,' 1  days  after  the  occurrence 
of  the  injuiy,  and  is  evidently  not  infected,  it  is  jierhaijs  best  to  leave 
it  entirely  alone,  unless  the  physician  has  had  ex|)erieiice  in  the 
t(chni(|ue  of  ai)plying  conjunctival  tlajjs.  The  majority  of  such 
|ir()lai).ses  subside  (|uietly  and  are  abundantly  i)rotected  by  new- 
fi  limed  coimective  tissue  if  the  eye  is  kept  quiet  and  hot  applications 
arc  used. 

The  ideal  treatment  of  iris  jirolapse  Ls  to  replace  it.  and  thus  restore 
the  form  of  the  pupil :  but  this  .seldom  is  done  after  accidental  wounds, 
partly  because  adhesions  form  so  (juickly  that  unless  the  eye  is  seen 
MMin  after  tlie  injury  the  iris  cannot  be  replaced  without  t<'aring  it; 
anil  partly  because  when  replacement  is  attempted  in  the  ordinary 
way.  the  replaced  iris  is  immediately  pushed  back  into  the  wound 
a-  the  instrument  used  is  withdrawn.  A  plan  which  gives  better 
ivsults,  es|)ecially  if  the  wound  has  not  reached  the  extreme  peri|)hery 
uf  tlie  (ornea,  is  to  make  a  new  incision  at  some  distance  from  the 
wound  just  sufficiently  large  to  permit  the  introduction  of  a  small 
sp.iliila,  with  which  tlie  prolajised  iris  can  be  drawn  back  into  the 
anterior  chamber,  and  as  the  first  wound  closes  behind  it  there  is  little 
trndeiicy  for  it  to  be  again  exj)elled. 

Management  of  Foreign  Bodit^s  in  the  Eye.  \\'here  a  foreign  body 
lias  entered  the  eye  the  management  depends  upon  the  presence  or 

ilisence  of  infection  and  the  nature  of  the  foreign  body.  Wh(>re  a  piece 
•  if  iron  or  steel  ha.s  enten^d,  it.s  removal  shoulil  be  attempted  at  once 
\\\\h  some  form  of  magnet.  Other  foreign  bodies,  except  when 
ill  I  lie  lens,  nnist  naturally  Ix-  removed  with  forceps  or  hooks,  if  they 

ic  to  be  removed  at  all.    Sometimes  their  removal  is  not  neces.sary. 
i'iices  of  wiiud,  stone,  lead,  copjier,  and  gla.vs  may  be  tolerated  in 

lie  eye  for  an  indefinite  period  if  no  infection  has  occurred  at  the 

26 


402 


THE  EYE. 


timo  ..f  tlu'ir  cntranco.  So  that  wl.il.',  h.  a  recent  case,  if  such  a  f..rnRn 
l)(„lv  can  .-asilv  be  seen  an.l  reached,  its  removal  should  he  atten.i.tcl 
at  once,  it  sh.ml.l  l.e  left  alone  if  this  is  not  the  case  and  there  are  no 
svniDtoms  of  intVction  nor  other  serious  disturhunce,  suice  the  attempt 
t;.  remove  it  in  the  dark,  even  with  the  best  localization  possible  by 
means  of  the  x-rays,  is  more  likely  t..  do  harm  than  good  unless  it 
be  very  large.     The  amount   of  toleration  which  the  eye  exiiibits 
towanl  as.-ptic  foreign  bodies  which  have  enten-d  it  without  carrying 
in  or  Iwing  followed  by  g.-rms  from  the  conjunctival  sac,  depends 
primarily  upon  the  amount  of  chemical  reaction  whicli  occurs  between 
them  and  the  fluids  of  the  tissues:  secondarily,  upon  their  becoming 
firmly  fixed  by  fibrous  exudate.     ('oi)i)er,  iron,  zmc,  and  lead  all  are 
acte.l   upon  so  as  to  pro.hice   irritating  compounds,   copper   inos 
markedly,  lead  least  of  all.     Col.per  is  the  only  one  which,  without 
the  aid  of  germs,  will  produce  a  purulent  exutbte.     It  also  has  the 
property  of  producing  a  softening  effect  upon  the  tissues,  so  that^  m 
i.uil  anumber  of  ca.s<.s.  if  left  to  itself,  it  will  work  its  w.iy  to  the 
surface  and  be  expoll.-d  spontaneoasly.     This  h:us  been  known  t.. 
liappen  after  a  lapse  of  twenty-one  years.     In  rare  ca.ses  a  bit  ol 
copper  is  encapsulated  so  completely  that  its  chemical  action  appears 
to  cease  and  it  causes  no  disturbance  after  the  hrst  reaction  ha.s  sub- 
KXiWiX      It  is  iini)ortant  to  remember  the  chemical  activity  ot  copper 
in  the  eye,  because  a  moderate  amount  of  reaction,  even  when  long 
continued,  need  not  cause  the  same  anxiety  that  would  be  natural 
if  the  inflammation  were  thought  to  be  the  result  of  infection.     Ihe 
copper  mav  be  merely  working  its  way  to  the  surface.     It  is  not  best, 
howeve'    for  the  physician  to  assume  all  the  reaponsihihty  of  advising 
against  openition  in  such  cases.    Whenever  the  reaction  is  prolonged, 
there  is  a  i)os.sibilitv  of  symi.athetic  ophthalmia,  which  can  only  be 
obviated  by  removing  the  foreign  boily  or  sacnhcmg  the  eye;  and 
if  it  is  .lecide.l  t.)  attempt  to  remove  a  bit  of  copper  which  has  l)een 
in  the  eve  for  souk-  time,  it  should  be  remembered  that,  however 
accurately  it  may  have  been  located  at  the  time  of  its  entrance,  it  is 
liable  to  be  found  at  some  distance  from  this  point  later  on.     Lea.l 
oecurs  in  th.-  eve  chiefly  or  .-xclusively  as  the  result  of  shot  wounds. 
These  wounds  -ire  p<'culiar  in  that  in  spite  of  iKMiig  so  small,  unless 
tin-  shot  is  going  with  sufficient  rapidity  to  go  clear  through  the  globe, 
th<.  impact  of  the  blunt  though  small  object  is  sufficient  to  produce 
so  much  internal  disturbance  in  the  form  of  heniorrhag.-s  or  detach- 
ments that  the  sight  is  lost  or  very  seriously  injure.l,  even  when  n<. 
sepsis  occurs,     .\lthough  the  woun.ls  produced  by  shot  m  the  ..xternal 
tunics  are  so  small  that  th-   are  generally  left  to  thems<'lyes,  fresh 
ones  should.  I  iH'lieve.  always  l)e  protected  by  a  conjunctival  Hap 
drawn  far  l)eyond  their  limits  in  the  manner  previously  indicated. 
This  having  been  done.  I  consider  that  any  attempt  to  remove  the 
>hot   uiilc.s.s  il  can  actually  !k-  seen  with  the  naked  eye,  is  a  mistake 
If  aseptic,  as  lh.>v  usually  are,  shot  will  generally  become  encapsulate. I 
•uid  cause  n.:  su"bs.M,u.-Mt  irritation.     These  injuries  generally  cans.' 


^ff*f-"^Bf-"*i^^ 


SYMPA  TIIETW  OPHTHALMIA. 


403 


s(i  iiiucli  tissue  (listurlmncp  that  the  congestion  is  apt  to  be  prolonged, 
even  wliere  tliere  is  no  sepsl.s,  and  if,  some  days  after  the  injury,  the 
anterior  chamber  fills  up  with  blood  from  the  vitreous,  it  is  well  to 
IM'rform  a  paracentesis,  even  repeatedly,  to  help  clear  up  the  vitreous. 
Siiots  that  go  clear  through  the  ball  into  the  orbit  need  no  aUenticm, 
tliDUgh  they  sometimes  cause  complete  blindness  by  injuring  the 
optic  nerve,  either  directly  or  by  the  pressure  from  the  hemorrhage 
which  they  cause.  But  even  where  the  sight  is  inuuediately  and 
completely  lost  after  .such  an  injury,  an  absolutely  bad  prognosis 
-liipiild  not  Ix'  given  at  once,  because  at  least  one  such  case  is  on 
iccord  where  the  sight  returned,  j)robabIy  because  the  blindnest-  was 
due  to  pressure  from  lieniorrhage  rather  than  from  direct  injury  to 
the  nerve. 

The  diagnosis  of  shot  in  the  eye  should  not  be  made  too  ha.stily. 
( t(  casionally  a  shot  strike.s  the  eye  obliquely,  causing  a  hemorrhage 
:it  the  margin  of  the  cornea  and  a  rupture  of  the  iris  with  hemorrhage 
ill  the  anterior  chamber  without  any  penetration,  although  at  Hrst 
glance  the  physician  is  inclined  to  believe  that  the  shot  must  be  in 
tliecye. 

( >tlier  metals,  except  iron  or  steel,  which  will  be  discussed  later  on, 
(iccur  so  rarely  in  the  eye  that  they  hardly  need  to  be  considered. 

Small  pieces  of  wood,  glass,  .stone,  and  other  indifferent  .substances 
:irc  often  retained  indefinitely  without  disturbance,  if  they  remain 
inminval>le:  but  if  frot^,  they  oft<>n  cau.se  a  mechanical  irritation 
uliicli  necessitates  an  attempt  to  remove  them.  In  deciding  upon 
■■iich  an  operation  tlio  iaiiger  of  mistaking,  for  the  foreign  body,  a  bit 
nt  exudate  on  the  iris  or  lens  -should  be  kept  in  mind.  Such  a  mistake 
i-  sometimes  impossible  to  avoid,  and  it  is  probably  often  fnade. 

A  small  foreign  body  in  the  lens  without  infection  is  best  left  alone 
until  the  lens  is  opa(|ue,  when  it  will  generally  come  out  with  the 
latter,  especially  if  a  broad  incision  and  an  iridectomy  are  made. 

Ilvelashes  are  not  infrequently  carried  into  the  anterior  chamber 
"V  vitreous;  they  of'':i  cause  no  disturbance;  but  in  the  anterior 
'  liainlier  they  apparently  sometimes  form  the  starting  point  for  cysts. 
Mild  ill  other  cases  the  germs  which  commonly  adhere  to  their  roots 
nay  cause  the  loss  of  the  eye. 

The  Management  of  Bits  of  Iron  or  Steel  in  the  Eye.  The  manage- 
•iHiit  of  bits  of  iron  or  steel  in  the  eye  deserves  to  be  considered 
'  |iaiat<'ly.  both  on  account  of  their  behavior  in  the  eye  and  from  the 

't  that,  unlike  all  other  foreign  Ixxlies,  a  large  proportion  of  them 

■  ill  l>c  removed  withoui  their  being  visibit   beforehand.     Although  a 

■  ir  proportion  of  them,  if  aseptic,  become  encai)sulate(l  with  so  little 

'  "tion  tiiMt  the  inifiression  is  given  that  no  further  harm  will  be 

'!(■  by  their  presence,    .sooner  or    later  they  almost   invariably 

"line  (l('(iiiii])osed.  and  the   .soluble  compounds  thus  formed  are 
v!!iijiaii'd  through  the  eye.  producing  the  cr,n<lition  known  an 

"■'i.v/.v,  which  shows  itself  externally  by  a  brawn  discoloration  of 
iris,     I'yes  in  which  this  decomposition  has  gone  on  for  any 


404 


TUE  EYE. 


IcnRtli  of  tiiiio  iiliimst  alw:iys,  tliroiigli  disorgiuiization  of  the  vitreous 
iiiul  (Iftacliiucnt  of  thf  riMiiia,  los(>  any  siglit  tliat  may  liavc  Ix'cn  left, 
and  rnMiuciitlv  Ixtoihi-  so  irrital)lo  tliat  they  liavc  to  lie  sacriticcd, 
both  for  the  .-Mkc  of  comfort  and  to  avoid  the  danger  of  syinpatlictic 
oplitlialinia.  A.-<  an  example  of  the  danger  of  allowing  apparently 
innocent  hit-s  of  steel  to  remain  unmolested,  the  following  history 
may  l«'  useful.  A  young  man  was  brought  to  me  shortly  after  a  bit 
of  .steel,  not  largertlian  half  the  head  of  a  pin.  had  i)enetrated  his 
cornea,  iris,  lens,  and  reMna,  and  remained  so  Hrmly  fixed  in  the 
choroid  and  sclera  that  U.v  giant  magnet  did  not  move  it.  As  the 
opacity  first  i)iesent  in  the  h-ns  cleared  up  almost  entirely  and  the 
vision'became  nearlv  normal,  the  eye  In-ing  e?  tirely  free  from  irrita- 
tion, it  was  thought  best  not  (o  interfere  with  it.  This  condition 
remained  unchanged  for  .several  montlis,  when  thi"  sight  iM'ga.i  to 
diminish  and  the  eve  became  irritable.  He  did  not  return,  however, 
for  nearlv  a  vear.  and  when  he  did  the  sight  was  entirely  gone  anil 
the  eye  was  "so  troublesome  that  it  was  removed.  As  illustrating 
what'nmv  l)e  accomplished  in  a  similar  case  by  bolder  methods, 
there  is  one  case  on  record  in  which  the  operator  with  the  aid  of  the 
ophthahiiosco|)e  loosened  the  bit  of  steel  with  a  discission  needle 
passed  through  the  sclera,  and  then  with  the  giant  magnet  drew  it 
into  the  anterior  chamber,  whence  it  was  easily  removed. 

Where  the  piece  of  metal  is  very  small  it  sometimes  U'comes  entirely 
disintegrated  before  the  sight  is  wholly  destroyed,  and  in  this  (■  vent 
the  siderosis  sometimes  clears  up,  and  useful  sight  is  retained  without 
aiiv  oju'ration  to  remove  the  metal. 

in  the  management  (.  these  cases  the  physician  .shouUl  have  at 
least  one  electro-magnet,  for  while  a  certain  number  of  bits  of  steel 
can  be  removed  f' mi  the  anterior  chamber,  the  iris,  lens,  or  even  the 
vitreous,  withou'  magnet,  the  attempt  to  do  this  will  not  infre- 
(lueiitly  fail,  an.,  laiiy  an  eye  which  might  otherwise  be  saved  will 
be  lost'  if  no  elficimt  inagnet  is  at  hand.  If  a  man  can  have  but  one 
magnet,  jxThaps  the  most  generally  available  form  is  the  small  .>ne 
of  ilirschberg  or  Sweet:  each  has  several  interchangeable  points, 
of  which  the  larger  and  !)luiiter  ones  should  be  tried  if  there  is  any 
probabilitv  of  the  mct.il  being  near  the  surface,  while  the  sinalU'i' 
ones  can  be  passed  into  the  anterior  chamber  or  deep  into  the  vitre- 
ous. ,      ,       •    ,  -1 

This  can  be  oirrated  ,.ith  various  kinds  of  galvanic  batteries,  hut 
it  is  much  more  satisfactory  to  have  it  connected  with  some  power 
current,  and  if  this  is  to  be  done,  the  voltage  of  the  cunvnt  to  1"' 
used  should  be  mentioned  in  ordering  the  magnet.  Hut  to  do  tlw 
most  satisfactory  work  in  this  line,  it  is  necessary  to  have,  in  addition, 
a  giant  magnet  or  Haab  magnet,  a  sideroscope,  and  access  to  an  x-ray 
ap|)aratus.  ( Fig.  210.)  The  Haab  magnet  may  either  be  mounted  oii 
a  stand  or  suspended  from  the  ceiling,  and  while  it  can  be  o{iiTatf.! 
with  storage  or  other  batteries,  the  connection  with  a  power  curreiii 
is  much  more  desirable.     Some  apparatus  for  turning  on  the  current 


SYMPATHETIC  OPHTHALMIA. 


405 


(rnuliially  is  an  advantage,  but  much  the  same  effect  can  he  pro- 
iliiced  l)y  gradually  bringing  the  eye  toward  tlic  niagn«'t. 

Tiic  si(ienise()|M'  of  .\.snius  consists  essentially  of  a  magnetic  needle 
suspended  by  a  fibre  of  silk.  By  attaching  a  mirror  to  tliis  and  view- 
ing tlinmgli  a  telescojH'  the  image  of  a  light  reflected  from  it  upon  a 
scilc  at  some  tlistance,  extn-mely  delicate  results  can  be  obtained 
in  detecting  and  locating  bits  of  steel  or  iron  within  the  eye;  but  as 
I  lie  instrument  lequires  a  special  room,  at  some  distance  from  any 

FlO.  210. 


Iliiab'8  mognet 


.  lley  wires,  it  will  ])robably  be  used  chiefly  in  eye  hospitals.  Ilir.sch- 
■v'l  iiMs  liMil  M  less  complicatecl  form  of  the  sideroscope  made  which 
ly  edtne  into  more  general  use. 

I'lie  \ise  (if  the  .r-rays  in  discovering  and  locating  foreign  bodies 

eve  is,  of  course,  not  confined  to  bits  of  iron  or  steel.     Their 

\\<f  fj  in  determining  whether  or  not  any  foreign  IkkI}-  is  present. 

I  lie  body  is  large,  it  can  frequently  be  .seen  with  the  fluoroscojx',  in 

'li 'li  ease  a  fair  iilea  of  its  location  can  sometimes  be  had  by  having 


Ilie 

;..r 


40(i 


THE  EYE. 


the  patient  i.u.vc  his  <>vr  in  diflVrnit  direct i..i.H  .luring  the  obwrva- 
lion!  the  .sluuL.w  iu..viiig  with  liie  e.,ruea,  if  the  foieigii  btxly  W  lu 

Kio.  :iJ. 


Uirschbcrg"*  dlderoKop*. 
PlO.  212. 


S-.vt.vts  avparstus  f'>r  liwallzliig  foreign  txxllcs  in  the  eye. 

the  anterior  half  of  th"  ^IoIk-:  against  it,  if  it  is  in  tl'^x^f  ^^^  l>;;'; 
Much  n>ore  !:,-euratc  woriv   may  he  Aon.  l.y  th.-  method  of  S?«'-t. 


W 


.S  VMPA  TllEllV  OI'lITllALMlA. 


407 


wliiili,  in  hru'f,  cdiisists  in  taking  fuo  or  nmn-  radioisraphs  with  the 
tiilw  in  (litTcrcnt  iiositioiis,  the  [il.itcs  hcinn  held  in  fxactly  the  sinie 
|Misitii>n  l)y  a  wix-cial  arranKcincm  uliich  ai  .I>c  sanir  time  lioiils  two 
riictai  iM)inls  apainst  the  lids  at  a  definite  di.-<Iance  from  the  platp. 
liy  (•(pni|(ariiijj  tiie  |ii.^itiiins  (if  the  shadows  of  tiiese  points  and  of  the 
loreijrn  hody  on  the  radiograph,  and  ean'fully  plolfinj;  the  jiaths 
whieh  the  j--rays  must  take  from  fiie  tulM-  to  the  plate  through  a 
circle  representing  the  position  of  the  eyehaii,  the  location  of  tlie 
tnieigii  |)ody  rail  he  deterinineil  with  considerahie  aceuraey  i)y  tho 
point  at  which  the  paths  of  the  rays  through  it  intersect  within  this 
circle.  If  Sweet's  apparatus  is  not  at  hand,  fair  results  can  he  obtained 
hy  fastening  three  shot  with  collo<|ion  and  cotton  on  the  outside  of 


Kio.  2l:l. 


Kadiiigraph  showing  piece  of  iteel  In  the  eye.    iBweet  ) 

i!ic  closed  lids,  aixive,  opposite,  and  below  tho  cornea.     It  is  al.so 

M  II   lo  do  this  before  fluoroscopic  examinations.     Af  an  example 

•  ■I  liie  advantage  of  having  dilTereiit  methods  of  diagnosis  at  one's 

M-l«>sal.  a  recently  reported  ca.se  may  Ik-  cited  in  which,  after  an 

ury,  a  piece  of  .st<'el  in  the  eye  was  su.spected,  and  where  the  sidero- 

-'■\»-  plainly  indicated  the  existence  of  such  a  fragment:  the  giant 

i;rnet,  however,  produced  no  effect  ujion  it,  and  tin-  .r-rays  showed 

■    presence  of  a  rather  large  foreign  bo<|y  in  the  ti.ssues  under  the 

L'c  of  the  (irbit.     The  patient  tlien  remembered  that  he  had  been 

Mck  in  this  locality  with  a  piece  of  steel  a  long  time  before. 

\>Miiiiiiig  ihrn  that  the  jihy.sirian  has  all  the  desirable  instrument.'; 

till'  locating  and  extracting  of  bits  of  iron  and  steel  in  the  eye,  it 

lid  be  realized,  in  deciding  what  ca.^es  it  is  worth  while  to  use 


4m 


ruK  I    /•.■ 


If 


|| 


tlii-ni  111.,  tliat  rniuiy  jwtifiiis  lul^'  f,  .n  ijiii  hoiji-s  in  tli  esc  withcitt 
kiii'wiii^  it  Nlitiiy  ciiscs  ii'  otht'i  wiw  uin  xplaiitfil  oik  ilcd  catant- 
m  '.ouiij;  [i-oi'lc  arc  Itn-  to  m  rwcivol  or  lnii);-f(ii-};i  ilcii  'ujuri-- 
\\]  h  si-iiictiii.'s  \m\v  iin-iii'li'il  uif  futraiicf  of  li'icijrii  hodii-  TJw 
f\,  iici  if  -ulfTosj!>i  will,  ot  criursc,  always  .siijyifsl  ic  pn'siiirc  of 
in.ii  or  s'li!  Ill  whi  <  tlii-n-  is  ri"  history  of  an  ii  ry.  In  many 
fri-slr  niH's 'J  •  :istoi  i  "ill'  t!ic  oaticii!  fn'<ni«'ntly  •  cm- <li''Ttly 
t.i  icintraii- ill,  tc  fit  •■i  aw<-  of  a  forcifrn  iMuly  into  ic  ex  ■  Tin- 
|ialiint  wiil.  "iily  .-loail  "r  uii  iii  nro^i  :zal)lt>  wniiiul  or  sv  ir  Uv\» 
sure  that  iir  iihjsi  hav(   Uf.i  strui-k  by  a  1   rvs'  pit  ro  of  metal,  iK-caust- 

stales  I"  siti\  'ly  that  li<' 
;•,  am    yet    lit'       'imnatioh 
till    stil>siii      ii   his  'irs      :'l  t 
Im-  ])l;i  i-a  ujif         I'll  st;  it'HH'iiLs,  a 
*!vini.i     itctai      .      -<M\\    iii^-iwiT    I   csii 
•THiaufii  111  iiifial      ■  stoii         rJunL'  m 
lx>  susfi     ♦eil  ami  ■  .«•»'  .ivpv 


Uf.i  strui-k  by  a 
the  'liow  ah  lost  kiKH'l  d  I  mi  duuii,  or 
li<'-u(l  the  |.n  <■'  diMpa't'r --rikiiin  the  .> 


i\v  tliat   111.  \vi  .,iil    -lioiihl 
in  all  cases  of  iiijui  v  from 


s   ill    the    iiioNimily 
.  i^n   hody  in  ilie  <'y( 


Mien 
mild 


leh  roil;  'le 
•lit-:    aftt  I 

light    at:  1 

"his  i- 


>ome 

the-e  \y. 

by  1  5>iiqi 

S!   ■i\-H    .  1 

Will    -oiHC  lilies  ^ 
deniiv  -■      11  Miiil 

if  a  '  't  ^- 

Mist     ;         :  : 

1)1  it   tt«-  [I.  iiei 

gi.i'H   mag  ict. 

nearly  as  possi 

Uicn  irnidu 

r.nl  III' 


a  illo  is  (Icsi-    hie  when  e.\;  ij; 

-.  t'  hr  I        should   1m;  e\..    >i.  id 

K'si  villi  the  opii'      liiio- 

the  fiehl  of     isioii 
.reign  Uiidy  is  <'vi- 
lea  or  close  to  it,  or 


pus- 

"ill. 

at  til 


..I  a  p 
•  il  ]>aiii 
when  ' 
hange.- 
iito  the 
.ther 

.x\     I'll 


•lul    ti 

Uir  suspecti 
:hrou8;h  the  ci 
-  evidently   foriimig,  no  time  ini'd  he 
with  the  use  of  the  j-niv,s  or  the  sidi"    seoiw: 
r  cociiiiiizatioii,  should  lie  placed    ipjic     e  th<- 
!•     irectioi!  of  the  wound  canal   correspi"       ic    i.s 
'  with  the  long  axis  of  the  magnet.  '-ntit 

luna'd  on  or  the  patieii"  -  head  is  gnu!  irht 

let,   the  eye  being  kepi    brightly   illi  id 

•ved  meanwhile.      The  first  sign  of  tti^  -e 

I  V       fieijuently  tiien  be  given  by  tin    '■■ 
iris  V       iii'gin  to  bulge  in  some  part  of  its  ;k 
inn  of     :ie  eye  to  the  axis  of  the  m.igni't  shi 
to  I'avii    drawing  the  piece  of  niet;il  through  tin-  juipi! 
■rior  chamber  rather  than  directly  through  the  iris  root. 
I's  the  first  sign  is  the  su'lden  appearance  of  the  frag- 
posterior  surface  of  the  come!!,  whence,  as  tli(>  current 


1 

tri.n: 
vvitl 
sniu. 
Sleril? 
into 


iriied  off.  it  generally  tails  to  the  bottom  of  tlii'  anterior  chamber. 


wliicli    I  can  easilv  be  remove'   ;!  rough  a  jieripheral  incision 

he  sn 
iiaui" 


II  magnet,  or,  in  some  (.i    ■.-,  with  the  huge  one.       The 
and  the  necessary  instruments  should  previously  be 
'!  kept   ready  ;it  hand.)     If  the  steel  cannot  be  drawn 

lior  clianiber,  nor  through  the  root  of  the  iris,  it  may 
III.  11,  V  to  excise  a  piece  of  the  latter,  in  order  to  complett 

the  extrai-i  ii:n. 

Where  there  is  a  fresh  .scleral  wound,  or  where  then    is  a  cliaiic 
of  jireserving  the  lens  clear,   it   is  best    to  attemiit   tjio  extraction 


A  t'MJ'A  ruaw  (ifUTU.iLHIA 


Am 


tlimiipli  !ln'  rf'  |«'n(il  \mhiimI,  vUiicli  slmuld  1 


M-  <'ih  irRcd  at  «iii.   mil 


If  iiK'i-ion  at  lijjlit  aiijflcs  to  i(t*  iimin  (liri-ctii>ri.     Ii 


1  sonic 


Midi    asos  til'  >ii'c|  .xluHits  (lilt  tliroiifrli  the  wouiul  tn  the  JarKc  iiiajjin  i 
liiliiiv  tin-  laucr  tiiuciif.-i  the  cyi":    in  hIIhts  tlif  st-lcra  in  tlir  ni'ijjji- 


liiiMwl  of  the  wniuiil  may  Im-  sccti  to  lnilni',  but  llic  cMract 


iiini 


>l«'t('i 


Ion  cannot 


wiiliniil  introducing  the  tip  of  liic  Miiall  nia^iict  for  a 
lort  (li-?ancc      In  all  ca.-^s  wli<'n>  the  extraction  is  attempted  IhrouKh 
-cleral  \souii       ii.'sfivaterdaiipTof  iiiteetion  should  l.e  kept  in  mind, 
precautions  tin   wound  should  Iw  thorou);hl\ 


lid  h'side  tl 

•  lolccitu    l)\ 


rdiliai 


onjuiiciiv 


■r 


al  flap.     U  here,  in  using  either  the  large 
iiiall  magiii      a  gradual  approach  to  the  eye  or  to  the  su.H|)ected 


..e.'itioii    .f  the  loreig'i  ImmIv  tails  to  remove  it,  th 


tun 


ott  and  nil  quickly  several  times, 


ddi'ii  jerks  thus  prmluced  may  loosen  it. 


e  current  .should 
in  the  hope  that  the 


Where  the  hit   ol    metal  is 


•rohahly  large— /.  c,  if  the  external 


v\nuiid  is  t!iiee-sixte<'nf'i-  <.f  ::,,  inch  long— it  is  |HThaps  h-st  not  t< 
iiM'  til.  la  I  k'e  magnet  at  hrst,  Miice  the  foreihle  tearing  out  of  such  a 
lr;t>:iiieiit  lia>  in  some  ca.ses  caa-d  the  1ok.s  of  an  eye  which  might  other- 


have  Ih-cii  saved.     In  thcM'  eases  and  in  others  where  tl 


!ii;igii«  !,  pr(Kluce>  no  result,  the  metal  should  he  located 


;  }Mi~.>il)h',  and  if  il  is  .supjxised  to  lie 


;is  ace 


in  W\ 


arge 
urately 


ill!--,  t 


Vitreous  an  angular  coii- 


ival  Hap  should  he  dissected  up.  using  the  wound  for  part  of  it  if 
tiu-  is  siiil.ihh  located,  and  one  of  thchluiit  tips  of  the  small  inagiu't 
itnidueed  m  short  way  iH-fween  its  iijKs.    If  several  clo.sures  of  th( 


cir- 


■  nil  |indiiee  iio  result,  a  longer  tip  should  Ik-  introduced  as  near 
i  .issihle  fc.  the  supposed  iocation  of  the  metal:  and  if  thisattempt  fail, 
Mir  lip  -hoiild  he  moved  -lightly  in  ditTeii'iit  directions,  and  the 
•I'  ng  .iiid  clo.sing  fried  ag;iin  hefore  it  is  withdrawn.  Often  a 
I'll'  laiiseil  liy  the  metal  coming  into  contact  with  the  magnet  is 
II-  1  nil  clnsiiig  the  .-ireuif.  If  it  is  decided  to  move  the  point  to 
'!!  '  iitirely  different  part  of  the  vitreous,  it  is  best  to  withdraw  it 
iMss   it   in  straight   to   the  desired  point,  in  order  to  avoid  as 

If  three  or  four 


pnssiiile  disorganizatinii  of  the  vitreo 


III 


finiluctinii>^  fail  to  bring  forth  the  metal,  it  is  best  to  desist,  and, 
iNr  cnvenng  the   wound   with    tl 


le  conjunctiva,   wait   for  further 


i''Vi|,,pm,  Ills.     Sninetimes  a  bit  of  steel  that  eludes  the  first  attempt 
■   lie  heller  located  .'n   I  removed  .-ifter  the  clearing  up  or  extraction 


•I    .'111    u 


,tn   t 


p.'ii|ue  lens.     Ill  other  ca.ses  the  signs  of  infection  become 

lent  that  evisceration  is  called  for. 

lien-  a  piece  nf  steel  i-  known  t!i  be  in  the  opaipie  lens,  it  may 

niestiniii'd  wii'ther  it  is  better  to  extract  the  latter  fir.sf,  with  the 

I'latioii  ihal  ihe  steel  will  come  out  with  it,  or  to  draw  the  metal 

lie  anterior  chamber  with  the  magnet,  and  remove  it  before  ex- 


iiiil  till 


Th 


■euvre  lias  al 


t.il 


in  which  I  have 
"ling  liie  lens  ri. 


-iicceeded  in  the 


-eason  m 


were  ( 


certaiiilv  m 


xpellr 


410 


rut:  K  YE. 


Evisceration,  Enucleation,  and  Opticociliary  Neurectomy.  These 
arc  the  (iperatidiis  most  edimnoiily  eiii])loye(l  as  prophyhictics  and 
to  some  extent  as  treatment  for  symimthetic  ophthahnia. 

KviscKUATiox  or  I'xKNTKKATioN,  as  orifiinallv  deseribed,  consists 
in  (hsseetiiifi  Itack  tiie  eo?ijnnetiva  for  a  sliort  distance  all  around  tlie 
cornea,  making  a  small  incision  through  the  sclera  about  one-eijihth 
of  an  inc'.i  outside  of  the  former;  then,  with  blunt-pointed  scissors, 
which  shoulii  be  kept  between  the  sclera  and  chomid,  comi)ieting  the 
excision  of  the  cornea,  including  a  narrow  riuf;  of  sclera;  then,  with  a 
narrow  blui  '  patula  loosenin>j  the  coimections  between  tlie sclera  and 
the  choroid,  :lien,  with  a  broad,  flat,  sliarp-ed^ed  si)oon  severinj;  the 
connections  Ix'tween  the  choroid  and  the  optic  nerve,  and  by  pushing 
with  the  spoon  from  behind  and  pulling  with  a  forcejjs  from  in  front, 
removing  in  one  piece  choroid,  retina,  vitreou.s,  lens,  iris,  and  cornea. 
Any  bits  of  choroid  or  retina  which  may  have  escaped  this  jjrocess 
are  then  scraped  out,  and,  after  irrigating  th(>  cavity,  the  conjunctiva 
is  drawn  together  over  the  oiK'uing  with  a  purse-string  suture. 
(Fig.  214.)     For  obtaining  pathological  specimens  this  method  is 


no.  214. 


FlO.  215. 


Fm.  214. 
Fill.  ■Jl.'i. 


-Slump  after  evisceration.    (DE  Weckib.) 
-Mule«'  vitreous  sphere*. 


undoubtedlv  the  best,  but  it  is  followetl  often  by  ([uite  an  extreme 
reaction  with  long-continued  pain.  For  the  comfort  of  the  patient 
strictly  simple  exisceration  — ('.  c,  without  excising  the  cornea— is 
much  "suiierior.  This  is  done  by  i:  akhig  an  incision  clear  across  the 
cornea,  extending  for  a  short  distance  into  the  sclera  on  either  .side, 
utilizing  any  extensive  corneal  wound  which  may  Ix'  present.  Through 
this  the  entire  contents  of  the  globe  are  scraped  out  with  an  evis- 
ceration spoon,  especial  attention  tn'ing  paid  to  the  ciliary  region 
and  to  the  posterior  part  of  the  cavity,  where,  otherwise,  fragments 
of  choroid  or  retina  are  apt  to  be  retained.  The  cavity  is  then  tilled 
witli  peroxiile  of  'ivdrogen,  and  after  this  has  mo.stly  boiled  out 
the  size  of  the  cavity  is  reduced  by  ])usliing  in  the  front  of  the  globe 
about  half-wav  toward  the  posterior  wall;  iodoform  ()r  .somethint; 
similar  is  dust('d  freely  onto  the  surface,  some  of  it  entering  the  cavity ; 
a  bit  of  gauze  is  j.re.ssed  against  the  semicollapsed  ball,  the  lids 
allowed  to  cio,se  ()v;t  it,  antl  a  firm  bandage  applied.  The  gau.'.e 
.should  tw  removetl  on  the  second  day,  when,  if  there  has  Im-cu  no  pain, 
the  first  dressing  sliould  be  made,  anil,  if  any  considerable  pain  occurs. 


6'  YMJ'A  TUKTW  OI'IITIIA  LMIA . 


411 


luit  iipijlicatioiis  for  lialf  an  liour  from  one  to  throe  tinics  a  day. 
(•(iiitiiiucil  for  three  or  four  <hiys,  will  control  it.  The  reaction  fol- 
lowiii}^  this  oiieration  is  comparatively  slif^ht,  and  the  cosmetic  result 
is  much  better  than  where  the  cornea  is  excised.  Where,  as  is  the 
case  with  most  subjects  under  forty  years  of  age,  the  (juestion  of 
the  after-ajipearance  is  of  much  nnportance,  Mules'  operation  or 
some  modification  of  it  should  be  employed.  The  essence  of  this 
operation  consists  in  adding  to  the  evisceration  the  introduction  of 
a  filass  ball  into  the  scleral  cavity.  As  originally  performed,  the 
(•ornea  with  a  trianjile  of  sclera  at  either  side  of  it  is  excised  by  two 
curved  incisions,  the  contents  of  the  glolK-  scooped  out,  a  hollow 
glass  ball  introduced  (Fig.  215  and  216),  preferably  with  the  aid  of 


Fl(i.  216. 


Introducer  for  Mules'  sphere*. 

Mules'  injector,  the  elliptical  o|)ening  closed  by  catgut  sutures,  and 
over  this  the  conjunctiva  is  brought  together  by  silk  sutures,  so 
aitanged  that  the  line  of  union  is  at  right  angles  to  the  scleral  wound. 
Tiiis,  on  the  average,  gives  an  even  Ix'tter  stump  for  an  artificial  eye 
liiaii  the  simi)le  evi.sccration.  Its  main  drawback  is  that  as  the 
cavity  contracts  the  .sclera  is  sometimes  so  tightly  stret^-hed  over 
tiie  enclosed  ball,  Ix'fore  union  of  the  wound  is  complete,  that 
tiic  latter  reopens  and  the  ball  is  extruded,  somethnes  months  after 
ihc  ojM'ralion.  Something  may  be  done  to  lessen  the  danger  of  this 
l>\  uniting  the  scleral  wound  with  a  contirmous  silk  sutun'  and 
.Iniwing  the  conjvmctiva  from  above  down  at  least  three-sixteenths 
"i  an  inch  below  the  scleral  wound,  where  it  is  anchored  by  stitches 
p:i>siiig  through  the  episcleral  tissue. 

More  time  is  given  for  a  firm  union  of  the  wound  if.  instead  of 

•  M-ising  the  cornea,  the  latter  is  left  intact,  and  after  dissecting  up 

ihe  conjunctiva  around  and  for  some  distance  back  of  it,  the  contents 

nl  the  globe  are  removed  through  an  angular  .scleral  incision,  one  arm 

■  4  \\\\\c\\  should  be  al)out  three-(|uarters  of  an  inch  long,  ruiming 

I  lack  along  the  border  of  the  sujierior  rectus  muscle,  the  other  from 

"iii-<|uarter  to    one-half    inch    long,    parallel    to   the  border  of   the 

'■.iinca.  three-sixteenths  of  an  inch  back  of  it.     This  W(  und  sluaild 

iir  held  widely  open  with  hooks  while  the  evisceration  is  being  com- 

I'lrtrd,  and  sjiould  be  closed  with  a  single  silk  suture  at  the  angle, 

lie  conjunctiva  being  then  drawn  over  the  cornea  by  a  purse-string 

iiture.     It  is  more  ditlicult  to  evisc(Tate  the  eye  thoroughly  through 

nil  an  incision,  but  it  gives  a  better  stump,  and  if  the  glas,s  ball 

i.ouM  ever  be  extruded  from  the  scleral  cavity  after  it,  which  I 

i\  »■  never  known  to  happen,  it  would  .still  lie  beneath  the  ccnjunotiva, 


412 


rilK  EYE. 


;;;ri.S  ilt    h.^Si       i  -usi.!;  ...,  inu.rf..n.nce  .hi.  vv.arujg 

1        t,      i,   s.-leeting  a  ball  for  this  ..lu-ratiun,  ..no  of  m.t  inon- 

uS;  i;;?;>f  u!;  ail^u.,.? ..f  tlu.  ..y..  .h.,uUl  b..  tak.....  a,ul  .f  the  cornoa 

-  .•x..iso.i  a  still  ..n.^..  j;;;;;;-::;;;';:;;'^,, .,  ,,„„,,  ,..ui  plating; 

FlO.  217. 


Laer'B  eye  speculum. 
Fio.  21S. 


Fox'B  fixation  foroeps. 
Fio.  219. 


IriB  Bclasors. 


U,.  l.ttor  IS  intr.Hlu.....l  proporly.  an.l  son,.  ..f  thnu  an-  .listinctly 
"' Kvrn  K UH.N  .,.•  <l...lling  tl...  .-v.-ball  out  of  its  capsulo  is  ,M^rfonue.l 


SYMPATHETIC  OPHTHALMIA. 


413 


disc,  or  if  syinpathetir  ophthalmia  is  present,  and  dotachiiig  the 
olili(|iit'  muscles  as  tlie  hall  is  drawn  forward.  A  pa<l  of  wet  gauze 
or  cotton  is  then  pressed  against  the  lids,  to  check  the  bleedii  ^. 
iodoform  is  dusted  in  freely,  and  the  eyelids  closed  with  mthe  i 
tight  bandage,  plenty  of  cotton  being  ased  beneath  it.  Many  op. 
atois  close  the  conjunctival  wound  with  a  stitch  or  two,  but  I  have 
never  found  this  necessary  nor  advantageous.  In  cutting  the  rectus- 
icndoi.s,  sufHcient  of  the  external  one  should  Ix'  left  attached  to  the 
glolx-  to  afford  a  point  of  attachment  for  fixation  forceps.  Where 
the  oiieration  has  been  preceded  by  long-continued  or  s<'vere  infiani- 
niatioii,  Tenon's  sjiace  is  sometimes  so  nearly  obliterated  that  the 
globe  has  to  be  di.ssected  out  slowly,  great  care  being  necessary  to 
Mvoid  ])erforating  it. 

To  obtain  the  Iw^t  i)ossible  stump  after  enucleation,  each  of  the 
rictus  nniscles  should  Iw  secured  by  a  catgut  suture  as  the  tendon 
is  divided,  and,  after  introducing  a  gUi.ss  ball  into  the  cavity  left  by 

Fia.  220. 


KnucleattoD  Missors. 
Fig.  221. 


Strabismus  book. 


tlic  globe,  the  nuiscle.';  shoild  Ix*  united  in  jiairs  over  its  surface, 
tlii'  conjunctiva  Ix'ing  brougiit  together  over  them  and  united  to 
iliciii  by  silk  sutures.  Enclosing  the  ball  in  a  thin  layer  of  sterilised 
-|  Hinge  probably  favors  its  ntention.  I  have  had  no  "xperience  with 
iliis  operation,  and  it  is  too  .«oon  to  .'-ay  how  well  the  glass  ball  is 
nt:iincd  and  tolerated  after  it.  If  retained,  it  .  -tainly  will  give  a 
iiiudi  better  result  than  can  Iw  obtained  without  it.  Kven  where  an 
ye  lias  iMH'n  enucleated  for  some  time,  the  attempt  to  introduce  a 
u'l  iss  ball  into  the  orbital  tis.sues  is  justifiable,  and  has  given,  it  is 
■  lainied,  excellent  results. 

n'TKdcii.iAHY  Nki'KECtomy.  This  operation,  vdiich  practically  has 
-  |i"rse(lcd  the  previously  |)roposed  neuro+omy  or  simple  division  of 
III'  iHTvcs,  consists  in  making  a  three-quartets  inch  vertical  incision 
iniMigli  the  conjunctiva,  over  the  insertion  of  ihe  external  rectus. 
'iviiiing  the  tendon  of  the  latter  so  as  lo  leave  a  stump  one- 
■  Mil  nth  of  an  inch    long   attached  to    the   sclera,    securing    .he 


414 


Tllh:  EYE. 


l,mp  ciul  wit'p.  a  suture  which  is  .h:i\vn  well    to    one   sulo,  passing 
siio'ifi   eurved   scissors   aloiisi    the   nl<'!)e    until    the    optic    lUM've  is 
reached   and  plahilv  felt,  which  can  i)e  facilitated  i)y  drawni);   tlie 
eyebiill  forward  as  far  as  possible:   then  dividiiifi  the  optic  ni-rve  as 
far  hack  as  possible,  rotatinR  the  posterior  end  of  the  jilobe  forward 
until  it  can  be  seen,  cutting  off  the  optic  nerve  stump  one-sixteeiith  of 
an  inch  back  of  the  gVAn\  clearing  the  posterior  poh'  of  the  latter 
by  curvetl  scissors  of  all  connective  tissue  and  possible  ciliary  nerve 
attachments,  replacing  the   globe,  uniting   the  ends  of    the  rectus 
tendon  with  two  hue  silk  sutures,  and  closing  the  conjunctival  wound. 
Immediatelv  after  cutting  the  optic  nerve  the  lids  should  be  closed 
and  hrin  pressure  made  upon  them  with  a  cotton  pad  for  at  Iciust 
three  mhuite.s:  unless  this  is  done,  the  bleeduig  hito  the  orbital  tissue 
is  such  that  the  ball  sometimes  cannot  be  replaced.     Kor  the  same 
reason  it  is  important  to  complete  the  operation  as  rapidly  as  pos- 
sible and  hold  the  lids  clos.-d  with  a  Hrm  bandage.     It  is  sometimes 
necessary  to  sew  the  lids  together  temporarily,  in  order  to  protect 
the  cornea.     In  spite  of  these  precautions  it  may  become  necessary 
to  enucleate  the  globe,  and  the  possibility  of  this  shoukl  always  be 
insistetl  upon  to  the  patient  before  doing  the  operation. 

Choice  Between  These  Operations;  Their  Dangers  and  Advantages. 
Death  from  meningitis  has  been  known  to  follow  each  of  these 
operations.  Kvisci-ratioii  was  first  systematically  employed  to  avoid 
the  ilanger  of  death  after  enucleation  during  panophthalmitis,  and, 
altlu)ugh  tleath  has  U-en  known  to  follow  it  also,  it  j  robably  is 
less  dangerous  tlian  either  of  the  others,  since  there  is  less  chance 
in  doing  it  of  infecting  the  orbital  tissu(>s.  The  danger  is  slight  in 
anv  event,  but  its  possibilitv  should  be  kept  in  mind  and  the  strictest 
precautions  to  avoid  it  observed.  Whether  any  operation  beyoiul 
freely  incising  the  globe  should  be  ihme  in  florid  j)anophthalmitis  is 
a  moot  pohit:  but,  on  the  whoh",  a  simple  evisceration,  followed  by 
the  free  use  of  peroxide  of  hvdrogen  in  the  cavity,  is  the  most  rational 
procedure,  though  it  niu.st  be  admitted  that  where  the  intlanuiiation 
has  been  especiallv  violent  or  long  continued  the  sclera  itseil  is  occa- 
sionally so  thon.ughly  ii-.f>'cted  that  it  becomes  necessary  to  excise 

it  later  on.  ,     •  •         i,  • 

Enucleation  is  the  ojjeration  preferred  by  most  authorities,  it  i> 
:i  necessity  in  cas<'s  of  intra-ocular  tumors  of  the  eye  aiul  m  some 
'.■i..;.'s  of  malignant  .lis(>ase  of  the  exterior  of  the  globe,  or  of  the  con- 
iimctiva  or  orbhal  tissues.  It  should  always  be  preferred  m  the 
tn'atiiK'nt  of  an  actiiallv  broken-out  .sympathetic  oi)hthalmia.  Ihe 
nnin  advantages  in  otlier  ca.ses  are  tiie  slight  reaction  which  gen- 
eraliv  follows  it  and  its  greater  simplichy  as  compared  with  Mules 
oi>eration  or  opticociliarv  neurectomy.  The  dangers  connected  witli 
it  are  first,  that  of  enucleating  the  wrong  eye.  It  would  seem 
iihuosl  incredible  that  this  muKl  ever  hai']M>n  wn-  it  not  that  H 
has  actuallv  occurred.  A  good  ey^'  has  b.>en  enucleated  and  a  bim.l 
one  left,    this  danger  is  not  i)cculiar  to  enucleation,  for,  while  it 


C; 


iSaSBH 


"«M9fWn^«lli!" 


a YMI'A  TIIETIC  Ol'IirUA  I.MIA. 


41 -• 


liiis  not  hccii  known  to  omir  with  cither  of  the  other  o|}orations, 
iImtc  is  n;)  reason  why  it  might  not  occur  with  thcni  also.  In  sonic 
clinics  it  is  customary  to  guard  against  tiiis  possibility  by  marking 
\itli  pencil  or  ink  the  l)row  on  the  side  to  be  operated  upon.  Death 
iriiiii  hemorrhage  has  been  known  to  occur  after  enucleation,  also 
iirliital  cellulitis  and  orbital  abscess,  but  these  accidents  are  of  the 
iiuiiost  rarity. 

Evisceration  is,  in  my  opinion,  the  operation  of  choice  as  a  prophy- 
laitic  for  sympathetic  ophthalmia,  although  the  weight  of  authority 
is  in  favor  of  enucleation.  Where  the  sinii)le  evisceration  is  done,  it 
i>  easier,  .sa."er,  and  much  more  likely  to  give  a  gooil  stump  than 
( Mudeation,  and  the  reaction  following  it,  if  hot  ajjplications,  or,  as 
Minie  i)rcfer,  ice,  are  employed  for  a  few  days,  is  little,  if  any,  greater. 
The  same  advantages,  excej)!  that  of  simjjlicity,  with  the  additional 
(iiic  of  giving  a  better  stump,  pertain  to  Mules'  operation,  and  the 
iMct  that  the  eyeball  does  not  have  to  be  entirely  removed  induces 
>onie  peoj)le  to  permit  evisceration  where  enucleation  would  l)e 
ntused.  The  objections  conmionly  urged  against  it  are  the  great 
icMclion,  which,  as  has  been  said,  can  be  jiractically  done  away  with 
if  I  lie  simple  ojjeration  is  done,  and  the  greater  danger  of  sympathetic 
nplithalmia  after  it.  an  objection  which,  in  my  opinion,  rests  upon 
I'litirely  insufficient  ground.  Another  pos,sible  objection  is  that  a 
Miiall  choroidal  .sarcoma  whose  existence  was  unsuspected  might  be 
<'\  iscerated  without  being  noticed,  although  retrobulbar  mctasta.ses 
were  already  in  progress.  I  know  of  one  such  case,  and  only  one, 
wliire  a  subse(|uent  evisceration  of  the  stump  showed  a  retrobulbar 
^:iic(piiia  In  the  rare  cases  where  there  is  the  slightest  (|uestion  of 
iiiytliiiig  of  the  kind  this  cfn  generally  be  guarded  against  by  careful 
iiis]icction  of  the  contents  of  the  globe  and  the  inner  surfaces  of  the 
-ilcra.  .\n  infectious  necrosis  of  the  inner  layers  of  the  sclera  hits 
liiiii  iiientioiied  as  a  possible  complication  of  severe  or  long-continued 
I'.iMiipiitlialmitis,  which  .should  contraiiidicate  the  use  of  the  glass  ball 
'Alicfe  the  eye  is  eviscerated  under  these  conditions. 

'  ipticociliary  neurectomy  is  highly  reconuiiended  by  a  few  opera- 

'  lis;  but  since  it  leaves  the  choroiclal  ti.ssues  intact   as  a  breeding- 

.'I'liiiid  for  germs,  which,  it  has  been  shown,  can  pass  freely  out  of  the 

••\a\v  nerve  stump,  it   jjrobably  is  the  least  efficient  of  any  prophy- 

iiiic  iiperatioii   for  synijiathetic  ophthalmia.     It  shouhl  l)e  recom- 

iiiidcdas  a  prn|)hylactic  only  where  one  of  the  other  o|)erations  is 

■■  tiisi'd,  or  when>.  in  the  mind  of  the  operator,  the  risk  of  .symjiathetic 

I'liilialmia  is  so  slight  that  lie  feels  warranted  in  a.s,suming  part  of  the 

-liiiisibility  for  it.     In  ca.ses  of  absolute  and  [lainful  glaucoma  it 

"Iteii  efliciciit,  though  not  so  certain  in  its  results  as  evisceration. 

advantages  are,  that  it  will  sometimes  be  consented  to  where 

i '  I-  operations  are  refu.sed,  and  that,  although  the  eye  thus  saved 

-.  Iddiii  as  good-looking  iis  an  artificial  eye,  it  is  less  troublesome, 

i  ill  i-hildri'ii  it    permits   normal  development    of  the  orbit   aiui 

pi'ial  region.     The  evisceration  can  be  performed  later  on  in  life 


41U 


THE  EYE. 


if  it  is  (U>siml  for  cosiiiPtip  i)uriK.scs.  The  operation  is  inoro  dithcult 
and  prol)al)ly  n. on- dangerous  tlianoither  evisceration  or  enucleation. 
Artificial  Eyes.  An  artificial  siiell  may  l)e  nis.'rted  either  into 
tlie  cavitv  left  l)v  enucleation  or  ov.-r  the  stuni|.  ohiained  by  an  evis- 
ceration ;.r  one  of  its  inoditications.  This  shouUl  not  l)e  (  on.;  m  any 
event  until  tlie  wound  is  entin-ly  heale.l,  wh^h  is  usually  in  froin 
ten  .lavs  to  thr.-e  we.-ks  after  the  operati.)n.  The  use  ..f  an  artihcial 
cv.>  shoul.l  ahvavs  h-  a.lvise.1,  f..r.  in  a.l.lition  to  its  csmetic  value, 
it"  pn-vents  th.-  irritati..n  ..f  the  conjunctiva  which  results  wh.-n  the 
lower  lid  lM'coin.-s  inverteil.    To  insert  an  artificial  ey.'.  tl-  J 

lid  sh.)uld  be  .Irawn  f.)rward  an.l  th«'  larger  end  of  tlu'  slie.  ■!) 

shoul.l  Ik'  nioistene.1.  sliiiiM-.l  vertically  under  it.  Fhe  l..wer  h.  . 
then  lM>  depr,-s.se.l.  an.l  the  sh.>ll  sU.wly  rotate.l  int..  its  hoiy.  .. tal 
nosition  Th.'  shell  is  removed  by  slii)ping  a  small  hook  under  t  ..• 
low.T  e.lK.',  an.l  th.-n  making  gentU-  traction  upon  the  lower  lul 
downwar.1  an.l  while  the  shell  is  .Irawn  f..rward.  The  •'  ref..rm  eye 
has  broad,  smooth  edges  an.l  is  better  adapted  to  some  stumps. 

\s  the  enamel  covering  the  eye  soon  U.ses  its  p..lLsh,  great  care 
should  l)e  taken  to  preserve  it  as  long  as  possible.    For  this  piu-pose, 


Fni.  £0. 


Artiflclal  human  eyes. 

as  well  as  f..r  the  opportunity  offere.1  to  flush  the  socket  with  some 
n.il.l  antiseptic  l..ti..n,  the  eve  should  always  Im>  remove.l  .luring  s.eeii. 
a,„l,  after  careful  wa.shing,  tlu.r.mghly  .Iri.-.l.  If.  as  s..m<.times  hap- 
pens, the  li.ls  a.lh.-reto  the  shell,  a  little  vaseline  may  '«.  lutroduc.Ml 
int.>  the  s.)ck.-t :  but  if  the  onjunctiva  Ix-wmes  rough.-n.-d  an.l  catar- 
rhal it  luav  be  neccssarv  to  discontinue  wearing  the  (\ve  f.)r  a  tune, 
until  the  m'ucms  membrane  has  received  proper  treatment. 

As  a  rule,  an  artificial   eye   re.piin's  repolislung   after  eight.'.'ii 

months  of  coiitinu.ms  use.  .     . 

It  sometimes  haDpons  that  an  artificial  eye  cannot  b.-  r.;tam.Ml 

on  acc.unt  ..f  a  deformitv  in  the  c.)nt..ur  .)f  the  s.)cket.     llus  liap- 

,„.,.s  after  burns  an.l  l..ng-stan.ling  diseiises  ..f  the  conjunctiva  whi.'l. 

;,censi..n  cicatrices,  an.l  lu.t  rarely  aft.-r  the  use  of  ill-htting  ..r  ba.ll> 

p.,lishe.l  artificial  ey.-s.     Vn.ler  such  circumstances  an  operation  is 

iec.-s.sarv'.    One  of  the  best  of  these  is  the  proceilure  of  Harlan 

Transi)lantati..n  into  the  orbit,  after  excision  ..f  the  cicatrices   nt 

Thiersch  grafts  or  mucous  membrane  from  the  lips  or  vagma.  H:'^ 

also  been  tried  with  success. 

.  de  aohwelnlii  and  R«n<liill.    Amertcn  Textbook  of  Dleua  of  the  Eye.  p.  W. 


«Er»» 


^ 


CHAPTER    IX 


DISEASES  OF  THE  RETINA,  OPTIC  NERVE,  AND  ITS 
CEREBRAL  ORIGIN. 

By  T.  holmes  SPICKR,  F.R.CS. 

THE  RETINA. 

TnK  living  rotina  is  a  transparent  membrane  of  a  slightly  purple 
color,  poiitaining  the  expanded  termination  of  the  optic  nene. 
It  is  in  contact  with  the  choroid  on  its  outer  surface,  and  with  the 
hyaloid  membrane  of  the  vitreous  within.  It  extends  forward  a» 
far  as  the  ora  serrata,  where  it  ends  in  a  wavy  edge  near  the  base 
of  tlic  ciliary  processes.  Beyond  the  ora  serrata  it  is  continued  in  a 
riidiiiientary  form  over  the  ciliary  processes  (pars  ciliaris  retina')  and 
ilir  hack  of  the  iris  to  the  edge  of  the  pupil  (pars  iridica  retina-). 
Tlic  ])arts  <if  the  retina  which  ciin  l)e  identified  are  the  optic  disk  or 
p,i|iilla,atwliich  the  retina  starts,  and  the  yellow  .spot  or  macula  lutea, 
a  horizontal  yellow  oval  patch  at  about  two  and  one-half  optic  disk 
liiaiiu'tei-s  outside  the  disk.  At  the  centre  of  the  macula  is  the  fovea 
n  iitralis,  a  .small  i)it  or  (lepres.sion,  where  all  the  layers  of  the  retina, 
I  \((|)t  that  of  the  rods  and  cones,  are  absent;  cones  are  present  only 
ill  the  fovea.  The  rods  become  numerous,  and  the  cones  decrease 
ill  iiuiiiber  as  they  recede  from  the  yellow  spot. 

Till  fibres  of  the  optic  nerve  within  the  eye,  consisting  of  axis 
cvrmil  IS  only,  radiate  in  all  directions  from  the  disk  and  form  the 
inncriiiost  or  nerve-fibre  layer  of  the  retina.  The  retina,  in  sec- 
ii HIS  made  perpendicularly  to  its  surface,  is  found  to  contain  the 
fallowing  layers' 

I.  Xcrve-tibre  layer. 

■J.  (ianglionic  cell  layer. 

:'«.   Inner  molccul.ir  layer. 

1.  Inner  imclenr  layer. 

.").  Outer  molcular  layer. 

fi.  Outer  nuclear  layer. 

7.  Rods  and  cones. 

'^.  Hexagonal  pigment  cells. 

Tlicre  are  al.so  an  inner  and  an  outer  limiting  membrane,  the  latter 
■  iiit:  between  the  outer  nuclear  and  the  ro(l  and  cone  layer. 

^|o«t  of  the  fibres  of  the  nerve  layer  end  in  the  cells  of  the  ganglionic 
(T   but  a  few  are  continued  into  the  inner  molecular  and  inner 

rlcar  layers.    The  molecular  and  nuclear  layers  of  the  retina  con- 

27  (417) 


418 


Adjtoent  to  the  choroid. 


Tin:  t:YE. 

Fi(i.  .-a. 


AilJHiiMil  111  llie  vitreous.  .   ^    .  . 

'  Stlifiiic  of  the  ntniotiirf  "f  the  hiinmii  reilo'i. 

t  llnri/..MlHl  sfctlon.  li!em.it..xyliii  stnin.  I  I-itjinent  cpithelUl  Uyer.  II.  Ijiyer  of  ix.ls  aii.l 
com«  <i  KMinml;  I-.  ImcriiiiUlemints,  III.  ExlernalUmlllnK  mumbrnne.  IV.  Kxtornal  mole<  u- 
inrluycr:  f.  Fibre  l.iyer.  V.  Ksteriwl  gramiliir  Uyer.  VI.  Inlernal  moloculur  layer;  ./.  "P""!--'"- 
blii^s;-  SiiHiortinR  lihn-^ol  MiUUt;  /  Nuclei  of  the  same  VII  Internal  Kraiinlar  layer.  \I1I 
Uver'i.r  i!iii!?H"n  eell«     IX    Nerve  liiire  luver.    X.  Internal  lliuitlng  membrane. 

ii  Denion-^tiali..,,  ..II.  i  li.e  m,tl.,«l  ..f  (Jolgi.  I.  Pigment  epilhelial  layer.  II.  Layer  of  t,Kis  an.l 
cones  III  Molecular  a.i.l  vi~u.il  eelis.  IV.  External  i.lexlf.irm  layer.  V.  Layer  of  h(,ri/.Mital 
relU  VI  Lav.T  of  bipolar  cells.  VII.  Layer  of  amacrine  cell..  VIII.  Internal  plcxiform  lay.r 
(lil.re  layersi.  'iX,  I^iver  of  ganglion  cells.  X.  Nerve-libre  I»ver :  1.  Diffuse  amacrine  .-ells;  -•.  im- 
f.ise  aanglioM  cells ;  :i,  (Vulrifugal  nerve  ilbres ;  4  A>.MHiatl..n.araacrlne  cells  ;  C.  Neupiglla  cell, . 
I.  Sii'.porting  tibres of  Mailer. 

::;ist  of  nerve  cells  or  of  their  jiroeesses.  The  rods  and  cones  :iiv 
iiniiedded  !it  their  outer  ends  in  the  retinal  pigment,  a  layer  of  hexiij:- 
..II.  1  cells:  the  inner  smfaees  of  these  cells  are  imilonped  into  tiii-' 
processes,  which  p:iss  between  and  among  the  outer  parts  of  the  ro.i-- 
■uid  cones.  Under  the  influence  of  light  tiie  i)ipnent.  comes  forwani 
into  the  anterior  part  <'f  the  cell  and  is  found  between  the  rods;  m 
darkness  it  is  coUectetl  ii^  the  body  of  the  cell.  The  function  of  tin- 
pi-'inent  is  to  renew  t!i<'  visual  jiurple  or  rhodopsin,  aft<'r  the  hitl.  r 
hirs  become  bleached  l)y  the  influence  of  light.  There  are  certain 
other  Hustentacular  or  supporting  fibres  in  the  retma,  jjassing  fn  ;■ 
llie  anterior  to  the  [joslerior  limiting  ni-nsb-rane— fibres  of  Mnller 

Th(>  vessels  of  the  retiiiU  are  tlerive.1  from  the  central  artery  :i' '1 
vein  of  the  retina.     Tnese  start  at  the  disk,  dividing  and  subdividii  :, 


umm 


--%• 


IlirnSA.  OVTIC  SERVK,  .IM>  ITS  CEHKIIIIAL  ()1U(1I.\ 


11!) 


until  tlicy  rcarh  tlic  poriiihcrv,  but  tho  hranchos  do  not  aiiafitoinosc 
witli  one  another;  tlic  circulation  is  terminal.  The  importance  of 
this  is  sliown  in  the  interference  with  the  circulation  of  the  eve 
by  blockage  of  a  vessel.  No  assistance  can  1m>  obtained  from  the 
circulation  in  thi'  adjacent  parts.  There  is  a  limited  collateral  'ir- 
culation  between  the  retinal  vessels  at  the  marfrin  of  the  optic  di.sk 


Flii.  r.'.". 


I'iffmt'ril  citidu'liiini  (if  the  human  n 


1 


mil  branches 
known  as  the 
;i  ri'liiial   vess( 


of  the  short  ciliary  arteries, 
circle  of  Zinn,  ami  sometimes 
I  mav  arise  entirelv  from  this 


-"Urce;    it   is   then  known   as   a   cilio-nt'nial 

I -SI  I.     The  vessels  li(>  in  the  innermost  or 

M(ive-fil)i-e  layer;  hence  the  outeriijost  {)arts 

■  111  not  receive  nutrition  from  the  retinal 
Msscls,  but  fiom  the  rich  choroidal  cai)i!- 
'iiiis,  with  which  they  are  in  close  contact. 
I  l\i-  retinal  capillaries  are  extremely  fine,  and 
ilii'ir  meshes  are  closer  at  the  yellow  sj>ot  and 
i'-  immediate  neighborhood  than  toward  the 
I '  lii'liery;  but  at  the  fovea  or  central  de- 
i  i'>sioii  the  capillaries  !ir(>  entirely  .absent. 

Tlie  retina  is  the  es.sential  organ  of  vi.sion : 
i -lit  entering  the  eye  traverses  all  the  laycik   of  tho  retina  until  it 

■  iclies  the  posterior  surface  of  the  layer  of  rods  and  cones.    Tlie  light 
iniuli  are  received  by  the  rods  and   cones,  and, are  transferred  by 

'  i  alls  of  the  optic  nerve  to  the  brain,  where  they  gr\-e  ri.se  to  the  im- 

n  ssidii  of  sight.     The  region  of  acute  sight  is  at  the  fovea,  a  .small 

fression  at  <he  centre  of  the  macula  which  corresponds  with  an  area 

■  'he  centre  of  thr-vi.-ua!  ti(!t!,;)ne  ainloiie-lialf  degrees  in  diariieter. 

'  'ii  elements  of  the  retina  at  this  point  are  ,3//  apart ;  this  is  exjjre.ssed 

-t  by  saying  that  two  bodies  in  the  visual  field  are  not  seen  clearly 


ninnaii  rtxl  .uul  lune. 

(lilIAt:rG-S.4E.MISCII.) 


VM 


THE  EYK. 


\ 


II 


,n.l.-s  sul.t.-nUih.  Ml.  anpio  ..f  at  l.'ast  aV .  The  marve  Bupply  of 
the  f..v<'a  is  inor.'  al.uii.lant  than  tl.at  of  any  part  of  tlw  retina.  In- 
.,  .-w,.  ill  vvl.ici;  ,,n(-l<.rtiftli  oiiiv  of  llu'  fi<'l<l  <»f  vision  was  lost.  BuiiKc 
fouiKl  an  alrochv  "I'  al)oiit  on.-.|uart.'r  of  ttu-  wiiole  optic  n<TV«>. 

Tiir  niclullarv  sliratli  nf  the  oi>tic  nerve  til>res  ends  at  tiie  lanunii 
rril)rosa.  I)ut  it" is  in  rare  cases  prcs<Mit  in  the  disii  and  extends  to  a 

Flu.  'Ui.  ' 


aHliim  thrniiKh  (lie  inacula     (i.kai  tK  and  Saembch.) 

This  condition  is  iviiown  as  opaque 


varying  extent  into  the  retina. 
nerve  fihns  or  retained  nerve  sheolh 


(Fi};.  227.)  It  may  affect  a  por 
tion  o'r  the  whole  of  the  disk,  and  Mi:iy  extend  a  hniR  way  into  tht 
n'tin.'i.     In  rare  cases  separate  islands  o 
in  the  retina. 


-f  opacpie  nerve  fibres  are  seen 
These  fibres,  of  a  pure  white  or  greenish-white  color. 


Opaque  optic  nerre  llbrcs. 

are  denselv  opa<|ue.  wilh  a  >iriati>d  surface  and  an  ak  which  can  be 
seen  to  spread  out  along  the  fibres  of  the  nerve.  Tlie  retinal  vessels 
are  .-ci'ii  on  the  surface  of  the  opa(iu(>  (ibres  or  lie  buried  or  partly 
buried  beneatii  the  surface.  The  portion  of  the  ivlina  affected  wii!: 
<)pa(|ue  nerve  fibres  is  blind.  .After  severe  ()i)tic  neuritis  or  neuro- 
retiiiitis,  these  fibres  have  been  found  to  disappear. 


!fB*! 


mmmmmm 


KEllSA,  OJ'TIC  .V£,7i' »•/;•.  .I.\7>  ITS  (  KRLliliAL  UUKUS.      421 


Retinitis. 

Iiiflaiiiiniitioii  of  llic  ri'tiiiji  may  orcur  .is  ilic  rc><ull  of  an  injury 
or  from  the  ('oiicciitratioii  of  lirilliant  li^lit  (  ''  tlic  sun  or  of  ilu- 
I'icctrir  an-  U|)oii  it ;  l>ut,  as  a  rule,  il  is  tlic  matiifistatioii,  often  tli<> 
<inly  one,  of  ^ravc  <'oiislitntionai  disease,  sucii  ;is  albuminuria, 
};enerai  arterial  sclerosis,  syphilis,  Icuka'inia,  or  dialii'teM. 

Mypera'tiiia  or  conjrestion  of  llie  retinal  (•■•ipillaries  caimot  iw  recoj;- 
iii/.ed,  the  retinal  capillaries  Ix'iiin  themselves  invisible,  hut  tliecon- 
.lition  of  the  visible  bloodvessels  may  often  cjiablc  one  to  diapnose 
a  condition  of  jreneral  retinal  hyiK-ra'inia,  such  as  larpeia'ss  or  tor- 
tuosity of  the  arteries,  and  distention,  tortuosity,  and  d;irk  color  of 
I  he  veins. 

All  pathological  chan>;es  in  the  retina  show  them.>'elves  by  a  loss 
nl'  transparency,  the  alTi'cted  parts  become  gray  or  white  and  opaijue, 
the  vessels  are  indistinct  or  entirely  obscured,  and  the  undeilyiiiK 
ilioroid  less  clearly  seen  than  in  other  places.  In  .some  cases  the  red 
nliex  from  the  choroid  is  dulled,  so  that  the  retina  apjiears  to  have 
.1  smoky  hue.  This  opacity  may  be  diffuse  and  occupy  a  larpe  part 
■  if  the  retina,  or  it  maybe  limited  to  one  region,  or  may  show  it.-^elf 
ill  circumscribed  areas  separated  by  healthy  retina. 

Inflammatory  changes  ;ire  often  accompanied  by  hemorrhages  into 
till'  retina.  These  may  be  linear  in  shape,  and  iiuiylM-ar  a  relati()n 
'm  a  visible  bloodvessel:  they  may  be  punctate,  streaked,  or  flame- 
-liMped.  owing  to  the  direction  of  the  nerve  fibres  in  which  they  lie. 
They  are  generally  rounded  iii  the  (U-eper  parts  of  the  retina:  the 
niily  symptoms  pre.-^cnt,  as  a  rule,  are  diminution  of  sight  with  occa- 
-ioiial  Hashes  of  light  or  flickerings,  distortion  of  obj<cts,  such  a.s 
~iiaight  lines  (metamorphop.'^ia),  diminution  in  size  of  objects  (mi- 
'i'lipsia^  or  night  blindness.  In  some  oa.«es  floating  specks  are  seen 
111  lure  the  eyes,  which  are  ascribed  to  bi'iousnrss:  and  ophthalmo- 
-iiipic  examination  may  be  the  hrst  indication  afTorded  of  severe 
iniislitiition.al  disease. 

Syphilitic  Retinitis.      Syphilitic  retinitis  may  show   itself  either 

ill   association   with  choroiditis,  as  choroido-rotinitiK,  or  as  a  pure 

iiliiiitis.     It  occurs  during  the  secondary  period  of  syphilis,  betwet  n 

the  sixth  and  the  eighteenth  month  after  the  pri  uary  sore.     It  occurs 

ill  congenital,  as  well  as  in  the  acquired  di.'iease,  and  g(  nerally  attacks 

I'litli  ey(>s.     It  runs  a  very  chronic  conrs*-,  lasts  many  months,  an<l 

-liows  a  marked  tendency  to  recur.     The  ophthalmoscopic  signs  are 

11  exudation  into  the  vitreous,  generally  into  its  posterior  j)art.     This 

\tidation  is   very  fine,  but   can   generally  be  resohcd   into  actual 

iiist    opacities    by    the    ophthahiiosco])e:    it    obscures    the   fundus 

lid    may    hide    the    deeper    parts    (<ntiri'ly    from    view,    but    it    is 

iteti  ].nv;v:i!>!c   fu  PToguizt-   thfoiigh   the  Ir.ixe  tl--    hyp-''";!  niic  cni)- 

'iiion  of  the  ojitio  <lisk,  with  great  enlargement  and  tortuosity  of 

"ith  arteries  and  veins.    Then    may  1m>  spois  or  white  areas  of  exu- 

iation  into  the  retina,  and  heniorrliages  are  olten  pn.-ent.     In  \\\o 


i     i 


n 


ti  I 


iL 


vi-.'. 

later  >t;i;i<>  ihr  vitn-oUH  r 


THF  fry 


!ll  ftlZC,  ;i;ii 


1  iH.ih  arteries  anil  veins 


then  finitiil  (li!iiiiiishe<l 
are  slieatlietl  III  white.      I       retina 


lears;  tlie  art  tries  an 


I'maiiix  ()|i:i<|ne  am 


I   fibrous  lodkind,  ami  contains  piKii 


iloiiK 


I  he  slieat!i>  of   liie  vesseU   or  scut 
jHTipliery.     il'i»£   -->»  ' 


tiTcil   irregularly,  chid'       it   the 


Atr.,ph>-  or  retina.  I'lsment.tlo.,  -.f  -heath,  of  retinal  v  »el.  after  «''•''''"''«  """'•'L!'."^"'^ 
llne«  along  tfo  retinal  veius  ;  plgmenuition  of  vel..-  at  periphery,  armngement  of  pigment  bet»f*" 
thu  mam  vesaels  rraerobllng  rellnltli  pigmentoM. 

Th.'  lo^s  of  siftht  hears  no  relation  to  th(-  lithalmoscopic  chanps. 
It  nun  Iron,  tlie  Hrst  he  nuich  n-duce.l,  an  ,  after  suhsidence  of  the 
diseasi'  niav  remain  so;  while  in  other  eases  the  sipht  generally  niav 


•   -  I  -   "     t;i:iiM 


iMi 


RETrSA,  01  lie  SKRVE,  AXD  ITS  CESEB- 


ilGlX      423 


!H'(niii*i<l(r.il>ly  Tstdfi-d,  but  blind  un-uM  (sci  tiiinal.  "i  ii  riiiff  ^IuiimhJ 
uri'ii  iif  l>liinlii'-M  (uiiiuilar  sct)t(iiiia)  iiuiv  Im"  k>f'  Im-IuikI.  Tn'iit- 
riM'iit  riliiHilil  lit-  iM'pun  wit!  iit  ilclay.  It  in<rciiry  Ix- given  to  the 
limit  "I  Mifi'ty,  tlif  rounw'  of  llu'  ili.st'iiwt'  tnuy  Ixj  shortfiicd  und 
Miriip  of  its  worst  clu'ct.''  avoidi-d.  Iniitution  i.«  pfrlmiH  tln'  most 
sitisfiicl.iry  II  fthfxi  of  pvinc  niiTcury;  it  Hlnnild  In  piifhcd  until 
llicic  is  sliftlii  tciidcriicss  in  thi-  ftutns.  This  may  Im'  iltcriiatcd  with 
siiliciifaiiioiis  mjfctinns  uf  mirciirv,  nr  uitli  nicrniry  with  '-halk, 
taken  liy  till'  mouth  The  mcrcuria!  fn-atmi'iit  sliouhl  Im-  carried  oU' 
iiiilil  the  dis<:ise  hii-  comf  to  an  end    iid  siifTu-ient  time  hiw  piiK'til  to 


Albuminuric  retlnttla  In  *.  CMe  of  acute  nepbritli.  ibowInK  «reM  of  soft-edged,  (edenutoiu- 
looklD(  exudatloa  lato  tbe  retina,  with  bemorrbanet. 


reii(k>r  HTurrences  improbable.     To  thu*  treatni.Mit  should  bo  a<l(led 

Turkish  baths,  subc   taneous  injections  of  pilocarpine,  and  iii  the 

I  iter  stJines  ioditle  of  jHJtiissiuni.     At  the  same  tinio  dark  glasses 

-liould  Im-  worn  and  all  ase  of  the  eyes  prohibited;  the  glasses  should 

\<>-  domed,  of  neutral  color,  and  rather  tlark  shade,  with  sides  pro- 

■rted   by  gauze  or  crape,  to  exclude  light;  some  surgeons  speak 

iisrhly  of  sfv'ctrum  blue  glasses     Tt  is  doul)tful  whether  other  local 

i-isures,  such  as  leeching  or  counter-irritation,  have  any  effect. 

Albununaric  Retinitis.      Inflammation  of   the  retina  associated 

ith  renal  disease  occurs  very  often  during  the  course  of  a  chronic 


42) 


THE  EYE. 


intorstitial  lu-phritis  or  jiranular  kidney.  Tt  occurs  also  in  chronic 
pari-nehvn.atous  nephritis,  in  the  i^i.hley  disease  of  |)rf'KJ'ancy,  ai"! 
also  less"coninionly  during  an  attael<  of  acute  nephritis.  (  ;ig.  229.  it 
is  convenienl  to  chiss  all  these  varieties  under  the  heading  of  albu- 
minuric retinitis,  althougii  it  must  be  understood  tiiat  albumin  is  not 
present  constantly  in  all  cases:  it  occurs  in  two  fonn.s,  at  least:  the 
inflammatorv  and  the  degenerative. 

Intlammaior,,  Retinitis.  Where  the  disea.se  is  running  an  acute 
course  whatever  ;)e  the  fundaiiH-ntal  nature  of  the  kidney  aftec- 
tion  we  meet  in  the  retina  with  soft  whit.>  flocculent  patches  of 
cxu<lation,  combined  with  (edema  covering  large  areas,  with  swelling 
and  haze  of  the  disk.  Heinorrhag.'s  are  sometimes  present  as  small 
red  points  or  Hame-shaped  masses  of  blood  in  the  nerye-hbre  layer 
Thi.s  form  of  retinitis  is  not  alwavs  associated  with  much  impairment 
of  vision  and  is  seen  less  fre.iuently  than  the  other  form.  It  is  most 
commonly  met  with  in  the  chronic  large  white  kidney  stage  of  neph- 
ritis- it  persists  for  a  f<-w  weeks,  .-md,  with  general  treatment,  it  may 
disappear  and  leave  no  trace.  This  exudative  or  inflammatory  form 
of  retinitis  is  fieciuentlv  accompanied  \y  a  great  deal  of  exudation 
into  the  optic  nerve,  producing  a  condition  closely  resembling  the 
optic  neuritis  of  intracranial  disea.se.  _  _ 

The  other  form  of  retiniris  the  dcqcnerative,  is  sometimes  seen  after 
subsidence  of  the  acute  exudation,  but  generally  occurs  independent  y. 
It  consists  of  verv  brilliant  dazzling  white  spots  about  the  macular 
redor.     Its  most 'characteristic  form  is  very  like  an  astensk  radiating 
from  the  vellow  spot.     I'aeh  dot  of  which  the  a.sterisk  is  made  up 
has  a  sharplv  defined  or  hard  edge,  and  the  surrounding  retina  apjiears 
to  be  darkened,  possiblv  from  contrast  with  the  brilliant  exudation. 
The  exudation  .-onsists  mainly  of  granules  mixed  with  fatty  deiH.sit 
in  the  n.  ivous  and  supporting  elements  of  the  retina,  and  probably 
owes  its  peculiar  arrangement  to  the  folds  into  which  the  retina  is 
thrown  bv  (edema.     H(>morrhages  are  generally  present  also,  and 
mav  be  punctate,  .striated,  linear,  or  tlam'.-shai)ed     The  tendency  is 
for  "the  exudation  to  become  absorbed  -md  for  sight  to  be  somewhat 
imt)rove(i      It  is  rarelv  (.ntirelv  absorbed,  howevei ,  and  months  after 
H  few  dots  mav  generally  Ix-  seen  near  the  yellow  spot :  the  hemor- 
rha<res  also  bec-ome  absorbed  slowly.     A  peculiarity  which  is  seen  in 
.onVe  cases  is  pigmentation  of  the  retina,  which  ha.s  l>een  found  on 
microscopic  examination  to  lie  outside  the  external  limiting  mein- 
brine      In   severe   cases  of   albuminuric   retinitis  accompanied  by 
marked  ..apiilitis  the  recovery  of  sight  i.ever  proc(-e(ls  v<>ry  far,  and 
if  the  disk  becomes  af-Mpliic,  vision  may  be  almost  entirely  lost.     Night 
may  be  lost  also  in  kidnev  disease  without  the  occurrence  of  retinitis. 
The  sight  fails  rapidiv  an.',  completely  without  any  cause  being  di.s- 
cernible  bv  the   ophthalmoscope;    but    after  a   few   hour.s   recovers 
slowly      the  patient  h:is  headache,  vomiting,  and  the  other  symp- 
toms of  ura'inia.  and  the   blindness  is   i'r,nuic  amnimmx.     In   the 
albuminuria  of  picfiuancy  the  retinitis  may  come  on   comi)aralively 


BJCTiy.'.,  Ol'TIC  SERVE,  ASU  ITS  CEJtEllHAL  ORluLV      425 

cMrly,  or  may  Ix-  dclayod  until  near  the  ond  of  the  prPRiianry.  It 
|(,ll<i\vs  a'->  acute  course,  and  is  attended  hy  great  tli.sturhance  of 
finu'tion,  out  eonijjlete  recovery   is  often   ..htained. 

{{ecovery  is  more  likely  to  occur  in  the  inflammatory  or  exudative 
form  of  retinitis  than  in  tfie  degenerative  form.  Changes  in  the  vess<-ls 
arc  marked  in  the  degenerative  form.  The  small  arteries  are  thick- 
ened and  rigiil,  esjieciallv  the  iimer  coat,  and  their  lumen  becomes 
diminished:  the  capillaries  particii)ate  in  this  rigidity.  (Fig.  2;«).) 
This  change  shows  itself  verv  clearlv  by  the  ophthalmoscoj)e,  as  has 
been  d.'scribed  by  Marcus  Cunn.  the  smaller  arteries  of  the  r<  (Uia 
have  their  central  light  streak  wider  and  more  brilliant  than  usual, 

Fig.  230. 


Mbuminuric  rellnitls.    (iranuUr  kidney.    Note  hard-edged  "Mterl.Hk  •  exudntion  at  y  t,  the  .liver- 
» ire  conditiun  of  the  aileriee,  and  the  punctate  and  linear  hemorrhages. 


Ml  that  the  whole  vessel  appears  like  a  piece  of  silver,  or  rather,  of 
-old  wire,  and  gives  one  the  impression  of  being  hard,  round,  and 
uiwe.  At  the  same  time  the  artery  shows  signs  of  degeneration 
ill  the  form  of  small  l)right  spots  in  its  coat.  \Vhen>  it  crosse,-  the 
M  ins  the  blood  current  in  the  latter  is  interfered  with,  so  that  the 

nlumn  of  blood  apjiears  to  l)e  cut  in  two,  and  the  distal  part  is  dis- 
iriided  bv  the  obstniction.  In  more  advanced  arterial  disease  there 
■ire  slight  ine(ni!ilities  in  calibre  of  the  arteries  in  different  places,  and, 
.ceasiimallv,  sm;..l  aneurisms  may  form  on  them.  The  distended 
\rin<  sometimes  rupture,  owing  to  degeneration  of  their  coats  from 
-i.isis  of  tlu-  blood  within  them,  and  they  may  undergo  lusitori.' 

ilargement.     Hemorrhages  may  occur  also  from  the  arteries  them- 


420 


THE  EYE. 


I 


I II 


K,.lv,w     ( )...-  ..f  ll>.-  .•oinnu.n  results  of  this  fcrin  of  arfrml  .  r^ciKTii- 
,i„„  i^  ,h,.  .KTU.n.nco  of  an  area  of  tl.ron.l.os.s  of  th.  vo.n  at  the 
„  wlu-rr  it  is  .toss,hI  l,y  a.,  art.-ry.    Tl.is  is  follow...!  l.y  an  mflan.- 
",  rv  -uaati..n,  .•..n.pl..t..ly  ol.s.-urinK  tlu-  vossj-ls  at  t  ««  pla.-.-  ..f 
,.  nta.-t.  wl.il.-  luMn.,rrl.aK..s  an-  p.u.n.l  .mt  from  tl,.>  voin  iH.y.m.l    1 . 
;,.,s,r,u-ti.m.     Tlu-s..   .-han^.-s  in  th.-  v.-s.s,.ls  arc-  s..,-,,  R.-n.-ra  ly  at. 
about  fortv  v.<ars  ..f  a^.',  hut  may  ai.jH-ar  ..arluT-~u|.l.;.Ml   ahn..st  at 
.  v..«'«-     ■'n'..'v  n.ay  Ik-  sai.l  to  U-  ahnost  ohara.-t.-nst.c  ..1  granular 
khu-v.  although  thoyar..  .s.H-n  fr,..,u.;ntly  h,  patu-nts  m  whom  no 
oll',.rsi«..s  of  granular  ki.lney  .-an  Ik-  foun.l,  except,  ix-rhaps,  a  har.l, 
iiiconiDressihl.'  art.-ry  at  die  wrist.  . 

? Sosis.    This  is  t..  iK.  r..gar.l...l  from  the  p..int  ..f  vu-w  of  r.>.-..v..ry 
„f  visi..n    an.l  also  with  h'simh-I  t..  the  .hrat.on  ..f  h  .■•     As  hiu, 
ten    a  i.    he  .-xu.lative  or  inHanuuat..ry  f..nn  of  r..t.n.t|s  ,nay  be 
Xorbnl  Vntin-ly  an.l  leave  the  visi^.n  littl.-  .mp^.-r...!.     The .  -gen- 
,,-ativ.-  form  takes  nmch  long.T  t..  Ix'con.e  abs..rbe.l    .s  l''>>     1^  ly 
,„  b,.  absorlH..!  at  all,  an.l   n.ay  leave  ,>en..anent  changes  .n  tlu 
Lu-ular  r.-gio...  which  may  i.iterfere  gn>at  y  w.th  v.su.n.     Ih,-  prep- 
.-  fornrsar..  lik.-ly  to  n-cover,  provi.le.l  that  pr,.gnaney  .s  near    s 
!  ,rl.r  if  it  .-an  Ik-  .l.'t..rmine.l  by  pr..n,atun«  .lehvery.     As  n-ganls 
th.-'.luration  <.f  life  in  the  ..xu.lative  forn.s  aee.-mpanvmg  paren.-h>- 
„nt..us  u.-phritis,  although  the  rethial  .'hanges  nuiy  be  v.-ry  gr.-at. 
1^       .gnolis  is  n.>t  .-xtHMuely  grav.-,  for  the  eon.ht.on  ..f  the  k>.lne> 
v'  b.rr.M.ov..r..,l  fr..m.     In  the  .leg.-nerat.ve    <"•">-',*■"";;•';: '>^^,^ 
granular  kian..y  the  .lun.ti..n  ..f  life  is  short,  m  '"-P'tal  !«  •      >jl^ 
;,,,-,-.■  .luratu.n  ..f  life  has  b.>en  not.'.'  l.y  M.ley  anu.ng  4.)  .".s.-^  t.. 
'b,  u.;:i.T  four  .n,  nths,  an.l  the  extr.MU.-  .luratu.n  un. ler  t^^^  y'■a-^■ 
,,,,  .„lH.r  .>bserv,-rs  have  not.. I  less  untav..ral,le  ^^f^;  '  '     ^ 
Inn.'utiun  of  lif.-  s<HMns  t..  .h-i,en.l  up..n  the  anu.unt  of  .-an-  t  ut    a 
...  Taken  of  the  health.     Thus  an.,ther  ..bserv.-r  f..un.l  an.ong  ...    , 
pati.'nts  that  all  th.-  men  .lied  within  two  y.-ars.  an.l  t,S  l..-r  e.-nt.  ..ft. 

on.en,  a...l  an.o..g  privat.-  pati.-nts  ..nly  5'. ,«.  e.-nt^  ut  the  n.en  . 
.i„,l  .-,:{  p.-r  ••.M.t.  ..f  th.-  WO..UM..     A  f.-w  .-x.rpt.onal  .•ase>  1  a^.■  i...n 
,,..■< .nl.'/l  in  which  hf.-  was  proh.nge.l  f..r  s..v..n  <.r  «-v(:"tw.-lve  y.-ars^ 
Di-oetic  Retinitis.     Although  th.-  .•xist.-nc  ot  a.,  .ntlamnu.tu.n  o 
,„.,  ,,lina  p.-'uliar  to  .liab.>t..s  is  n..t  a.lmitte.   by  n.any  auth..rs  >. 
, vtinal  .•hang.-s  a.v  n...t   with  in  .liab-t.-s  wl.u-h  are  .hstu.ct   frm 
"„.et  .Tth  in  a,.v  other  .liseas..,  an.l  suHi.-.ently  hke  .-a.-h  ..th. 
iustifv  th.-ir    <.c..gniti..n  as  a  s..,>a.at..  var,.;ty.    /h..  t..n.,  «1  mh 
JHi.- V..tinitis  takes  is  that  of  a  group  ..f  l.nlhan.ly  .•eH..ctn,g  Ao^ 
.,,  ,n.ns  of   .(.•g.Mu.rati....  in  th.'  retina,  vury.ng   .nu.-h  n,   size   a 
,rroup..l  an.un.l  tlu'  v.-llow  spot.   Th.-  app.>a.-anee  ..  .-a.-h  .lcg<'"era     ' 
u,.    is  tnucl,  lik.-  .hat  ..f  the  in.livi,!ual  spots  n.et  w.th  m  =''  '""|"' 
n.tinitis,  but  th.Mr  an-a..g.-..u>nt  is  n..t  lik.-  the  .spok.'s  of  a  ^vhc'l,  ra  1 
..ih„-  fron,  th..  vllow  spot,  but  like  the  c.r...unfe.vn.-e  ..f  a  «h    ' 
.  rr,n....l  ,-.n.un,l  it.     .\t  th.-  sa...e  tin.e  tlu-re  are  nm  ...n.us  pm..-  .i. 
;;;„i  irn..ar  h..n,orrhages  in  the  n-ti..a.     This  for...  .>f  exu.lat...n  p.. 
si.sts  for  a  v(.ry  long  tin..'. 


wm 


Rl.TlSA,  OPVW  SEIiVE,  AA'D  ITS  CEnEUiiAL  OJiltilX.      427 

Leuksemic  Retinitis.  ( )wiiig  to  the  poverty  of  the  hlooil  in  colorinp;- 
iiiattiT.  Olio  of  the  most  striking  features  of  the  fundus  in  tliis  (Usease 
is  that  the  color  of  the  choroiihil  reflex,  instead  of  heing  a  full,  rich 
red,  is  111  a  light-yellow  color.  The  retinal  veins  are  large,  flahby, 
and  tortuous,  and  have  the  appearance  of  flattened  bands.  Retinal 
licniorWiajres  are  j)resent  with  white  masses  of  exudation,  due  to 
extravasations  of  white  blood  cells  into  the  retina.  These  spots  are 
sometimes  surrounded  by  a  fringe  of  colored  bloo-l.     (Fig.  231. > 

FlO.  231. 


t^'iikn^mlc  rt ;  inltln.    Note  the  Indlntinctneiw  of  the  ill«k  ;  the  eiiorinoui.ly  rllsiiMiduil  veins ; 
and  thu  hemorrhages  at  the  yellow  fiwt  surrounded  by  a  light  halo. 


Treatment.  The  treatment  of  albuminuric,  diabetic,  and  leuka'ii  ic 
t'linitis  is  tiie  treatment  of  the  disease  which  is  the  cause  of 
Im'  retinitis,  ainl  calls  for  no  remark  here,  except  that  rest  of 
he  eyes  should  1k'  enjoined  and  the  use  of  dark  protective 
I :i>s(s.     In   retinitis  occurring  during  pregnancy,  the   (piestion   of 

I'lcing  premature  labor  often  ari.<*es.  If  the  retinitis  be  seveix', 
;   i-  advisable  to   induce  labor:    but  this   should  be  postponed  as 

nir  .'IS  possible,  if  it  can  be  done  with  safetv.  in  order  to  save 
■     .liild. 

Hemorrhagic  Retinitis  (Thrombotic  Retinitis).    The  ophthalmo- 

"pic  jippeariiiices  in  this  disease  are  the  formation  of  a  very  large 
iiiher  of  small  flame-shaped  hemorrhages   all   over   tlie    retina   or 


42« 


nn:  AVi-;. 


Pio.  'JS2. 


Tiew  of  inverted  iirnme) 

Fin.  23S. 


.heath  of  llie  vii..  ^houi^l  U-  iilioU. 


KETIXA,  (H'Tir  .VA/.TA",   AM)  ITS  CKHEItHAl  <HiliilS.      429 

over  a  portion  of  the  ictiiia  drained  hy  a  s'nglc  vein.    ( Figs.  232  and 
2'-\A.)     At  the  sanir  time  tho  veins  in  this  region  are  enormously  dis- 

Fio.  2»4 


Bemonb«ct<!  retinitli.    (Jaeoeb.) 
Fia.  2S&. 


*'{e  ^iihhvHlnld  hemnrrfanip^  lit  yellow  upot,  which  han  buret  thmtiKh  Il«  (interior  limiting  mem* 
'■  (.'  iitKl  fiirniiil  H  rjrrurascribed  hemorrhHge ;  a  tieooud  BUbhyAluUl  hemiirrhHKu  In  seen  at  the 

T  imrt  iif  the  liiiutils. 


3j.'^"isK^fla&-T;Lit'r^r=3*- 


4:}0 


Tin:  i:yt-- 


I! 


ft 


I ' 


4:}0 

n.tina  is  ,.-.u..liy  -«-=;;:  ^.^^.^  u;::;;;,,...;  ..r  tlu.  trunk  of 

ais.MS<'  of  111.-  valves  ..t  tin    '"  :\V  ,,.,.,, rs  inH-n-' those  wl...  l.avr  n-. 

--  -"VV«  !'"'  •^'"V:;:;i[  "  'l  "n'lu;;  s...onaafy  to  orl.i- 
,r,s,.ov.Tal.l.>  .lisc'asc  '''f'>.'^'"\;.  ,',,.,  „r  .li^-asc  of  the  cavernous 
tal  aiseas,..  suel,  as  .■ellulit.s.  '  ^^;       ''^j;'  ;   ,.  ,  ,,„„.  ,1„.  ,...ur,-e  of 

sinus  ana  the  ^^^^^r"''' ^TZ-^nt^t^^  .l.-'l'ti."  -•-'•  - 

,„.„.  nveulat-  '-'-;f":;,;:;£.;  't-isher-s  observations.  1-neath 
hvaloia  nu'inhrane.  ana  •<""^"'>  ,1,,.  .-unture  of  a  vessel,  prohal.lv 
tl,.  nuMnl.vana  li.nitans  n.terna,  t.o.n  '  '  ^^  ^j,    ,,,  ,  „a  „,,.„- 

\  retinal  vein,  h  is  ^.Mt.-n.lly  ;;•;;:;'",;:',,;;.«.  a^^oeiatea  with 
,,i,.s  the  yellow  sp...  >•.'!.....'.  l"^;' J  ,;  S  nuieh  itnpairea.  hut  as  the 
lu-n.orrhaK('sni..therpait..    .  .  .^^  l„.,.„nu-s  exposed. 

,,,.,„„,,„,,,,.  ,ets  slowly  a bs    1>  '         .        ;,^.,,,     ,„.  .,iff,„„,  i,„o 

,i,„l  vision  ts  restorea,  o.       '    "     .     ;,;i.,ia  .ne.ni.rane.    (V\?.-2^.^ 

U,MUorrha-<s  an-  also  ""  ;  '  .^^J„f  „„,  ,i,i„.  l.ar};e  retnu.l 
a,„vloU  ais..ase.  purpu,  u  ^"'  '''"'i;^  ,\,,,  ,itreous  are  seen  oe.a- 
,„„i„,,ha.es  whieh  -"""7';^  ^,,„  .^  .>.  Souu-  of  the  patients 
.sionally  it.  y-mttfl  aaults  ^v"  '<  '  P-'  " ',  J'.,.,  ,,,,,,1, ;  sueh  p.^tients 
.„.,.  a  ueniic.  others  are  ai.pai.-ntlv    u.  1    '  '  ,„.,.„nlinf:  t..  I'.nles. 

;;;..  ...uerally  suhje..  to  --;;i^;^:- ^  '    j'^U'i.rn.s  of  .et inn ,s 

who  tirst  aes,.nl.ea  the.n.    Ih    ^  •'  .^    j,,„,„  p.jjularaoses  ot  l.lue 

^,„i,.  ,-,.„lr..  .-h..!..'"'  "■  ll«-  l""l>  ■  ■  t    ,;    ,i  nil  l.l.-.«-l.l«  <.r  l.v  any 
„„,„  ,|,,,„„|«"...K  i"»"";»'  »'         ,     ,   ■,,„,|„,  ii,  tto  ro(,na.    II 

™s?;:';^^.5.HS"'s;ri,:Jt.'......... >«, 

r-  "< « ';j;T;^cr,i,i;;;™.*  m.-*--"  -'  -i;:: 

retuia.      1  ne>'-  i'''--  ■'    ■   ,        K.,>.,ai.ts  mve  wav.  tornunp  penou"'*".' 

I.-: »'- *''•■»"■  I'" ; ,:: ;  "';.Tn.i»iJy  h-  •.'»  ««i"  ■"  "»■ 


iiETixA,  orrw  .\j:i:yj-:,  a.w  ith  cEnEitUM.  oiuais.    431 

whuli  llu'  l);iii(ls  of  fibrous  tissue  form  in  tlu'  rctiiiii  itself, and  jieiicr- 
ally  fiiliow  tiic  course  of  tlu-  bloodvessels. 

Retinitis  Circinata.  Tliis  is  a  rare  atT(>(-tioii,  in  whieh  larKc  areas 
(il  biilliant  white  exudation  with  dots  of  dark  color  on  them  are 
f(irtue(l  ill  the  rcfiion  around  the  yellow  s])ot.  The  central  jiortion  of 
till'  retina  itself  has  iinderjione  nuich  dej;eneration,  and  is  jrniy  and 
ii|>a<|iie;  the  aitpearanee  of  the  white  jiatches  in  the  retina  is  rather 
like  tiiat  of  passover  bread.  Ilemorriiafies  nenendly  accomjjany  the 
disease.     It  occurs  mainly  in  very  old  |)eo|>le.     (l''ift.  2H(».) 


Flo.  23<i 


KinniiisrircinKta.    Note  the Kray  (le(ieii»nition of  tliv  retiiiB  ul  Iht  yellow  »i«)t.  uiid  the  white 
t'xiiilutiuu  conieutric  with  the  jtllov,'  simt,  huviliK  the  a|>|iearuliee  oi  i«.>»over  breml. 

Sxanmetrical  Disease  of  the  Macula  in  Toung  Children.    This 

'    liiiiti,  liist  described  by  Tay.  associated  with  disease  of  the  cere- 

■  ;!  <()rtex,  is  a  rare  disea.se:  it  <iccurs  iluriiif:  ihe  first  two  years  of 

,    ireiierally   amonfi   the   ofTs])rin}i   of    Jewish    jianiits.     A   white 

'ih  i>f  exudation  having  a  ('herry-re<l  sjiot  in  the  centre  is  .>^eeii 

'III    Miacuhi:  the  optic  nerve  slowly  atrophies,  the  ciiild  becomes 

.  i.    :i;id    dep'iier.-ites    !nent;dlv    until    'ieath    ensue<    after    some 

■■•lis. 

F.mbolism  of  the  Central  Artery  of  the  Retina.    W  Ihi:  i  his  occurs, 

11   is  sudden  and  complete  failure  of  sight.     The  iiatient  is  ibout 

"idinary  oc''upat'o!)   and   is  conscious  of  snineihintr  [teculiar  in 


432 


TIIK  EYK. 


his  sijilit.  Oil  (•((VcriiiR  oiio  rye  ho  finds  that  tht-rc  is  only  faint 
|MTcci)tii)n  <if  liplit  in  the  :itT('cic<i  cyp.  (Fiji.  2:17.1  When  cxiiniincd 
by  tlic  n|>liiiialni(>sf(iiM>  al'tiT  :i  few  Imurs  the  arteries  itrc  fnund  to  Ijc 
iiiueh  sliniiikeii,  luit  jjcneraiy  not  i|uite  li'.nodlcss;  the  veins  an*  of 
ni)nna!  size  "r  ratiier  sinalliT,  i)nt  tend  to  i.KTear-f  in  size  away  from 
the  disk.  The  whole  retina  is  whiter  t'nin  nonnal,  tlie  whiteness 
Ix'inn  most  marked  aronnd  tlie  yellow  spot.  The  fovea  a|>|)enrs  hy 
contrast  l>ri<;htly  red,  as  if  there  had  ?K-en  a  hemorrhage  in  it.^  This 
apiM'aranee  is  known  as  "the  eherrv-red  sjiot  at  tlii'  macula."  The 
whiteness  nl'  the  retina  is  due  to  ledema,  and  this  is  most  marked 
just  around  the  yellow  spot ,  where  the  n  tin  i  is  thickest ;  the  cherry- 

Klll.  287. 


Embolism  of  centnl  »rtery  of  the  retln«.    (Liebbeich.) 

red  spot  at  the  fovea  is  owinf;  to  the  red  of  the  choroid  fjcing  seen 
thnniv'li  the  retina,  which  is  very  thin  at  this  spot.  The  cherry-red 
spii  lias  JM-eii  seen  within  twenty  minutes  after  embolism  has  taken 
place.  The  column  of  l)lood  present  in  the  vessels  is  sometimes 
broken  uji  and  moves  about  in  an  irre<;ular  manner,  sometimes  from 
one  vein  to  another;  sometimes  in  a  reverse  direction  to  the  normal. 
.Ml  the  small  vessels  in  the  re<j;ioii  of  tlie  macuLi  stand  out  very  dearly 
asjainst  the  opaipK-  white  retina,  .\fier  the  tirst  tew  (lays  there  i- 
freiiuently  .sliftlit  imjirovement  in  sisjrlit,  owing  to  paii'.al  restoration 
of  the  circulation  from  anastomosis  of  small  ve.'^sel.  situated  around 
the  entrance  lo  the  oi)tic  nerv(>,  but  tlie  hniirovement  is  v<-ry  slight; 
the  (ed'ma  clears  up  in  a  few  weeks,  and  atrophy  of  the  di.sk  follow> 


lit  I 


HKTISA,  Ol'TlV  .SKUyt:,  -I.V/>  ITS  VKHKURAL  OHUilS.      4:5:1 

„„uHiin.-s  only  a  branch  of  tho  central  artiTV  is  afr.'ctr.lMvitl. 
,1„.  .orrcsiM.n.linK  iK.rtion  of  the  r.-thm.  In  one  j.uhl.she,!  ca«-  the 
„,„.„lar  region  wsus  su,.|.lie.l  l.y  a  cili..retinal  i.rter>-,  an.l  central 
vi'.;  Ml  was  retaine.1.  althoURh  all  the  oth.T  parts  ot  the  retina  weiv 
l,li„,l  A  cas«-  has  Ix-en  seen  recently  in  which  cnibohsni  of  one  artery 
wi-i  loUowe.l  l)V  a  sitnilar  acciih-nt  in  tlu-  other  eye. 

OauM  The  "most  coinnionlv  lussigned  caus<'  is  the  s«>|)aration  of  an 
,,„lH.lon  from  a  .lis«'as«Ml  valve  of  the  heart.  ( Hher  caus.-s  are  uth.- 
,,„„.i  „f  the  aorta  or  other  lurge  vess<'l.  aneurism,  pn-Kiiancy.  <.r 
Uriehfs  ilis..as.'.  But  cases  are  not  ran-  in  which  there  is  lu.  cause 
,,t  this  s„rt  to  Ih'  found  by  most  careful  examination,  and  it  is 
,„,,|,al.le  that  many  of  the  ca.s.-s  presentiiiK  typical  featu.rs  ot  em  ...- 
Lni  ar."  really  cases  of  sudden  thromhoms  of  tli.'  central  arterj-.  due 

"" Treatment. '''".\s  to  treatment,  nothing  can  he  sui.l  to  he  henefi-'d 
with  certaintv.     Paracentesis  of  the  anterior  chamlx  r  and  iridectc 
have  Inrn  tried  without  result :    massage  of    the  eye  may  !«'  In.d 
will,  the  hope  of  causing  the  emholon  to  move  to  some  mure  distaii 
part  of  the  circulation:  it  has  Imm-u  successful,  hut  it  must  he  api n- d 
radv  a  id  vith  force.  ,.,  •       •  ■       . 

Thrombosis  of  tte  Central  Retinal  Artery.      I  his  i^nes  ns.     ,, 
<vi.i|.toins  an.l  oplitlmlmo.scopic  apiK-aiaii'-'s  uUiuical  ;vil h  Iho.^;  o 
,,„h,.li-,i.    the    uain  .iilu-rence  being  that  m  thrombosis  the  pa  n,ii 
i-  w.iiT  v'  '     V  irorar>-  failures  of  sight  which  pas.s  away,  until  -ne 
..(•luiv  w  i.rt's  not  clear  up. 

Quinin'.^iiuiiaeas.     v>>'e  Optic  Npr>-e.) 

Meet  of  Light  on  the  Eetina.    The  effect  of  hgld  on  the  eyo  ^how,. 
ii.lf  in  the  conjunctiva  and  hi  the  retina.     Kxposun-  l-  ih'    -un, 
,,„.ducing  sun  blindn<-s.s,  or  to  the  electric  arc.  as  a  n„,  causes 
inteiis,.  conjunctivitis,  a  comlition  amdogous  to  blistenng  of  the 
.kill  bv  direct  sunlight.    Thoughtless  exposure  of  the  eyes  to  tli.-  sun, 
„r  to  ihe  ravs  of  a  powerful  arc  lamp,  may  produce  r,.su!t,-<  on    h- 
.vtiiia  which'  are  sometimes  penimnent.    Many  instances  are  rec  ..led 
i„  which  patients  have  stared  at  the  sun  during  an  ecli|-..<'.      llu- 
rrM.lt  has  been  in  ...-me  ca.sos  a  persistent  positive  scotoma,  pi-ducmg 
indi.stinctness   or  a  blur  ..ver  every  object   directly  looked  at,     l.i 
,,th.T  cases,  'vithout  the  sight  Ix-ing  at  all  dim,  the  consciouMu  ^.s 
n mains  of  a  col..red  spot  in  the  centre  of  tlu-  held,  s.-en  gen.-r.dly 
nheii  a    white   background   is   looke.1   at.     Other  cas,-s   have  been 
,v,-,.r.ied  in  which  a  permanent  central  scotoma  with  loss  of  a  cut  e- 
„...s  of  vision  has  lK-<-M  left  behind.    ObserA-ation  of  the  f.n.-a  in  such 
,as..s  has  .-hoNvn  it  to  b'-  swollen,  or  to  have  a  hemorrhage  at   its 
-iiiti-e.  or.  at  a  h-t.-r  stiijx? ,  to  be  atrophic.     Treatment  should  be  liy 
vr-\  and  dark  glasses  v.orn  for  a  prolonged  period. 

Atrophy  of  the  Becmi.  .\trophy  of  the-  retinr.  may  occur  as  the 
vsult  .  f  i<,ng-(oritii.'ie<l  !>n-vious  inilammation.  It  may  be  the  con- 
-.•,,uei..,.  ut  a-i  cnibolisi..i"..r  thrombosis  of  the  central  retinal  artery. 

28 


434 


Tin:  KYK 


I 


It 

\ 


li 


ii 


in  1 


Or  II  iiiuy  In- a  s|MTial  afffctioii  (•lianu'l<'iiz<'<l  l)y  tlir  forniatioiuif  new 
niniMciil,  ami  known  as  retinitis  inpnii-ntdsa. 

li.linilis  I'uiimnliMi.     This  disiasc   is  cliaractcrizi'd   at   its  (ins«'l 
l»y  loss  (if  iM>\v<-r  to  s.-.'  at  niplit  «>r  in  twilight  (night  hliiiiliiissM,  the 
visii>n  ri'iuaining  K»)tMl  during  liaylinlit.     If  tiu'  fi<'l<l  of  vision  Im-  taltrn 
at  this  tinii-.  il  will  Im-  foun.i  iionnal  or  nearly  so  in  hriglit  iigiit :  Imt 
if  the  ilhmiination  Im-  diiiiinishetl,  some  reduction  in  the  sizi- of  tlie 
fields  will   Ix'  found.     As   the  disease  progresses  tlu'  fii'ld  Ix'eonies 
eont ran. -d.  even  in  bright  dayliglit,  and  the  eontraetion  may  advance 
so   far  that    the  patient    has  dithculty  in   finding   his   way  aN>ut: 
in  extreme  cases  the  field  is   reduced  to  a  mi-re  point      Kven  in 
this  stage  central  vision  may  be  almost  unimpaired:  in  some  raws 
the  whole  of  the  field  is  luit  lost,  iuit  a  zone  or  Ih-U  of  the  retina 
l)ecom<>s  blind,  giving  rise  to  a  ring  scotoma.     Hy  opiithalmoscopic 
examination  the  retina  is  found  to  contain  a  large  amount  of  pig- 
ment in  its  anterior  layers,  deposited  in  the  fonn  of  (U>ts  or  islands, 
shaped  much  like  Ixme  corpuscles,  having  branches  which  coninnmi- 
eate  with  other  ni'ighboring  dots.     Pigment  is  deposited  also  along 
till"  sheaths  of   the  smaller   vess<'ls.     In   more  advanced  cases   the 
red   background  of  the  eye  app<>ars   to  Im-  covered  with  a  delicate 
bl:ick  lacework:  in  its  most  severe  form  the  pigment  is  so  dens*-  that 
little  of  the  red  choroid  is  visible.     The  general  arrangement  of  the 
jiigment   is  in  the  form  of  a  zone  situated  about  midway  between 
the    peripherv   of    the    retina    and    the   optic    nerve.     This    In-lt    is 
densest  at   the  centre,  and  thins  otT  at   its   inner  edge,  toward  the 
disk  anil   also  toward   the  jwriphery.     The   retinal   vessels  Ix'come 
reduced  in  size;  the  arteries  may  Im-  mere  threads;  the  disk  under- 
goes  a    peculiar  dirty  yellow  atrophy   known   as    imst-rttinitic  or 
\mx!i  iilriiplni:   the  leiis " may  become   atTected   with   jjosterior  jxilar 
cataract,  and  opacities  may  apix'ar  in  the  vitreous.     Although  this 
is  the  usual  character  of  the  dis«'ase,  cases  are  occasionally  met  with 
in  which  night    blindness  .and   loss  of   helds  are  present   and  some 
post-retinitic  atrophy  of  the  disk  is  seen,  but  in  which  no  pigment 
can  be  seen  in  the  retina,  or  in  which,  instead  of  jngment,  a  iuuuImt 
of  soft-edged  rounded  yellow-white  spots  are  seen.     These  two  condi- 
tions are  spoken  of  as  rilinilif  />((/'"<"'"•■>"  irilliout  piipmnt  and  ritiuHi" 
piinrldin  (inivsrrns.     The  retinal  hexagonal  pigment  is  gradually  ab- 
sorbed or  travels  forward  to  the  antenor  layers  of  the  retina,  so  that 
the  choroidal  vessels  ainn-ar  to  stand  out  very  clearly.     There  is  soni'' 
doubt  at  present  as  to  whether  this  disc:-  '  should  Ix'  considen-d  as 
choroidal  or  retinal  in  origin,  as,  ■.icccriling  to  Wageiunann.  if  the 
choroidal  circulation  is  interfered  with  by  division  of  the  ciliary  ves- 
sels, a  migration  of  pigment  forward  iiito  the  retina  takes  jjhuy  like 
that  seen  in  retinitis  ))ignientosa.     The    lis<'ase  is  first   met  v.ith  in 

1  111  conseqiience  of  the  ooiifuslmi  which  has  arisen  with  n-ttiircl  to  the  wonln  nyctalopl*  an 
hcmeraliipla,  Ihcy  beinit  iiwl  in  opposite  nense?  hy  Kuglish  and  Continental  wrlten.  It  la  better  i 
n«c  tlie  terms  ninht  anil .    y  bliiidnem.  which  explain  themselvea. 


n 


RETISA,  OPTIC  SEHVE,  ASO  ITS  VEREHHAL  OHIUIS.      4;Ji> 

.liil.lli.MMl.or  iiUnH  puU-rly,  ami  julvaiiccs  f«l<.wly  lo  iiltiioxt  n.inplctf 
l,liii.|ii.r.s  iilttr  miiiillf  life;  it  attack;*  Inith  cyi-s.  Its  <-au!^'  if  tinkiiown. 
h  i-  livquiMitlv  luTcditarv.aiul  occvirH  in  those  wIk.sc  parciits  wen- 

1,1 1  rrlatioiislM'lon-iimrriauc.    (MIkt  defects  of  the  i.ervous  system 

,1.  utteii  present.  s\ich  as  deafness  and  want  of  mental  (Miwer.  No 
irraiment  is  known  to  Im-  successftil  in  thi»  dis«'ase.  Iodide  of  jxitas- 
Muni  and  strychnine  may  Ik-  tried,  with  the  application  of  the  constant 

riirrenl.  ,       , ,.    , 

The  prognosis  is  had,  althouRii  complete  bhiidness  may  not  come 

oil  until  verv  late  in  life.  . 

The  alrophv  which  follows  syphilitic  n'timtis.  esjK'cially  in  ehild- 
|i,.,mI.  i>  often'  similar  in  apiK-ai-ance  and  coursi'  to  true  retinitis  piji- 
iHiiiln-^a;  Init.  as  a  rule,  there  is  .some  evidence  of  involvement  of  the 
1  lidinid  in  the  syphilitic  affection. 


»1o.  2SH. 


Deucbment  of  the  rctinu.    (Jaeger.) 

Detachment  of  the  Retina.  The  retina  i.s  continuous  witii  the  optic 
.v\r  at  thi'  ilisk,  and  is  atniched  to  the  choroid  at  the  ora  serrata; 
,;it  l«'tweeii  lliese  jxtints  it  is  iield  in  apposition  with  the  choroid  only 
,v  the  support  or  pressure  of  the  vitreous  within  it.  It  is  lial'le  to 
.i>  detached  from  itsjiosition  by  various  causes,  such  as  injury,  ex- 
i.ivasatioii  of  blood  or  serum,  by  tn.ction  from  within,  from  bands  in 
r..-  vitreous,  by  tumors  of  the  choroid,  or  cysticercus.  It  is  met  with 
,1-1  cummoiilv  in  mvopic  eyes.     (Fig.  2.'JS.) 

The  eau-sj-  (If  the  detachment  hits  b.  'n  accounted  for  in  many 
,v,_by  exudation  of  fluid  from  the  clioroid.  by  sudden  oxtrava- 
'iMi,  ,,fbl„„d  from  the  choroid.  Neither  of  these  theories  exi)lains 
■  larjie  number  of  ca.ses  in  wiiich  the  detachuient  comes  on  suddenly 


MICROCOPY    RESOLUTION    TfST   CHART 

(ANSI  and  ISO  TEST  CHART  No    2! 


A  APPLIED  IISA^GE     Inc 

^^  '655   r-as'    Mo  ^    '-"Ml 

=^  Rochester.   Ne«    ■■J''  '  *609       i'^ 

'.as  ('16)     -S^   -  030'j   ■   Phone 


436 


TUE  EYE. 


without  sign  of  honiorrhago.  It  is  owins  to  the  work  of  LoIkt  ami 
Xordeiison  that  the  theory  of  shrinkage  of  the  vitreous  was  estab- 
lished and  most  of  the  difhcuhies  of  the  subjt  ct  answered.  Accordnig 
to  their  observations,  the  vitreous  beronies  fibrillary  in  structure 
while  retaining  its  transparencv.  This  ehange  is  due  to  a  shrinkage 
from  inHamiiiatorv  processes  in  the  choroid  or  ciliary  body:  serous 
Huid  l^ecomes  poured  out  into  the  vitreous  chamber  to  fill  the  vacuum 
ciustvl  by  the  shrinking.  The  traction  on  the  retina  produced  by 
th.'  shrinking  vitreous  lea. Is  to  ripture  of  the  retina.  The  .serous 
fluid  Iving  in  the  vitreous  chamlxr  passt>s  through  this  rent  into  the 
subn-thial  space  and  allows  the  retina  ><>  become  suddenly  detached. 
More  recentlv  Raehlmann  has  explained  the  iletachnient  on  Xhv  (Illu- 
sion theorv:  the  Huid  behind  the  retina  is  more  albuminous  than 
that  in  froiit  of  it;  (Uffusion  ten.ls  to  take  place  more  rai)idly  towanl 
the  fluid  of  greater  densitv-that  is,  from  the  vitreous  to  th('  sub- 
retinal  snaces-than  in  the  opposite  direction,  .\lthough  this  theory 
may  explain  some  of  the  slow  detachments,  it  hardly  sutftces  tor  thoac 
of  sudden  onset. 

The  detachment  inav  take  place  at  any  part.     It  i-^  less  common  al 
the  macular  region  than  at  the  periphery :  but  wherever  it  Ix-gias,  it 
soon  settles  to  the  lowest  part  of  the  retina,  owing  to  gravitation 
of  the  fluid,  while  the  part  first  detached  may  liecome  reapplied.     It 
mav  remain  stationary,  but  it  generally  progres.ses  until  the  whole 
retina  is  detached,  so  that  in  a  jwst-min-tem  examination  of  the  eye 
the  retina  appears  as  a  cord  going  from  the  optic  disk  to  the  back  of 
the  lens,  containing  the  shrunken  remains  of  the  vitreous,  and  spread- 
ing out  thence  to  the  ora  serrata,  forming  an  umbn'lla  e-  convolvulus 
flower-like  detachment.     The  evidence  of  inflammatorv  changes  in 
the  eye  is  generallv  present   in  the  signs  of  iritis  or  iridocyclitis  or 
opacities  in  the  vitreous.     Secondary  cataractous  changes  in  the  lens 
generally  appear  late  in  the  disease,  with  a  reduction  of  tension, except 
in  thost>"  cases  where  the  detachment  is  caused  by  a  choroidal  tumor. 
Mvopic  eyes  are  those  most  subject  to  detachment  of  the  retina,  l)ut 
it  "is  not  always  tho.se  in  which  th(>  amount  of  myopia  is  higliest  which 
sutter  from  ("letachment.     \'ision  may  not  be  much  affected  if  the 
vellow  spot  be  not  involved,  but  there  is  always  a  considerable  loss 
I)f  field,  which  may  be  detected  by  the  )x>rimeter,  by  the  hand,  or  by 
the  light  projection  test;  the  part  of  the  field  which  is  lost  will  cor- 
resi)ond  with  the  ojjposite  portion  of  the  retina.     If,  owing  to  opaci- 
ties in  the  media,  it  is  not  possible  to  use  the  ophthalmoscope,  it  is 
generallv  possible  to  diagnose  the  presence  of  a  detachment  by  testing 
the  projection  of  light.     In  the  first  stages  of  a  detachment  exami- 
.ation    .f  th(>  field  of  vision  alone  is  insnflieient,  as  the  retina  may 
retain  its  function  for  some  time  after  the  detachment  where  tne  latter 
is  not   verv  dee]).     The  oiihthalmoscone  shows  a  changed  color  m 
the  reflex  from  the  fun.lus  over  th-  detached  area.     The  be.st  way  tn 
s<>e  this  is  to  observe  the  fundus  reflex  from  a  distance  of  about  14 
with  the  ophthalmoscope  mirror  alone,  and  to  get  the  patient  to  look 


RETINA,  OPTIC  NERVE,  AND  ITS  CEREBRAL  ORIGIN.      437 


ill  various  directions,  so  that  tlie  whole  of  the  retina  is  brought  under 
iil)s('rvation,  and  one  part  may  be  compared  with  another  or  with 
the  otiier  eye.  The  reHex,  even  in  recent  cas<'s,  is  generally  slightly 
iliillcr  over  the  detached  area  than  elsewhere,  and  in  old  detaciinients 
'lie  retina  may  apj)ear  opaiiue  and  gray.  It  may  often  be  seen  to 
lluat  about  with  movements  of  the  eye.  The  detached  area  should 
then  be  looketl  at  by  the  direct  methoil,  its  refraction  estimated  and 
I  -nipared  with  that  of  other  parts.  If  one  part  of  the  retina  is 
iiuich  more  hyjjernietropie  or  less  myopic  than  another,  suspicion 
liDuid  Ix!  directed  to  detachment  of  the  retina.  The  retinal  vessels 
ill  the  detached  area  appear  much  darker  than  normal,  owing  to  loss 
nt  their  central  light  streak  and  to  the  difference  in  transillumination. 
Ill  their  course  toward  the  jx'riphery  they  can  be  seen  to  disappear 
into  folds  and  depressions  in  the  retina:  rents  in  the  retina  may  be 
seen  at  times,  showing  the  bright  choroidal  reflex  l)ehind.  In  some 
cases  of  shallow  detachment  the  retina  api>ears  to  be  thrown  into 
innumerable  Hne  ripples  which  have  very  much  the  appearance  of 
tlic  ves.xels  of  the  choroid  seen  through  the  retina:  it  is  possible  that 
this  ap]x'arance  may  also  be  due  to  detachment  of  the  choroid  with 
liic  retma. 

hi  determining  the  cause  of  the  detachment,  regard  should  be  paid 
t(i  its  seat  and  extent,  its  shallowness  or  depth,  its  translucency  and 
ininiobility,  the  condition  of  the  vitreous,  and  the  hardness  or  tension 
III  the  eye.  New-growths  of  the  choroid  generally  fortii  globular 
|ir(iiiiiiieiit  steej)  detachments,  sometimes  dark  in  color,  <  ing  to  the 
]iigiiient  they  contain,  sometimes  showing  vessels  n(>t  of  retinal  origin. 
The  vitreous  is  not  opaque,  and  the  tension  of  the  eye  often  is  raised. 
It  the  detachment  lie  due  to  shrinking  of  the  vitrecms,  there  will  lie 
vitreous  oi)!icities,  a  widespread  detiichment.a  floating  retina, probably 
(iiiitaiiiing  rents  through  which  the  choroid  may  be  seen. 

Treatment.     The  tn-atment  .should  he  directed  toward  producing  ab- 

-iirption  of  the  exuded  fluid.     For  this  purpose  the  most  efficacious 

urent  is  complete  rest  in  lied:  the  patient  ,«hould  \ye  kept  on  his  back 

inr  a  month  or  six  weeks,  his  diet  should  Ix"  limited  in  regard  to 

lliiids,  and  free  action  of  the  skin  should  Ix-  provided,  either  by  vapor 

iiMtlis,  which  should  be  given  in  bed,  or  by  the  subcutaneous  adminis- 

! ration  of  pilocarpine.     This  may  be  combined  with  the  use  of  the 

inilides  of  ammonium  and  potassivim  internally.   At  the  same  time  the 

"\e  should  be  kept  bandaged  under  moderate  pressure.     If  more  rapid 

I i 'appearance  of  the  flui  I  be  desired,  the  situation  of  the  greatest 

'illcction  of  fluid  should  be  made  out  by  the  ophthalmoscope,  and 

111'  fluid  tapped  through  the  sclerotic.     This  is  done  Ix'st  by  a  broad 

"I'llle  or  a  (Iraefe  knife,  which  should  be  introduced  through  the 

'  liiutic  into  the  subretinal  space  in  the  eijuatorial  region  at  a  spot 

"  twccii  the  insertion  of  the  nuiscles.     If  the  knife  then  l)e  turned 

11 II 111  its  long  axis,  an  opening  will  be  made  lx»si(le  it,  which  will  allow 

!n'  albuminous  flui<l  to  run  out  of  the  eye.     Before  introducing  the 

iiiii'  the  conjunctiva  should  be  liisplaced  by  tk    ii.xation  forceps. 


438 


THE  EYE. 


V 


so  tliat  when  tlic  knife  is  withdrawn  the  conjunctiva  may  shp  back 
anil  the  wound  in  the  sclerotic  be  covered.  Fluid  will  pi  -  -  draining 
away  into  the  subconjunctival  connective  tissue  after  '  u  knife  is 
withdrawn.  An  addition  to  this  plan,  which  has  been  n  ■omniendecl 
and  has  met  with  some  success,  is  to  burn  tlie  sclerotic  slowly  with  a 
cautery  throu<;h  its  outermost  layers,  until  the  choroiil  is  just  reached. 
By  this  means  an  adhesive  intlanmiation  is  .set  u])  in  the  choroid,  which 
aims  at  bindinji;  the  retina  to  it.self  by  die  after-contractinf;  process. 
No  metliod  of  treatment  is  very  hopeful.  The  retina  may  In-come 
reattached  for  a  time,  but  it  s  -freiiuently  displaced  apiin  on  the 
patient  resuminji  ordinary  rouiine.  It  is  not  possible  to  overcome 
the  tendency  to  contraction  in  the  vitreous,  and,  if  the  retina  Ijeconies 
reapjilied,  it  is  likely  to  be  dis|)laced  again  by  continuance  of  the  con- 
tractinji  |)rocess. 

( Jther  methods  of  treatment  have  had  success  for  a  time.  Schoeler's 
method  of  injectinp;  iodine  into  the  vitreous  cavity,  which  scoreil  some 
successes  in  its  author's  hands,  led  to  disastrous  results  in  other  ca.ses. 
Deutschmann's  \  liod  of  inakin<;  a  punctinv  throufih  the  sclerotic, 
choroid,  and  retih  i  into  the  vitreous,  and  cuttinji  on  each  side  of  this 
track  to  divide  tlu'  l)ands  in  the  vitreous,  has  lot  turned  out  more 
successful  than  other  methods  of  treatment. 

Cysticercus  of  the  Retina.  This  is  a  very  rare  disea.se.  Its  diag- 
nosis dependN  mainly  upon  the  appearance  of  the  parasite.  It  is 
subretiii.il  as  a  rule,  it  has  the  appearance  of  a  flattened  cyst,  it  is 
light  gray  in  color,  with  light  edges,  and  undergoes  s])ontaneous  move- 
ment: the  head  may  occasionally  be  made  out.  The  only  treatment 
is  to  cut  down  upon  it  and  remov(>  the  cyst. 

Injuries  of  the  Retina.  Mesidcs  detachment,  the  retina  sometimes 
after  a  blow  on  the  e>e  will  be  foimd  to  have  an  injured  area,  white 
or  nearly  so  in  color,  with  ill-dehned  edges.  This  condition,  which 
usually  ])asses  aw.-iy  in  a  few  days,  is  probably  due  to  a  local  trau- 
matic (edema.     It  is  known  by  the  name  cummotio  rcliiin . 

Holes  at  the  Macula,  .\fter  injuries  to  the  eye.  especially  from 
concussion  by  a  stoni  i)all.  or  other  large  object,  in  which  the  glolx' 
is  not  rujitured.  there  is  freijuently  associali'd  with  loss  of  central  vision 
a  remarkable  appearance  at  'he  yellow  spot.  The  retina  ceases  ab- 
ruptly, so  that  tlK're  appears  to  be  a  circular  hole  in  it  at  the  centre 
of  the  yellow  spot,  e(|Ual  to  I'^out  one-third  the  diameter  of  the  disk. 
The  Hoor  of  the  hole  is  formed  by  the  choroid,  and  is  depressed  a 
measunible  ilistance  behind  the  retina.  .\Ilhough  no  pathological 
e\ainiii;',lion  of  the  condition  has  ever  been  maile,  it  is  higiily  probable 
that  this  a]»peMrnnce  is  really  due  to  a  hole  at  the  fovea,  caused  by 
lupture  of  the  retina  by  cimtrccoiip:  the  elastic  retina  retracts  and 
leaves  a  de.Mr  roimd  hole  whose  edges  an-  placed  at  a  distance  which 
can  be  readily  appreciated  from  the  choroid  behind.  Tliere  is  usually 
considerable  loss  of  vision. 

Glioma  of  the  Retina.  This  is  tlte  only  form  of  tunmr  that  attacks 
the  retina.     It  occurs  in  early  childhood,  iH'foie  the  age  of  three 


RETISA,  OPTIC  SERVE,  ASD  ITS  CEREBRAL  ORKUS.      439 


Glioma  of  the  retina.    (Leber  j 


years.  It  is  soiiiPtinies  congenital,  ami  is  met  with  in  rare  cases  ut 
a  later  afje.  It  starts  from  one  of  the  graimlar  hiyers  of  the  retina, 
and  either  grows  inward  toward  tiie  vitreous  or  outward,  producing 
ill  tacluiient  of  the  retina.  It  consists  of  cells  arrang»'d  in  long  tubes 
amuiid  wide  bloodvessels.  The  cells  vary  in  size  and  shape,  seme  c.f 
iliem  being  glia  cells  or  ganglion  cells,  others  being  cylindrical  in 
>hape  and  representing  the  layer  of  rods  anil  cones.  Tlie  exact  nature 
111'  the  glioma  is  still  a  matter  of  doubt,  but  it  is  probably  to  be 
icgarded  as  an  endothelioma  of  the  retina.     (Kig.  2.'^!).) 

The  first  thing  to  call  attention- to  an  eye  affected  with  glioma  is 
the  presence  of  a  gray  or  white  reflex  from  behhid  the  pup'l.     If  the 
eye  be  carefully  examined,  it  will  be  found 
I  hat   there  are  one  or  more  white  masses  no.  239. 

i;ii)\viiig  from  the  retina,  containing  blood- 
vessels. There  is  no  pain:  the  ey('  is  not 
iniigested.  At  a  later  stage  the  mass  ])ro- 
jects  more  forward  until  it  fills  the  eye. 
Tension  is  usually  rai.sed  during  jjart  of  the 
lime,  and  the  eye  becomes  painful.  In  the 
third  stage,  the  growth  invades  the  ojjtic 
nerve  or  finds  its  way  out  of  the  eye  by 
111  her  channels,  where  it  forms  ma.s.ses  which 
fill  the  orbit  and  produce  great  j>roptosis. 
The  growth  may  find  its  way  backward  to 
ilie  brain  through  the  ojitic  foramen:  it  may  invade  the  frontal  lobe 
I  if  the  brain  by  absori)ti(m  of  the  roof  of' the  orbit,  or  it  may  be 
icjirodiiced  in  other  distant  organs  of  the  body,  chiefly  in  the  liver. 
ir  left,  the  mass  of  glioma  grows  through  the  front  of  the  eye,  gen- 
eiallx  at  the  sclerocorneal  margin,  and  forms  a  fungating,  ulcerated, 
lileeiiiiig,  painful  mass.  In  its  latest  .stages  it  produces  death  from 
e\haiisii(in  or  by  its  attacking  vital  organs. 

(ilioma  should  k-  distinguishe<l  from  purulent  exudation  into  the 
vitreous— /),sr(((7m//!'on(rt.  The  ab.sence  of  pain,  tenderness,  and  in- 
llaintn.Mtion  in  the  early  stage,  the  raising  of  the  tension  hi  the  later 
Mages,  and  the  absence  of  retraction  of  the  periphery  and  of  the  iris, 
help  to  distinguish  it  from  jiseudoglioma. 

Treatment.  The  eye  should  1k'  excised  as  sotm  as  the  disease  is  dis- 
'■'ivered.  If  this  be  done  before  the  growth  escaiies  from  the  eyeball, 
Miere  is  a  good  chance  of  eur(>.  If  the  disease  has  advanced  further, 
'he  .(i-b't  should  1k'  emptied,  if  possible,  in  order  to  save  the  chilli 
I  rum  sutTering,  produced  by  the  fungating  mass:  but  in  such  a  case 
iiriigiiosis  is  very  unfavorable. 

Congenital  Pigmentation  of  the  Retina.    .\  numlier  of  cases  of 

i'iL'inentation  of  the  retina  have  Ix-en  described  by  various  authors. 

I       |iigmentation  occupies  a  section  of  the  retina  imly,  and  cim.sists 

I  ciillections  of  small  round  or  angular  masses  of  pigment  grouped 

f>,._reth..r  somewhat  like  <-Av<'mxv      They  .ire  unassoeiatrd  with  anv 

liiifoKlal  change;  they  lie  on  the  surface  of  the  retina,  and  some- 


J40 


TUt:  EYE. 


\ 


J 


tiiiifs  cover  tlic  retinal  vessels.  They  have  i)een  considered  a.s  anoma- 
lous forms  of  reiinitis  jiijimeiitosa,  but  they  are  not  progressive,  they 
do  not  accom|)any  loss  of  function  in  the  retina,  and  are  probably 
of  congenital  origin. 

Infantile  Amaurosis.  The  history  given  by  the  parents  in  cases 
of  infantile  amaurosi-  is  tluit  the  child  was  able  to  see  well  and  noticed 
things,  turned  toward  the  light,  grasped  at  objects  held  before  it 
until  the  onset  of  com|)lete  blindness;  this  generally  occurs  'inder 
twebi'  months  of  age.  The  chiid  may  develop  other  signs  of  i.  iiess 
at  the  same  time:  general  restlessness,  feebleness  of  limbs  and  of  back, 
or  a  condition  of  cervical  oi)isth()tonos.  .\n  ophthalmoscopic  exami- 
nation in  some  cases  shows  much  dust  exudation  into  the  vitreous, 
with  signs  of  syphilitic  choroidoretinitis:  in  others  optic  neuritis  due 
to  tubercular  meningitis  may  lx>  j..'esent.  Hut  in  many  of  the  infants 
nothing  can  be  seen  by  the  oi)hthalnM):.e()pe  at  all,  or  a  slight  pallor 
only  of  the  tlisk  is  seen  after  the  blindness  has  conti:  icd  for  some 
lime.  It  is  in  these  cjuses  that  retraction  of  the  head  is  most  fre- 
(piently  met  with.  The  cau.se  is  a  posterior  basic  meningitis  with 
(listention  of  the  ventricles  of  the  brain  by  fluid.  It  usually  happens 
that  t'.e  blindness  ])ersists  for  some  montlis  and  th"n  recovery  may 
take  place,  and  even  complete  restoration  of  sight  may  follow.  It 
is  )K)ssible  that  the  pu])ils  may  contim:e  to  res])oiid  to  light  during 
the  wholi'  attack,  showing  that  the  seat  of  disease  i  -  above  the  basal 
ganglia.  .\n  opinion  is  also  sought  by  parents  whose  infants  have 
never  b(>en  able  to  see  at  all;  in  such  cases  the  ])upils  may  respond 
actively  to  light,  and  the  o])tic  nerve  and  retina  are  jjerfectly  healthy. 
.\n  examination  of  the  head  shows  the  skull  to  Ix'  very  small  in  its 
ui)i>er  part,  the  sutures  to  be  prematurely  united,  and  the  fontanelles 
closed.  !^uch  children  are  microcephalic  idiots,  and  no  im])rovement 
is  to  be  expected  in  their  sight ;  the  fault  lies  in  imperfect  development 
of  the  brain. 

Treatment.  The  syphilitic  choroidoretinal  cases  recover  to  a 
great  extent  under  inunctions  of  mercury.  The  posterior  basic  men- 
ingitis cases  recover  if  the  health  of  the  child  is  restored.  The  idiotic 
children  do  not  gain  any  sighi,  and,  although  the  condition  of  synos- 
tosis of  the  sutures  has  been  met  by  craniectomy  or  removal  of  a 
jxirtion  of  the  roof  of  the  skull,  such  nu-asures  probably  do  no  real 
good. 

THE  OPTIC  NERVE. 

The  oi)tic  nerve  has  its  origin  in  the  retina,  pa.sses  through  an 
opening  in  the  choroid  and  scl(>rotic,  tlie  latter  consisting  of  ;i  fenes- 
trated membrane  known  as  the  lamina  cribro.sa,  traverses  the  orbit  in 
a  double  curve  iii  order  to  allow  of  free  movement  of  the  eye,  [)asses 
through  the  optic  foramen  at  the  apex  of  the  orbit  and  enters  the 
skull.  It  i.-  there  joiiied  bv  its  fellow  on  the  o|>po«ite  side,  to  form 
the  optic  commissure  or  miasma,  where  semidecussation  of  the  nerves 


HETISA,  OPl'W  NERVE,  AND  ITS  CEREBRAL  ORIGIN.      441 

t.iki's  placj".  The  two  halves  of  each  nerve  are  continued  backward 
Iniiii  tlie  chiasnui  in  one  cord,  the  optic  tract,  which  winds  around  the 
cms  cerel)ri  and  end-s  ni  the  l)a.sai  gaiiRlia  on  each  si.ie.  The  basal 
piiifilia  arc  the  ."xternal  c()r|)ora  geniculata,  the  anterior  corpora  (luad- 
iiP'Mn.ia,  an.  the  oi)tic  thaianii.  From  tliese  ganglia  fibres  pitss  in 
tun  niani  bodies  tn  the  oculomotor  nuclei  and  to  the  cerebral  cortex 
Hi.;  part  of  the  cortex  to  which  thoy  are  distributed  is  the  mesial 
smtace  (jf  the  occipital  IoJk",  the  cuneus,  an.l  the  neighborhood 
arr.und  the  calcanne  fissure.  It  is  probable  also  that  some  of  the 
optic  ii.Tve  film's  pass  on  .lirectly  by  the  corona  radiata  to  the  occip- 
ilal  c.)rtex,  without  enterhig  the  ganglia.     (Figs.  240  and  •>41  ) 


Kiii.  210. 


OpMc  radiations.    (Edinokr.) 

The  Sheaths  of  the  Optic  Nerve.  The  coverings  of  the  optic 
■  IV..  aie  three  in  number,  corresjx.nding  with  the  membranes  of  the 
■i:iiii.  Ihe  dural  sheath,  continuous  with  the  .lura  mater,  forms  a 
■•'-.■  covering  to  the  ner^.•.  the  pial  sheath  closelv  surrounds  the 
-IV.'  an.l  sends  .septa  to  enter  its  substance.  Between  these  two  is 
!"■  mt.rvagmal  spa-e  .'ivi.le.l  int..  two  by  the  arachnoid.  The  fibres 
'  III..  ,,i,tic  nerve  at  their  entrance  into  the  eve  through  the  lamina 
iil'n.Nt  contain  a  me.lullary  sh.>ath:  as  thev  pass  thn.ugh  this  struc- 
:v  t!u'v  !,.s,'  their  medullary  sheath  -nd  are  oonlhiu.-.l  as  transluc-nt 
.H-cylm.i.'rs  only.     Like  the  re.st    i  the  ner\-ous  system,  the  fibfs 


442 


Tin:  EYE. 


I  : 


of  tlu-  luTVo  lire  nia.lo  up  of  neurons,  tho  rolls  of  wim-h  lie  m  Ww 
UiinKlion-coll  lavcr  of  the  retina,  in  clos.'  union  with  the  visual  epi- 
th..huin,  the  lav.T  of  rods  and  eon.-s.  At  tlwir  other  ends  th.|  hl.res 
end  in  brushes,  chiefly  in  the  external  geniculate  i.odies  an,  optic 
thalaini.    These  are  known  as  r(<tino-thalainic  neurons     \  isual  hbres 

Fio.  -Ml. 


Visual  cortex,    (j^tarb.; 

tn  the  cortex  also  take  their  oripn  in  th(>  cells  of  the  external  Ronicii- 

late  bodies  and  optic  thalaini  and  pass  upward    to  be  ,listnbute.l  to 

the  region  of  the  cuneus  ami  calcarine  tissure-thalanio-cortical  neii- 

^  rons.    There  are  other  neurons  whicli 

have  their  nuclei  in  the  basal  ganglia 
anil  their  terniiiial  branches  in  the 
retina,  and  probably  some  also  which 
pass  from  the  retuia  through  the 
chiasma  and  optic  tracts  to  the  cor- 
tex direct.     (Plate  XVIII.) 

The  chiasma  lies  in  a  groove  at 
the  base  of  the  sphenoid  bone  in 
front  of  the  iiifuiidibulum.  In  this 
commissure  th<>  optic  nerves  un- 
dergo a  partial  decussation.  (Fig.  242.)  Tlu-  fibres  from  the  right 
half  of  each  retina  meet  in  tiie  chiasma  and  are  omtniued  on  m  the 
.ight  optic  tract:  the  fibres  from  tiie  left  half  of  each  ivtina  unite 
in  the  chiasma  to  form  the  l.-ff  optic  tract.     The  right  optic  tract 


Decuasation  of  optic  iiurve  librus. 


(Welis.) 


IL 


PLATE    XVIII. 


LEFT  VISUAL  FIELD.    RIGHT  VISLAL  FIELD. 
Fixatuml\>Oit.  ftxaiumfhutt. 


LlntCapsu/c 


h  Ocnpilf^  ^" 


i 


in 


I  !;!i 


RKTI.\A,  OPTIC  .SERVE,  AND  ITS  CEREIiRAL  ORIGIN.      443 

|i!iss('s  Up  to  thr>  occipital  cortfx  of  the  ligiit  side,  the  left  tract  to 
that  on  the  left  side.  From  this  it  will  Ik-  seen  that  the  left  half  of 
ihi'  visual  field  in  each  eye  is  served  by  the  rifiht  o|)tic  tract  and 
\\<i.\\\  cortical  visual  centre;  and  the  rijjht  half  of  the  visual  field  in 
each  eye  is  served  by  the  left  optic  tract  and  left  <'.rtical  visual  centre. 
The  division  does  not  pass  directly  through  the  yellow  spot;  if  one 
optic  tract  Im"  destroyed,  the  edj;e  of  the  hiind  area  does  not  pass 
tlinuiph  (he  yellow  spot,  hut  leaves  it  intact  'ii  e.ach  eye.  This  is 
cNplained  by  the  yellow  sp  \  beinn  sujiplied  by  fibres  p«ing  through 
each  tract,  -is  the  nerve  enters  the  retina,  the  most  |M'riplieral  fibres 
-upply  the  parts  around  the  optic  nerve,  and  the  central  fibres  are 
di-tributed  more  to  the  periphery.  The  fil)res  of  the  nerve  which 
>upply  the  retina  Ix'tween  the  papillii  and  yellow  s|M)t,  the  papillo- 
iiiacular  bundle,  are  the  most  important,  as  tl«'y  sub.serve  the  pur- 


Section  of  oiUc  nerve.    (Graf.fe-Saemisch.) 


li<is(>s  of  acu'.e  vision.  Immediately  Ix-hind  the  eye  they  occu  y 
iliout  one-third  of  the  area  of  the  nerve,  in  the  form  of  a  sector  with 
ii^^  apex  at  the  centre  and  ba.se  outwanl.  I''urther  back,  these  fibres 
lif  in  tiu'  axis  of  the  ner^-e.  From  these  anatomical  arrangements 
'\r  are  able  accurately  to  localize  the  seat  of  some  lesions  of  sight. 

I  lius,  if  one  eye  only  be  blind  or  defective,  due  to  a  nerve  lesion,  the 
-I  at  (if  it  must  be  anterior  to  the  chiasma,  while  affections  of  vision 

I  conjoint  halve.-  of  the  retina  are  due  to  di.''-ise  of  the  tract  or  of 
Mil'  visual  paths  at)ove  it.     Defects  involving  ,  le  fixation  point,  oeii- 
'I'.il  scotoni",  are  due  to  diseases  of  ♦he  pa])illo-macular  bundle. 
In  bitemporal  hemianopsia  the  seat  of  the  disease  is  \\\  the  chiasma. 

I I  one  o])tie  tract  be  affected,  producing  l)lindness  of  the  .same  side 
■  '-ach  retina,  a  condition  known  as  hunionynHius  hemianopsia,  the 
iijiils  will  not  react  to  light  thrown  upon  the  blind  halves  of  the 


4M 


riit:  KYK. 


i 


rHiiu.  l.nl  tlu'V  will  r.act  tu  li^l.l  thn.wn  u,...n  tho  sonnR  Iml     s 
(W.Tiiick.-s  lH.n.i..|.io  pui.illaiy  r.-arti..i.).     In  this  caM-  wli.n-     » 
nunillarv  li^l.l  n-tll'X  i'  i"t.Tl.T,..l  with.  th.  Usum  ...u.t  Im-  m    h. 
i..  tract  iM-low  th.'  .urpom  .,ua.lrig.-...i.m,  ,.m..nu<-h  as  th.  imthul 
, L  pupillary  li«ht  ntlex  is  tro.n  th.-  ..,.ti.-  tract  to  th-  ••«'n><'^>^  M"";  " 
ip-nina.  then.-.,  t..  th.  thir.l  nm-.-  nu.-l.'us.  ">"   ''"p^f'' !  J'"^/ 
thini  I..TV..  t..  thr  |.upil.     If  th.-  inipils  ros,...n.l  to  light  t»  rovM 
Ih"  h  halv.'s  of  tlu-  P'tina-.  th.-  lesion  is  higher  up,  either  ui  the  ..pf- 
thalunius,  internal  eapsule.  or  the  cortex. 


FM.  244. 


McUardy  perimeter. 

Tn  .H'^eases  of  the  optic  ner-  the  sight  may  Vk-  impairo<l  in  various 
wavs  central  or  peripheral  vision  may  Ik^  intorfere.l  with,  the  vision 

eadi  eve  mav  Ik-  lost,  or  the  jKTcei.tion  of  .  .,lo.s  may  k>  .lestroycMl. 

I'.Tiph'eral  vision  implies  the  ,H.rcrptio..  of  obj.-cts  all  arouiul  the 
point  'lirc-tlv  looked  at.  Thus,  if  wc  cross  a  street,  a  though  we  may 
b,.  looking  .lire.-tlv  in  front  of  us.  we  are  conscious  of  the  movement 
or  api.n.ach  of  vehicl  'S  on  each  si.le  of  us.  We  are  als<.  able  to  aj-i.re- 
ci:ite  generallv  tli.M,ualitv  of  the  surface  on  which  we  are  walking,  an. 
to  avoid  obstacl.'s  in  our  path  without  dir«>ctly  looking  at  them.  1 
this  iMnver  were  al^sent.  as  it  is  in  some  .liseases.  we  should  l)e  in  the 
position  of  a  person  looking  down  a  long  tulie:  it  would  »><' /'•m''"  ' 
for  us  to  find  our  way  about;  all  I'ower  of  orientation  would  be  lost. 


RKTISA,  Ol'TIC  SEHVk,  Alfl>  ITS  I    REBRAL  ORUilS.       |45 

The  wlitilc  uH'si  from  whirh  tho  oyi>  is  rnpahlf  of  rc'civitift  inipn's- 
'iciiis  is  called  tlw  field  of  vision,  aiul  it  is  capuhic  of  JH'iiifC  iik  asun 


N'  •■  »i  and. 


Normal  Held. 


446 


THE  EYE. 


in  several  wavs;  bv  the  hand,  by  lipht  niovo.l  bef..ro  tho  eye  or  nu.ro 
accuratclv.  b\-  an"instrument  called  the  iM-riineter.       I' '?•-«•'     ^[ 
■■   .1:..  ti.A.\  i„.  th^  hnnil  the  mtient  is  placed  with  his  back 


measuring 


r'thV  tield  by  the  hand,  the  patient  is  place 


FlO.  247. 

Riijht  Eye 


KcrtM.tric  conlmclion  .,f  tl«M  us  sc^n  In  Br«y  airophy  "1  the  o,.U.-  nerve. 


Flii.  JW 

I///  Eye 


Ecc«nlrle  «,atr«cUon  of  Held  u  «e.i  In  gr»y  atrophy  of  the  optic  nerve 


KETIXA,  OI'TIf  yKJiVK,  .l.V/>  ITS  CEREBRAL  ORIGIN.      447 

t<p  tlio  light,  tlio  hand  hold  in  various  positions  l)of()r('  liini,  and  lie  is 
asked  to  i)oint  out  its  direction,  at  the  same  time  l\eepin>j  his  eye 
lixcd  on  the  observer's  face,  (Hrectly  in  front  of  him.     A  small  i)iece 

Fio.  24a. 

Right  Eye 


HomoDymouB  quadrant  hemianopsia. 


Fig.  250. 


Homonymraa  quadrant  hemianopsia. 


448 


Till:  EYE. 


of  wliito  i)aiMT  nmv  be  used  witli  tlic  same  (.bjfct.  If  the  siplit  is 
in.i.airc.1  bv  .lis.^as;-  cf  the  front  of  the  ."vc.  wo  can  gc-t  sonio  knowl- 
,.,li,.  of  thi"  condition  of  tiic   visual   ticUl  by  holdnig  a   candle  ni 


Kia.  2&1. 
Ijft  Eye 


ivntral  srntom«  hb  8ecn  in  toxK  nroblyopia. 


Left  Eye 


\  I  n 


ScotnmBta  «s  wen  in  dlsseminBtert  choroiditis. 


HETtSA,  OI'TW  yEJi  VE,  ASD  ITS  CEBEBRAL  GRIG IX.      449 

various  pdsitions  before  the  eje,  or  by  throwii.;,'  ii])oii  the  eye  tlic 
lifllit  retleeted  from  an  oplithalmoseope  mirror— tlie  ^.rojectioii  test. 
The  perimeter  eoiisists  of  a  (|uarter  or  half-eircle  of  metal,  revolving 
.iroimd  a  \\\i'i\  i)oint,  iit  wliieli  is  plaeed  a  .>mall  white  spot,  the  object 
111  be  looked  at  by  tlie  eye  lUKJer  examination,  the  fixation  jHiint.    The 
eye  is  plaeed  at  the  eentre  of  the  eirele,  and  another  wliite  s])ot  is 
made  to  travel  along  the  eirele  from  the  fixation  point  until  it  can  no 
jonfier  l)e  seen;  the  ])oint  of  its  (li>apj)earanee  is  the  limit  of  the  visual 
li'ld  in  that  (hrection.     In  jiraetiee  it  is  customary  to  star    with  the 
travelling  spot  at  the  extreme  perii)ht , -■,  and  to  mark  as  the  outer 
limit  of  the  visual  fielc'  the  i)lace  at  winch  it  hrst  becomes  visible  as 
a  distinct  spot  of  white    This  limit  is  a  constant  one  hi  healthy  eyes. 
The  visual  field  extends  about  95°  to  the  temporal  side,  about  »)0° 
upward,  ,i()°  inward, and  S0°  downward.  ( Figs.  245  aiid  2-l(). )  The  limit 
upward  and  inward  varies  with  the  prominence  of  the  brow  and  no.<e, 
but  it  is,ai)art  from  this,  less  than  in  the  temporal  direction.   The  size 
of  the  travelling  spot  used  varies  according  to  the  degree  of  affection 
nf  sight.     It  is  well  to  use  as  small  a  spot  as  can  be  seen  with  ease  for 
this  ])ur!>ose:  5  mm.,  2\  nun.,  or  even  smaller  s])ots  may  be  used. 
Hut  where  the  acuteness  of  sight  is  mucii  reduced,  it  is  necessary  to 
use  spots  10  nun.,  15  nun.,  or  20  mm.,  in  diameter.     In  doubtful 
eases  it  is  also  desirable  to  take  the  field  with  diminished  illumina- 
tion.   The  color  fields  may  be  taken  in  the  same  way  as  the  field 
for  white  by  using  a  small  colored  object  instead  of  a  white  one. 
The  size  of  the  color  field  varies  with  the  size  of  the  object  and  the 
iirightne.ss  of  the  illumination.     A\'ith  very  bright  light  and  a  sufK- 
eiently  large  mass,  color  can  be  recognized  at  the  extreme  periphery 
nt  the  dsual  field,  but  with  small-sized  objects  the  periphery  of  the 
retina  is  incapable  of  appreciating  their  color.     The  field  for  blue  is 
I  lie  next  in  size  to  white,  then  follows  red,  and,  lastly,  green.     It  is 
important  to  take  the  color  fields  in  seme  cases  of  o|)tic  nerve  disease, 
,is  the  test  is  a  more  delicate  one  than  that  for  a  white  sjjot,  and  often 
indicates  very  early  stages  of  optic  nerve  atro]ihy.  (Mgs.  247  and  24S. ) 
Kel'eets  in  the  field  of  vision  may  take  the  form  of  a  concentric  con- 
'  I  act  ion,  or  they  may  be  limited  to  (,ne  portion  of  the  field,  such  as  a 
ictioiial  aii'a  triangular  in  shape,  with   its   ajiex  at    the  eentre,  its 
I'ase  at  till        riphery  (Figs.  249  and  2.50):  (  r  there  may  be  gaps  in 
'lie  field  or  blind  spots  of  various  shajies.     These  are  known  as  seoto- 
:uata,  ;Mid  may  be  either  at  the  point  of  fixation— central  scotoma 
1  ig.  251):  or  outside  it— paracentral  scotoma.     They  may  form  a 
lind  ring  around   the  fixation  point— ring  or  annular  scotoma:  or 
Ih'v  may  lie  situated  in  other  parts  of  the  field,  where,  as  a  rule, 
III  y  are  of  little  jiractical   sigiiihcanee.     (Fig.  2.")2.)     It   should  be 
'ited  that  the  entrance  of  the  optic  nerve  nito  the  eye,  inasmuch  as 
■   I'ontains  no  retinal  elements,  is  a  blind  spot.     It  is  placed  about 
"''  'nitride  the  fixation  point.     (Figs.  215  and  '1\{\.) 
SmliiDuiln  may  be  either  positive  or  negative:  positive  when  they 
111!  a  dark  s])ot  in  the  field  of  vision,  which  the  patient  is  conscious 

2» 


4r)(» 


Tin:  i:yj:. 


(if:  and  lU'jiativc  wlii'ii  tlicy  form  iiicirly  a  fia])  in  tlii'  Ik'1.1  wliicli  is 
l)lin<l,  l)ut  wliicli  is  not  ol).icctiv("ly  pivscnt  as  a  dai  k  area  to  tlic 
patiiii:  At;ain.  sc-otoiiiatu  are  citlx-r  absolute  or  ivlativc:  ahsolutc 
wlicn  all  i.circ|.tion  is  lost,  relative  .hen  i.envption  is  merely  ilulle.l. 
Thus  a  M-otoma  is  said  to  i)e  absolute  when  all  perceinioTs  ol  lifiht 
and  t'orm  is  lost   in  it;  relative  ,  wh.'U  ther.'  is  loss  of  pereeption  of 

color  onlv. 
The  Light  Sense.     (See  pajie  8').) 

Congenital  Peculiarities. 

Coloboma  of  the  Sheath  of  the  Nerve.  This  eondition.  due  to 
imperfect  closure  of  the  fietal  cleft  in  tiie  nerve,  is  sometimes  asso- 
ciated with  coloboma  of  the  choroid  and  sometimes  occurs  mdepen- 
dentlv.  It  anpeais  as  a  very  lar-ie  and  deep  excavation  of  tlie  lower 
part  of  the  neVve.  the  whole  disk  beinj;  s(.nietimes  very  nnich  ealarfied. 

Opaque  nerve  fibres  are  seen  on  the  disk  alone  sometimes,  but  they 
fieneraliv  spread  out  over  tiie  retina.     (See  Hetina.) 

Pigmentation  of  the  Nerve.  Th.'  optic  n<'rve  is  sometiiues  very 
luKhiy  colored,  of  a  dull  reil-firay  hue:  this  condition,  which  may  be 
mistaken  for  optic  neuiitis,  is  coni^enital. 


\cuif  "ptii-  niuriti-.  N-U' ilisk  much  s»(.lU-n:  .  .tim«tal  ai  7  l>.  K.lBe  iurtistiiiii ;  vessels 
ol».eii.e.l  III  cHlKe,  Uirgc  iiuniber  (if  hemorrlmges  unminl  Ihe  .lisk,  i«iielie.s  uf  ufleiiiu  in  the  relinu, 
veins  very  tnrtuuna. 

Inflammation  of  the  Optic  Nerve:  Optic  Neuritis.     Inll.unmation 
i,f  the  optic  nerve  may  take  i)iace  at  any  point  in  the  course  of  the 


Kj:n.\A,  oi'TK  y.jiVE.  asd  its  '  ereurm  ouiaix.     451 

iiiivc.  If  tlic  intni-dculiir  |)((iti<iii  is  iifTcctcd,  tin-  (liscMsc  is  spokon 
i>t'  ;is  papillitis;  hut  if  tlic  trunk  of  the  ncfvc  only  is  afTcctcd,  tlio 
iiillaniniation  <l()cs  not  show  itself  oplitliahnoscopically  in  the  head 
of  the  nerve,  and  it  is  known  as  a  retrobulbar  or  retro-ocular  neuritis. 
1  Fi-:.  •2h:i.) 
Papillitis.    Inflammation  of  the  Head  of  the  Optic  Nerve.    Tins 

-iiows  itself  in  two  main  forms,  hut  there  i.:  no  sharp  .ine  of  divi- 
-ioM  between  tin'in.  and  many  eases  have  eharacteristies  which  will 
brinii;  them  imder  each  heading. 

I.  The  swelling  is  sharjily  limited  to  the  disk;  in  the  earliest  stages 
I  lie  edges  of  the  disk  appear  blurred :  the  natural  striatioiiof  the  r<'tiiia 


Swollen  disk  in  a  oaseof  clirouic  nieni-iKitis.    (I.ikhkkrh.i 


11  !lie  edge  of  tile  disk  is  more  marked;  at  the  same  time  (he  disk 

ii-.ii  jiecomes  redder  in  color,  the  veins  are  full  and  siiow  tortuosity, 

wih   1  tendency  to  disajipcMr  into  the  (edeni;iloiis  reiiiiM  at  the  edge 

■'I  the  ilisk.     (Fig.  2.")4. )    The  vessels  as  they  emerge  from  the  central 

I'ii  appear  to  come  markedly  forward.  :iiid  a  movement  of  paralla.x 

-  iiblained  against   the  background  of  the  nerve.     Uy  this  test,  if 

lie  vessels  he  kept  ill  view  while  the  head  of  the  observer  is  made 

■"  move  a  little  from  side  to  side,  they  will  appear  »o  move  again.sl 

Sir  edge  of  the  disk  behind  them,  showinsr  that  they  ;ire  not  in  con- 

iit  witii  ii.  bu!  lie  ,ii  Mniie  distance  in  front  of  it.     .\s  the  disease 

dvances  the  papilla  becomes  niore  and  more  prominent  and  stands 

lit  into  the'  vitreous.     The  nerve  may  bo  uicreased  in  reihiess,  or 


I! 


i 


452 

it  iiiiiv  Ix'coiiu'  pale  I'ri'iu  l>r« 


rilE  EYE. 


'ssiirc  1)11  It,  an 


1  inav  contain  masses  ol 


f 


•xudation.     Tlic  artcru 


ire  small,  the  vcnis  vcn 


V  full  and  tortnoiis 


WlUTC 


tl 


IC   V('SS( 


Is  pass  over  tlic  cilgf  < 


f  the  disk  they  may  disappear 


into  the  (I'dcmatous  n 


tina  nr  i)cliiiid  the  i)ronmir 


lit  and  ovcrhaiiniiiK 


head  of  till'  ncrv 
the  direct  met 


Flic  amoui 


t  of  swelling  should  !«■  cstiiiuitci 


,,,.,\vitli  the  ophthalmoscope.     At  the  same  time  mm. 


)und  the  disk.     The  retina 
iid  is 


l».ix  of  retinal  hemorrhafies  may  ap|)ear  an 
„,>ol  Kim.ii   '  H  frciuentlv  ii'dematous.  a...- 

iK.tvveeii  the  d.A  =""'>;  :  ,      ,  .i,,,,,.  "si.ot   an.l  coiitainins 

tllir'h''  "-t-     Tl.i«  v„ri,.ty  ..t  ..|,lic  ,».urm»  .«  k,,...,,  ,s  ,M.«I 
'''■}'■  I„  tho  other  form,  ,U;fen,lm.j  mi.rilh,  ih'  il,fl-,mmalion  is  not 

»"™ '";;;;ir=i!i»';r;'e.;s;i  irri-...  ;n«,..  ,„  t„e 

':::;;  t ;,  r;,™  .v !»;.•  ...iH-r.-..!..--  ..f..i..;  .......  .^;;; ";,";-« 

S  iln.„;  it  .....y  Ik.  ,1.,..  to  |«.t..rior  l.as,c  ■."■■'"'f ';';;'»•  '>>,1^,^^. 

1 -;;;;? ;:;;;;;;:::,:  ^;  ;S;;:S;l;:.„ti; ,;;  :::s::!,:;^^  ™...i..- 

r'     T,        ,    .  -  i    -l."!.'  i..tr....r....i..l  en'"'!''  "'  ""'■>'  I*""'-  "''"■ 
"  ,  n,    .r,uloii« sw».  (iuiimial.. an. II..' ...... '■"......"" 

?-"      -;;;:r.j;:l::;;;s^:^"-.™;^;"r.!= 

h'-^i^eiuV-Tlu.  presence  of  a  fiumma   in  the   brain  not   m 


KETIX.X,  OPTIC  yERVE,  ASD  ITS  I  EREBIIAL  OllldlS.      45;$ 


oi>tic  tnu'ts  or  cliiasiiia  dirpctly,  or  it  insiy  in  some  cases  form  in  tiic 
licad  of  the  u\y\\v  nerve  nsvU—.-niihililic  fxipUlitix. 

Tlic  neuritis  is  peneraliy  double,  l)Ut  intiannnation  al)out  the  apex 
iif  the  orl)it,  the  optie  foramen,  the  s|)henoi(hii  fissure,  erysipelas  of 
the  in  .!  extendiiift  to  tile  orbit,  or  distention  of  some  of  tlie  fossr^  of 
tiie  nose  jiressinj;  on  tlie  nerve,  may  give  rise  to  un  optie  neuritis 
eonfine(l  to  one  side  only. 

The  general  or  systemie  causes  of  ()])tic  neuritis  may  Im-  pneumonia; 
exanthematic  feveiN,  such  as  influenza,  ty])hoid,  measles,  scarlet  fever, 
etc.;  severe  ana'mia,  h-ad-jHiisoni'-.g,  suppression  of  menstruation, 
_)ost-i)artuin  C(  ■  ditions,  or  sudden  loss  of  blood. 

Course  and  Symptoms.     The    optic    neuritis    may  exist    for  a  long 
time  without  disci>very,  the  failure  of  .sight    being  often   so  .slight 
as  to  1m'  unnoticed  by  the  ])atient.     If  the  attack  is  rapid  and  not 
severe,  the  ojjtic  nerve  may  recover  and  only  show  by  the  ophthal- 
moscope that  it  ha.s  passe<l  through  a  conditicm  of  neuritis.     On 
the  other  han<l,  the  failure  of  sight  is  sometimes  very  sudden  and 
ciimjilete.     In  one  ca.se  the  failure  was  so  sudden  that  the  patient 
(■omi)laiiied  that   someone  had  turned  down  the  gas.     Failure  may 
go  on  to  coinjilete  blindness,  and  yet  recovery  may  take  place;  in 
other  ca.ses  vision  fluctuates  very  much.     Occasionally  cases  are  met 
with  jiresenting  all  the  signs  of  cerebral  tumor:  headache,  vomiting, 
oi)tic  neuritis;  the  optic  neuriti"  may  subside,  leaving  the  disk  more 
or  less  atrophic  and  the  vision  impaired;  the  other  symptoms  may 
cea.se  ami  the  patient  may  be  restored  to  a  condition  of  perfect  health. 
( )thers  again,  es])ecially  childre.i,  pass  through  a  very  severe  attack  of 
double  optic  neuritis  without  the  general  health  ap])earing  to  sutT< . 
in  any  way  at  the  time,  and  recover  with  perinaneiitly  i)ale  disks, 
and  never  have  another  attack.     It  is  probable  that  the  cause  of  the 
neuritis  in  many  such  cases  is  tubercular  meningitis,  which  has  lx»pn 
ivcovered  from,  or  a  mass  of  tulxTcle  lying  in  the  brain,  shut  off  from 
tlie  tissues  around  it.  A  temjiorary  disturbance  in  the  mass  of  tubercle 
M'ts  up  an  inflainnmtion  around  it,  produces  neuritis,  and  then  rajiidly 
-iibsides,  giving  no  further  trouble.     In  other  cases  the  (luiescence 
is  not  ])eniiaiieiit,  but  recurreiic(>s  of  cerebral  irritation  follow  at  long 
intervals,   the  patient   iH'iiig  in  good  health  between  them.     I'.acli 
attack  corresponds  to  a  period  of  advance  in  some  slowly  growing 
•  eivbral  neoplasm.       One   such   case  was   that   of  a   girl  of  about 
'i^hteen,   who  is  still    under  observation,  who   has  been  known  to 
have  had  o])tic  atrophy  following  neuritis  for  ten  years.     She  has 
periods  of  good  health, "and  then  attacks  of  very  intense  pain  in  the 
hi'.id,  vomiting,  delirium,  etc..  recurring  at  intervals  of  several  months. 
In  one  of  these  attacks  she  had  violent  epileptic  fits,  which  produced 
petechial  li(>morrliages  of  the  conjunctiva  and  face.     The  disks  are 
(|uite  white  and  .she  i.s  jiractically  blind;  although  she  has  central 
virion  of  "-,  it  is  at  such  a  jiin-point  area  in  the  centre  of  the  blind 
^  isual  fiekfthat  it  is  with  the  utmost  difficulty  that  she  can  find  the 
■bject  she  wishes  to  look  at. 


454 


TllK  KYK. 


Tlic  -itl-ick-i  vary  vcrv  iimoli  in  tlifir  duration:  sonic  of  tiicni  an- 
v.-rv  la'i.i.l  an.l  pass  awav  entirely  in  a  few  weeivS.  en.lin«  in  r.rovery 
with  or  without  .lest ruction  of  sijjlit:  in  others  t lie  eonihtu-:.  is  very 
,.l,n,nie    the  appearance  of  neuritis  in   tiic  disk   hem};  present  for 

months'     As  a  rule,  attacks  are  sinjilc.  hut  cases  have  I n  descrilied 

hv  \udcrsoii,  (lowers  and  others  in  which  second  attacks  have  heeii 
observed,  and  Cunn  has  s.-en  oi-tic  neuritis  occur  u>  a  well-(h"veloi.e(l 
form  in  a  disk  wiiich  had  pri'viously  Ixrn  noted  to  he  atroi)liic. 
Optic  neuritis  occurring;  .lurinj:  or  after  pre«nancy  is  probably  .lue  to 
some  toxic  condition  arisiufi  Iroiu  the  uterus.  It  subsid.'s  alter  a  tunc 
without  much  iinpainiH'nt  of  vision. 

\n'cmi'i  may  give  rise  to  the  most  severe  optic  neuritis  ami  very 
ureat' swelling  of  the  disk.  This  may  Im-  a  .simple  swellinR  consisting 
niainlv  of  (edema.  <.r  it  may  Im"  accompanied  by  large  numlH'rs  of 
retinal  hemorrhages  and  exudations  into  the  retina.  Optic  neuritis 
,lue  to  ainemia  is  often  verv  sml.len  in  its  on.set.  It  pmsents  a  con- 
trast to  that  occurring  in  cerebral  tumor.  In  addition  to  making  an 
examination  of  the  g.'ueral  state  of  healtli  of  the  imtient,  with  analysis 
of  th<'  urine,  it  is  advisabl(>  here  to  make  an  examination  of  the  blood, 
counting  the  number  of  corpuscles. 

Suiii)ression  of  menstruation  from  exposure  to  cold  is  said  to  cause 
rapid  failure  of  sight  after  oj.tic  neuritis.  It  is  possible  that  many 
such  .-auses  may  come  umler  tlu'  heading  of  aiuemic  or  chlorotic 

Optic  neuritis  in  jead-poisonmg  varies  m  degree  from  the  slightest 
haze  of  the  disk  to  a  severe  acute  swelling  of  the  disk  with  hemor- 
rhages     It  .sometimes  extends  widely  into  the  retina,  i)roducmg  an 
ophthalmoscopic  api.earance   not    much  distinct    from   albuminuric 
retinitis  of  granular  kidney.     In  this  case  it   is  probable  that   the 
cause  lies  in  the  granular  condition  of  the  kidneys,  caused  by  Bright  s 
disease,  which   is  verv  likelv  to  occur  in  those  sutrcriiig  from  leail 
intoxication.    Tiie  urine  shoiild  be  exaiir --d,  an.l  other  signs  of  lead- 
pois.)ning  sought  for,  such  as  the  iiresence  .if  a  bluf  line  on  the  gums. 
Spurious  Optic  Neuritis.   Mention  must  be  ma.le  here  of  a  oiuhtion 
of  the  disk,  which  is  s.imetimes  met  with,  resembling  optic  neuritis 
in  the  acute  stage.     Tlie.lisk   is  re.l,  congestcl,  with  blurred  e.lges, 
an.l  a  measurabli-  amount  of  swelling,  or  it  may  apjiear  bhirre.l  and 
rather  jiale,  as  in  a  subsiding  neuritis.    The  vision  of  the  eye  is  normal, 
the  visual  fields  are  normal,  the  eol.ir  visi.m  and  the  light  sense  are 
normal,  and  there  is  n.i  hi.story  of  any  previous  defect  of  sight.     Many 
of  th.'se  ca.ses  have  hei'U  watche.l  for  years  and  n.i  change  has  been 
iiotice.l  in  the  ophthalm.iseopic  apiiearaiices.    A  smaller  .legree  of  the 
same  c.iti.iition  is  not  uncommonly  met  with  in  the  red  ami  streake.l 
ilisk  of  hv])ermetr.ipia.     In  Ixith  of  thi's.'  con.iiti.ms  the  appearance 
of  neuritis  i.s  prol)abiy  due  to  a  congenital  peculiarity  of  the  ..ptic 

I>apilla.  ,    .        ,     •  11 

Cause.     The  causes  of  ojitic  neuritis  in    their  relati.m  to  cerchrai 

tum.ir  have  lieeii  .liscusse.l  at  gr.-at  length  by  many  writers.     \'on 


ItETlSA,  IH'TIV  SKItVE,  AXD  ITS  VKREUUAL  OlilGLS.      455 


(Inu  IV  cxpliiiiicd  it  jis  IwiriR  a  swelling  imxlupcd  by  a  lilockinpof  the 
cavfiiiniis  sinus  and  of  the  trihiitaiy  ()|)litlialiiii('  vein,  licnc«'  the 
name  '"chdlicd  disiv."  Schini(it-Hiin|)l<'r  and  Manz  showed  that  the 
fluid  displaced  by  a  cerebral  tumor  found  its  way  into  the  lymph 
spaces  of  the  optic  nerve,  the  intersheath  spaces  became  distended 
with  liuid,  es|)ecially  at  liie  ocular  end,  where  there  is  an  am|)ulla-likp 
iiilarjii-ment  nf  the  inti'rsheath  space.  The  pressure  of  this  fluid 
passed  into  the  optic  nerve  and  compressed  the  retinal  vessels,  by 
which  the  thin-walled  veins  were  affected  more  than  the  arteries. 
Il(  lice,  a  hindrance  to  the  exit  of  fluid  was  produced,  which  gave 
rise  to  the  choked  disk  ajjpearance.  According  to  Leb-r,  the  presence 
iif  this  fluid  sets  up  a  toxic  condition  and  gives  rise  to  an  inflamma- 
tion of  the  nerve.  Other  'vriters  have  Ix'ld  that  tfie  neuritis  i.s  a 
true  descending  one:  they  nave  shown  that  there  is  an  increased  cel- 
lular exudation  in  the  ti.ssues  surrounding  the  cerebral  tumor,  which 
extends  the  whole  way  from  the  tumor  to  the  nerve  and  along  the 
latter  to  the  eye.  Wliether  this  be  the  fact  or  not,  there  can  \)c  no 
doubt  tiiat  a  great  deal  of  the  swelling  in  choked  disk  is  caused  by 
the  pressure  of  fluid  in  the  cranial  cavity,  and  secondarily  in  the 
-uiiarachnoid  .space  of  tiie  nerve,  inasmuch  as  relief  of  pressure 
iMUses  reduction  of  the  swelling  in  the  disk.  The  results  of  Hors- 
l(  y's  work  have  shown  that  trephining  the  skull  in  ca.se.s  of  cerebral 
tumor  causes  diminution  in  the  optic  neuritis,  even  when  it  has  been 
found  nnpo.ssible  to  remove  the  tumor. 

Prognosis  and  Treatment.  The  j)rognosis  depends  vvty  much  on 
the  nature  and  cau.se  of  the  neuritis.  In  a  case  of  cer'bral  tumor 
wiiicli  is  incajjable  of  removal,  and  which  is  steadily  growing,  the 
prognosis  is  serious;  the  treatment  is  that  of  the  cerebral  tumor.  But 
even  if  th  '  tumor  be  necessarily  progressive  and  incapable  of  removal, 
life  may  still  la.st  many  years,  and,  if  the  sight  can  l)e  .saved,  it  shouhl 
lie  done.  It  may  be  .said  that  the  operation  of  incising  the  di.stended 
-lieath  of  the  nerve  behind  the  eye  ofTeis  no  prospect  of  relief,  but 
I  lie  results  of  Horsley's  work  give  great  hope  of  lessening  and  even 
"I  stop])ing  the  optic  neuritis  l/y  trephining  the  skull  and  relieving 
iiilraer.-inial  pressure.  In  suitable  ca.ses  this  plan  should  be  carried 
"lit:  it  is  .scarcely  nece.s.sary  to  use  it  where  theoj)tic  neuriti.s  is  not 
very  severe  and  does  not  interfere  much  with  the  vision.  Much 
Mihietion  in  the  amount  of  .swelling  can  al.so  be  .sometimes  ob-tained 
l'\'  the  use  of  iodide  of  |)ota.ssium.  In  chloro.sis  the  prognosis  is  good, 
liiit  it  de])<'n(ls  on  an  early  recognition  of  the  cau.se.  Treatment 
-liii'ild  be  in  th(  main  by  iron,  aide<l  .-sometimes  by  arsenic  and  l)y 
I'gulating  the  other  factors  of    health,  e.sj)ecially  by  relieving  con- 

lipation.     In   cases  a.ssoeiated  with  disorders  of   men.s-truation  hot 
'i.illis  should  be  given  and  leeches  applied  to  the  temple.     In  the 

MUte  specific  fevers  the  progmwis  is  good  and  treatment  calls  for  no 
-!"!'i:d  rejiiark.     In  le.Md-jioi-r    .'vi^  the  prognosis  is  not  very  gODil; 

h"  cases  go  (;n  f"re(|uently  to  atrophy,  and  the  po.ssibility  of  renal 

'■niplications  arising  should  be  borne  in  mind.    The  treatment  is 


11 


HI 


456 


THE  EYE. 


that  of  Ica.l-poisoniiiji  generally.  'I'lu"  <^r-."s  occurriiiK  in  prcpnaiicy 
recover  without  Koinji  on  to  complete  l.limhiess;  they  re(|Uire  no 
siM-cial  ocular  treatment.  The  sy|)hiiitic  cases  sh..ul(l  Ih^  treated 
acconhiiji  to  the  seat  of  tlie  syphilitic  lesion.  If  it  Im-  a  local  atTec- 
tion  of  the  h.'a.l  of  the  nerve,  .svphilitic  optic  n.'uritis,  munction  of 
mercury  should  1m-  ti.sed;  if  this  Im-  carried  out  efficK'ntly  m  the  early 
stajre,  the  prospect  of  recovery  is  good.  In  the  other  class  in  which 
the  optic  neuritis  is  secondary  to  Rununatous  disease  of  the  hram, 
the  prognosis  is  less  pood  and  the  treatment  shouhl  be  in  the  main 

i)V  iodides.  .       ,         ,  ■     e 

'  Retrobulbar  Neuritis.  Hctrobulbar  neuntis,  the  other  mam  lorm 
of  iuflanmiation  of  the  oi)tic  nerve,  as  distinpuished  from  papillitis, 
shows  itself  l)V  chanpes  in  the  nerve  behind  the  eye.  an<l  only  ai)pears 
in  the  papilla"  at  a  later  stape.     It  jjroduces  a  diminution  of  central 

vision,  the  jK ral  area  of  the  visual  field  beinp  unchanp-d.     It  has 

iM-en   investigated  bv  maiiv  observers,  of  whom   t!ie  earliest   were 
Samelsohn  and  Net tieship.     The  results  of  their  investigations  showe, 
that  it  was  tin-  i)apillo-macular  bundle  of  fibres  employed  m  central 
vision  which  was  affected.     The  papillo-macular  fibres  supply  the 
yellow  spot  region,  and  in  the  optic  nerve  occupy  the  temporal  .side 
of  the  disk.     In  the  anterior  part  of  the  nerve  behind  the  eye  they 
form  a  wedge-shaped  segment,  whose   apex   is    toward    the   centre, 
and  ba.se  toward  the  temjioral  border  of  the  nerve.     Further  back 
in  the  nerve  these  fibres  occujiy  a  more  central  jjo.sition  and  do  not 
reach  the  edge  of  the  ru'rve:  in  the  .skull  they  form  an  oval  ma.ss  below 
and  to  the  temporal  side  of  the  centre.     In  inflammation  of  this 
bundle  of  fibres  there  are  proliferation  of  the  cells  of  the  neuroglia, 
engorgement  of  ve.s.sels,  and  interstitial  neuritis,  and  at  a  late  stage 
degeneration   of    the  axis-cylinders   from   i)ressure.     The  effect    on 
vision  of  this  inflamm;iii..n  of  the  papillo-macular  fibres  is  the  for- 
mation of  !.  blind  spot  in  the  visual  field,  extendi'  ,     rom  the  na.sal 
side  of  the  point  of  fixation  longitudinally  outward  as  far  as  the 
normal  blind  .sjiot.     The  density  of  the  scotoma  varies  from  an  ina- 
bility to  (listing'     li  color  o'   a  lessened  jyerception  of  color  at  the 
,.,.„,■,.,.— relative  color  scotoma— to  a  loss  of   percei)tion  of  form- 
absolute  scotoma.     The  cau.ses  may  be  classified  according  to  their 
,<eat  and  nature  into:  Lt.cal  causes -orbital  cellulitis,  erysipelas,  local 
])('riostitis,  sviihilitic  or  not:  tubercle  or  .•<ei)tic  inflammation  from 
the  neighboring  sinuses;  of  the.se,  the  sphenoidal  sinus  is  the  most 
likely  one  to  give  trouble,  as  it  is  sepjirated  from  the  optic  nerve  by 
only  a   thin   laver  of    bone,     ricneral   causes  :    gout,  diabetes,   the 
various  jioisons,  general    septicicmia,  hereditary  retrobulbar  neuritis, 
,•111(1  disease  occurring  in  the  optic  nerve  as  i)art  of  the  nervous  sy.stem 
generally.     The  disease  sho-vs  itself  in  an  acute  and  a  chronic  form. 
Anilf'  lirlrohiilhnr  Xciiritis.     This  is  manifested  by  a  nipid  failure 
of  sigiit  on  one  eve.  generally  jm-cedc-d  by  neuralgic  pain  in  the  toni- 
]>le.  ]<tnn  in  i)ressing  the  eyeball  back  into  the  orbit,  and  in  movenient 
of  the  eve  from  side  to  side.     As  a  consequence  of  the  pain  elicited 


as 


RKTiy.i,  (H'tic  seuve,  asd  its  veheiuial  oniais.    457 

!)>•  iiiovi'iiH'iil  of  the  cyi's,  they  arc  frcinicntly  kept  clowd.  At  first 
tlicrc  is  scjtrcrly  ally  ()|iiitlialin(isc<»|iic  cliaiijit',  hut  later  on  the  disk 
Imcoiiics  paler  ami  the  vessels  may  heeotne  contracted,  the  pupils 
,ire  dilated  and  sonii'what  inactive  to  liftht:  or  if  the  reaction  is  pxid, 
it  will  Im-  found  that  the  contraction  on  exposure  to  light  is  not  main- 
tained, the  pu|)il  quickly  n  Ixiunds. 

I'ailun-  of  sight  goes  on  increasing  for  four  or  five  days,  reaches  its 
height,  and,  after  a  week  or  so,  hegic;,  to  recover  slowly,  the  |K'riod 
(if  recovery  occupying  a  month  or  six  weeks.  The  (h'feci  is  often 
descrilx'd  as  a  mist  or  dark  sjiot  which  covers  the  ol)jecl>  looked  at, 
and  gives  the  ap[K'araiice  of  a  gray-brown  spot  r)n  a  white  surface. 
The  vision  is  worse  in  bright  light  and  imi>roves  after  rest,  as  in 
the  early  morning  after  u  night's  rest.  This  etTect  of  bright  light 
is  probably  caused  by  over-stimulation  of  the  weakened  nerve  ele- 
ments or  by  their  imperfect  insulation.  It  was  noted  by  Herry  as  a 
point  of  ditference  b'tween  papillitis  and  retrobulbar  neuriti.s"  that 
the  light  difference,  as  tested  by  Hjerrum's  types,  wa.s  .scarcely  j)resent 
:it  all  in  papillitis,  but  was  str(>ngly  marked  in  retrobulbar  neuritis. 
The  visual  fields  are  not  contracted  in  the  ordinary  cases,  but  there 
is  a  central  defect  of  vision  extending  from  the  yellow  sj)ot  and 
including  the  o[)ti?  nerve  entrance.  Sometimes,  however,  central 
vision  does  not  fail,  but  a  iMTijiheral  contraction  of  the  visual  field 
may  be  present,  as  in  the  ea.se  of  jxTiostitis  in  the  oj)tic  canal,  when 
the  defect  in  the  visual  field  corn's|M)n(ls  to  the  .seat  of  jjressure  cm 
the  nerve.  Hock  believes  that  it  is  pos.sible  to  indicate  the  .seat  of 
the  disea.se  by  the  direction  of  the  movement  of  the  eye,  which  j)ro- 
duces  j)ain,  this  iM'ing  due  to  stretching  of  the  .sheath  of  the  nerve. 
Thus,  pain  on  looking  uj)  would  indicate  the  lower  part  of  the  sheath 
of  th(>  nerve  as  the  seat  of  the  inflammation,  and  the  upiwr  {)art  of 
the  visual  ve.s.se!  as  contracted.  This  is  certainly  not  always  true. 
.Vfter  recovery  ha-s  set  in,  the  process  may  continue  until  the  sight 
is  (|uite  restored  to  the  normal,  or  there  may  be  jiermaiient  loss  of 
vision.  In  tho.se  ca.ses  where  the  focus  of  the  disea.se  is  clo.se  behind 
the  eye.  the  papilla  is  involved,  anil  it  is  not  easy  to  distinguish  the 
lase  from  one  of  ordinary  papillitis.  In  ordinary  papillitis  the  failure 
of  sight  comes  on  later  in  the  di.sea.se,  even  after  the  attack  has  begun 
to  subside,  while  in  retrobulbar  neuritis,  failure  of  sight  occurs  at 
I  lie  very  Ix-ginning. 

Treatment.  In  addition  to  the  treatment  of  whatever  may  l)e 
I  he  obvious  underlying  cause  of  neuritis,  such  as  syjihilis,  tubercle, 
iiout,  etc.,  much  may  be  done  in  the  way  of  local  measures.  Dark 
^'hi.s.ses  or  goggles  should  be  worn  in  bright  light;  leeches  or  the  arti- 
ficial leech,  or  blisters  should  be  applied  to  the  temple  and  all  use 
'■f  the  eyes  forbidden.  Iodide  of  potassium  should  be  given  and  any 
liical  disea.se  in  the  nose  shouhl  be  dealt  with. 

C/miiiir  Retrobulbar  Xeuriti.s.  Under  this  heading  we  find  the 
\  arious  forms  of  toxic  amblyopia,  the  most  common  of  which  is  that 
I'roduceil   by  tobacco  or  tobacco  coiubined  with  alcohol.    Other 


k 


! 


k 


II 


458 


THE  KYE. 


niiw'!*  air  l>i.-<iil|)hiil<-  of  carhoii.  iiscti  in  tin"  ciiriiiK  nf  vulcanite, 
iiMloform.  u<i-aMonally  s.mmi  ali.T  its  use  in  snrncry:  nitrulx-nzol. 
(lynainitc.  niciliyl  alcnhnl,  |i-ail,  male  IVrn,  |M.nii'nranatc  root,  .laniaica 
>;in>;i'r,  ami  otliiT  sul)stan('t•^*. 

Till-  (|uc?'ii<>n  of  till' fxistrnccdf  pure  aln>liulic  aiiil)lyi>|iia  a|'|K'ars 
now  to  Im-  .  -lalilislini  in  tin  atlirinativc,  liiif  tor  a  ioiij,;  titiii'  it  wan 
a  iiiiicli  ilis|niti'ii  point,  for  no  case  of  aiiililyopia  was  iiii-t  with  in 
which  there  was  an  entire  aliseiice  of  the  use  of  toliacco.  Alcohol 
(liM-s  uniioiihteillv  fre(|uently  influence  the  course  ami  nature  of  the 
toliacco  anililyopia.  The  \.orst  cases  met  with  ami  the  ones  which 
n-sult  in  iiiiiM'rfect  recovery  are  those  in  which  consiileralile  ainimnt.s 
of  alcohol  have  Im-cii  taken  in  aildit'-      •  ■  the  use  of  toliacco. 

Diabetic  Amblyopia.  The  questio..  of  anililyopia  has  also  In-en 
discussed  from  the  point  of  view  of  its  j  ssocialioii  with  dialn'tes  tin 
a  cause,  rndoulitedly  dialM'tics  are  ver.v  su.sceptihle  to  the  influence 
(if  tobacco,  which  is  apt  to  produce  in  them  a  toxic  aiiiMyopia.  The 
rapiility  with  which  this  may  lie  lirouftht  aliout  is  shown  liy  the  case 
of  a  p.-itieiit,  aned  fifty-four  years,  who  had  been  known  to  have  dia- 
t)etes  for  at  least  two  years,  .\liout  four  months  iM-fore  he  was  first 
seen  he  had  retired  from  active  work,  and,  time  heiuf;  heavy  <in  his 
hands,  he  had  taken  to  sinokiiiK  for  the  first  time  in  his  life.  He 
smoked  verv  moderately— not  more  than  one  pipe  a  ilay~and  his 
sifiht  hepan  to  fail  alM)ut  three  months  after  iH'jtinninft  to  smoke  and 
almut  one  month  Iw-fore  he  was  seen.  His  sipht  at  that  time  wjus 
!{•  "  .  I"  ("u*  "'■  '""'  '"'  <'''"^''"'  color  scotoma,  in  contraction  of 
his  visual  fields :  hir^  optic  disks  were  rather  pale.  Me  at  once  dis- 
continued tobacco,  liiil  his  si>;ht  cniitinued  to  fail,  and  two  months 
later  was  reduced  t«i  ^^  in  eiu'h  eyi-.  His  optic  nerves  were  then  very 
pale.  .Mthoujih  mot  of  the  dialierics  who  have  come  under  obser- 
vation with  central  scolom;i  have  been  users  of  tobacco,  a  few  ca.ses 
have  been  met  with,  some  of  them  amoii};  women,  in  which  ♦  here 
appiari'd  to  be  no  cause  for  amblyopia  apart  from  the  dialM'tes 
it.self. 

Pathology.  The  chanjies  that  have  lu'eii  found  post-mortem  have 
been  coiitiiicd  to  the  paiiiilo-macular  fibres  of  the  optic  nerve.  They 
consist  in  thickeiiinj;  nf  the  coats  of  the  vessels  in  the  optic  nerves  and 
an  iiitei-stitial  neuritis  or  increase  of  the  connective-tiss.ie  elements 
ill  the  optic  nerve  with  atrophy  of  the  nerve  fibres.  Lately  opinion 
li:,s  been  leaning  toward  tiie  view  that  iheehaiisre  bepns  by  a  dcpener- 
alioii  ill  the  macular  rejrioii  of  the  retina.  The  exiieriments  of  I.ang- 
ley  on  the  influence  of  nicotine  on  the  activity  of  the  gaiiplionic 
cells  has  further  stimulated  iiKjuiry  in  this  direction.  Xiiel  has  held 
from  eN.'Uiiinatioii  of  a  section  of  the  yellow  spot  that  the  disea.se 
starts  in  the  macula  lutea.  Whether  this  chaiifre  is  due  to  the  action 
of  nicotine,  or,  iir)ssibly,  some  of  the  other  constituents  of  tobacco 
smoke,  notably  pyriiiirie,  on  (he  >;a!ij:lioiiic  ceiis  or  ijieii'  .-yna]i.s<s, 
or  whether  tlii'  chaiifres  found  in  them  are  due  to  an  interference  with 
their  blood  simply,  must,  for  the  present,  remain  undeterinined. 


h! 


HKTISA,  Ol'TlC  SEHif:,  A.\D  IT.S  VKHKHRAL  (tRKllS.      459 

Sjrmptomi.  There  arc  soiiietitneM  pnwnt  the  symptuniN  nl  getieriil 
liil(:i(((i-|)oi.M>iiiii>t,  riipidily  of  the  heart-h-at.  ^leejilessness.  loss  of 
;i|>|Miite.  tremors,  ete.:  hut  these  may  Iw  eonspieiiously  al)seiit.  Thi' 
>iKht  i,-*  ilim.  there  is  a  mist  or  a  fog  over  the  objects  Ilireetly  looked 
at,  and  an  iiiahihty  'o  (hstiiijruisli  colors,  as,  for  instance,  to  tell 
readily  a  sovereipi  fi  .m  a  shillinij.  The  sijflit  is  worse  in  a  hright 
than  in  a  sulxiued  liKh  the  acutenes.s  of  vision  may  Ix'  eonsideraidy 
led  need,  from  g  to,,,,  or  even  lesv..  Ophthalmoscopic  exjirnina- 
lion  siious  slight  haziness  nl  the  disk  generally,  with  pallor  of  the 
lemiM.nd  half.  In  other  res|)ects  the  fundi  are  normal,  and  -vcn 
these  changes  are  hy  no  means  constant  or  easily  n-cognized.  The 
visu.il  fii'lds  in  true  tohacco  and)lyopia  are  of  normal  extent.  Hut 
at  the  fixation  point  there  is  a  .scotoma  or  hiind  area  for  colors, 
extending  from  the  fi.xatioii  jMiint  to  the  blind  s|H)t.  The  size  of  the 
,-cotoma  and  its  densiiv  vary  very  greatly;  its  average  size  is  an  oval, 
h.iving  a  horizontal  diameter  of  alwiut  Jn°,  with  a  vertical  diameter 
'!*  I"°',  '^'"i"'^'""''*  ''  '■'<  larger  and  extends  outward  almost  to  the 
limit  of  the  color  field,  when  it  is  sometimes  difhcult  to  discover  the 
natiiri-  of  the  .scotoma,  unless  we  use  test  .spots  of  con.sidernhle  size. 
I'erception  of  green  is  lost  first,  then  of  red:  })ercej)ti<)n  of  blue  and 
y(  !iov  are  le.ss  fre(|uently  lost.  The  |M)int  of  greatest  .saturation  of 
the  color  defect  lies  outsi<le  the  fixation  [loint.  It  is  nearly  ahvav." 
possilile  to  make  out  at  thi.ss|M)t  that  the  scotoma  is  absolute— that 
is  that  jK-rception  of  everything  is  lost  at  it— but  the  examination 
ni|uires  care  with  a  very  small  test  object.  It  is  sometimes  difficult 
to  obtain  good  evidence  of  the  .scotoma,  In-cause  of  the  inability  of 
the  patient  to  fix  the  object  steadily.  This  is  most  commonly  found 
when  t!ie  condition  of  tobacco  shakine.ss  is  far  advanced,  arid  csik'- 
I  iaily  hen  it  is  complicated  with  chronic  alcoholic  jM)i.soning.  The 
-liit'tn..'ss  of  the  eye  under  observation  and  the  wandering  attention 
I't  the  patient  are  well  marke<l  and  almost  characteristic.  If  this 
dricct  be  met  with,  the  best  method  of  making  the  examination  is 
to  cut  out  a  piece  of  paper,  re<l  on  (.ne  side  ano  ^reen  on  the  other, 
.iboul  ")  mm.  s(|uare,  and  stick  it  into  the  nib  of  a  pen.  Armed  with 
this,  stand  directly  in  front  of  the  patient,  and  tell  him  to  look  steadily 
:ii  liie  jioint  <  1  your  nose,  one  eye  being  covered.  It  is  possible  then 
I"  change  rap  <ln-  the  [josition  of  the  color  s[)ot,  and,  at  ti:.-  same 
lime,  to  k.'cr  a  close  watch,  on  the  fixation  of  the  eye.  In  this  way 
I  he  examin;  ion  \y  made  accurately  iind  rajndly.  If  it  is  desired  to 
keep  a  record  of  the  size  of  the  .scotoma,  it  .should  be  charted  on  the 
perimeter  In  addition  to  finding  the  scotoma,  it  is  necessary  to  see 
'hilt  the  fir.  ,  of  vi.sion  is  not  contracted,  that  the  jjallor  of  the  di.sk 
i-  litiiit<Ml  to  the  temporal  side,  thai  there  are  no  other  signs  of  nerve 
li-order,  like  talx's  or  insular  .sclerosis,  before  coming  to  a  conclusioe 
>-  to  the  nature  of  the  di.sea.-e. 
Prognosis  and  Treatment.  TIk-  prognosis  is  good,  provided  *hat 
!ie  patient  will  abstain  from  all  u.se  of  tobacco;  imjjrovement  nay 
'liow  diminution  of  the  amount  used,  but  it  is  well  to  insist  that  all 


is 


i» 


IL 


4G0 


Till:  EYE. 


t(il);u'e()  sliould  ho  fiivcn  up,  as  ;i  very 


,•  small  amount  is  often  sufficient 


to  koci)  up  ilic  irritation 


111  addition,  it  is  well  to  frivc  sin; 


ill  dailv 


doses  of  stryehnine.     Improvement  f;enerally  sets  in  a_ 
weeks  and  pies  on  to  complete  recovery 


fter  about  two 
\s  to  whether  the  patient 


niav  resume  si 


iioking  after  rec 


)verv  or  not,  lie  may  do  so  to  a  very 


moi 


lerate  desiree  after  an  interva 


that  tobacco  has  on  many  c 

habit  has  been  broken,  for  it  not  to  be  resunu 


l"of  months;  but,  seeiiis  the  hold 
nitirnied  smokers,  it  is  well,  when  the 


d,  for  relapses,  although 


ncominon.   may  occur 


11 
aico 


Ii 


1   some   o 


f  the 


worse  cases  oi 


tob:i 


hoi  blindiH'ss  the  loss  of  vision  amounts  to  all  but  a  ])erpepti(>n 
of  li'dit  111  such  cases  strvchnine  should  be  jjiven  in  full  doses.  It 
is  uM'ful  to  combine  it  with  nitroslyc'rin  or  to  fjive  inhalations  ot 
•imvl  nitrite:  at  the  same  time  the  general  health  must  be  considered, 
•IS  Mich  iiatients  are  often  broken  down,  and  .sometimes  on  the  l)rink 
of  delirium  tremens.     Sleep  and  a  sufficient  amount  of  nourishing 

food  must  be  secured.  ,,.,,•■      r        i 

Bisulphide  of  Carbon.  The  svmptoms  of  l)isulphide  of  carbon  jjoi- 
soiiiii"  resemble  much  those  of  the  most  acute  of  the  tobacco-alcoho 
cases'"  Thev  are  giddiness,  pallor  of  face,  unsteadmoss  of  Rait,  and 
tremors,  with  failing  sight,  a  mist  before  the  eyes,  dilated  pupil, 
and  ophthalmoscopicaliv  disks  which  are  pale  or  hazy  all  over.  1  he 
effect  of  carbon  bisul|)hid<>  is  more  severe  than  that  of  tobacco.  In 
■I  collection  of  cases  made  by  the  Ophthalmological  Society  of 
the  United  KiiiKdoiii,  :«  per  e(>nt.  recoven^d  vision,  25  per  cent, 
improved,  and  _'()  per  cent,  did  not  improve  at  all. 

This  disease  is  verv  rare  now.  owing  to  improved  methods  of  veiiti 
lation  in  factories,  In-  which  the  vapor  is  not  allowed  to  circulate 
among  the  workers,  but  is  ilrawii  out  of  the  room  by  ])roi)er  extrac- 
tors, so  that  cases  rarely  come  under  care.     Treatment  is  that  of 
tobacco  aniblvojiia. 

Chronic  lead-poisoning  is  churacterizeil,  in  addition  to  the  general 
signs  of  pluml)ism,  by  loss  of  sight,  often  of  the  central  scotoma  type, 
slHit  ••lironic  neuritis  of  the  optic  nerve,  passing  on  to  atroi)hy,  with 
some  contraction  of  the  field  of  vision.  In  addition  there  may  l.e 
the  signs  of  albuminuric  retinitis  secondary  to  granular  kidneys, 
caused  bv  lead-poisoning.  . 

Hereditary  Optic  Atrophy.  This  disease,  which  is  characterized  m 
it-;  ..iwet  by  loss  of  central  vision,  the  peripliery  of  the  visual  field 
beiM<'  retained,  prob:d)ly  belongs  to  the  retrobulbar  neuritis  grou]), 
•ilthougli  the  oiihlhalmoscopic  apiiearaiices,  .as  a  rule,  are  tliose  of 
simple  atniphv.  It  begins  in  early  adult  life,  generally  from  eighteen 
to  twenty-five  years  of  age.  attacks  the  m.de  members  of  a  family 
mo-^tlv  is  transmitted  through  the  females,  and  generally  appears  in 
successive  generations,  .\nolher  feature  of  the  history  of  these  fami- 
lies is  thelargi'  number  of  early  infantile  ileaths  which  it  reveals. 
Thi.  j!i=p;(se  is  geiiendlv  slow  in  its  progress  and  is  unaffected  by  any 

treatment.     It'^loes  not  go  on  to  ( iplete  blindness,  a  certain  amount 

of  periphera'  viMoii  being  retained. 


KHB^HNM 


^nv^io 


KETIXA,  OPTIC  SERVE,  A.XD  ITS  VEREBliAL  ORHilX.      4(J1 

Amblyopia  is  said  to  bo  produrod  by  a  very  largo  number  of  apoiits. 
Hut  siicii  oaiisos  aro  very  imt'ommou;  the  only  ono  which  calls  for 
s|(i'cial  mention  is 

Quinine  Amblyopia.  This  may  bo  caused  in  susceptible  individ- 
uals by  comi)aratively  small  doses  of  tho  salts  of  (luinine:  but  tho 
doses  known  to  have  caused  blindness  aro  from  15  jjrs.  to  r>j,  taken 
in  the  tlay.  Tho  loss  of  sight  comes  on  rapidly  and  varies  in  degree, 
but  it  may  bo  total.  The  pupils  are  dilated  and  irrespoiisiv<'  to 
light:  ophthalmoscoi)ically  tho  disks  are  seen  to  bo  pale,  tho  retinal 
V('ssels  very  small,  like  the  aj^pearancos  in  atnjphy  of  the  optic  nervo. 
(Kdema  of  tho  retina  is  sometimes  present,  and  a  chorry-red  spot  at 
the  macula,  like  tho  a])i)earances  in  embolism  of  the  central  retinal 
artery,  is  met  with.  It  can  sometimes  be  recognized  that  the  visual 
fields  aro  strongly  contracted.  Recovery  takes  place  first  at  the 
c('ntre  of  tlio  field  for  form  and  then  for  color,  but  a  certain  amount 
of  contraction  of  the  fields  of  vision  often  remains  permanently. 

Prognosis.  In  most  cases  recovery  takes  place  to  a  certain  extent, 
but  tho  process  goes  on  for  months  before  it  is  c(  mplete.  Relapses 
may  occur  if  tho  drug  be  again  administered.  The  oxporinionts  of 
Mniuner,  Baraba.schew,  and  do  Schwoinitz  have  shown  that  tho  lesion 
is  a  peripheral  ono,  depending  on  defective  nutrition  of  the  nervo  and 
retina,  from  oxtromo  contraction  of  tho  retinal  vo.ssols.  There  is 
no  neuritis,  but  thickomng  and  obliteration  of  the  lumen  of  tho  arteries 
supplying  tho  optic  norvo,  chiasma,  and  optic  tracts  are  .soon.  Accord- 
ing to  tho  experiments  of  Ward-IIolden,  in  dogs  fed  on  (juinino  tho 
I '  uigc  first  .shows  itself  in  tho  ganglionic  colls  of  the  retina  and  nerve 
tibres:  by  tho  forty-seveiith  day  tho  ganglionic  coll  layer  and  norvo- 
lilire  layer  had  almost  disappeared.  He  holds  that  with  a  los.-^onod 
blood  supply  the  loss  resistant  elements  of  the  retina— the  ganglionic 
rells  -break  down,  and  that  there  is  an  ascending  degeneration  of  the 
nerve  (ibres  secondary  t )  this  change  in  tho  nerve  colls. 

Treatment.  .\dministr:ition  of  (juinino  and  its  salts  nnist  bo 
-■tiipjicd.  Nitrite  of  amyl  or  nitroglycerin  internally  aro  the  best 
tmius  of  treatment.  Strychnin:-,  digitalis,  and  iodide  of  potassium 
in.iy  also  bo  used. 

Retrobulbar  Neuritis  Due  to  Disease  Affecting  the  Nervous  Sys- 
tem Generally.     The  most  fn^piont  cause  under  this  heading  is  insu- 
lir  sclerosis.     There  is  nuich  similarity  between  certain  ca.ses  of  acute 
ivtrobulbar  neuritis  and  insular  sclerosis,  and  al.so  between  the  latter 
iiid  tobacco  amblyopia.     In   insular  sclerosis  optic   nerve  changes 
ire  not  infro(|uent,  and  also  loss  of  vision  without  ophthalmo.scopic 
iiins.  probably  duo  to  an  actual  aflection  of  tho  nerve.    The  insular 
I  'rrosis  attacks  tho  norvo  as  it  attacks  other  parts  of  tho  nervous 
\-^teni  in  tho  form  of  islands  of  sclerosis,  in  which  tho  nerve  elements 
'AX  be  interfered  with  or  altogether  destroyed.     The  method  by 
liich  tho  pallor  travels  from  the  seat  of  tho  sclerosis  down  the  disk 
lint   explained.     It  may  possibly  be  due  to   wasting  of  tho  con- 
it'ugal  fibres,  which  go  from  the  bisal  ganglia  to  tho  retina. 


il 


462 


TlIK  EYE. 


Optic  Neuritis  with  Dropping  of  Watery  Fluid  from  the  Nostril. 

\  few  ca^cs  have  been  ()l)scrvc(l  in  whicli  there  was  a  persistent  How 
of  fluid  from  one  nostril,  with  lu>a(laehe,  vomiting',  .Irowsiness  or 
,i,.iiri.i.n,  and  an.hlvopia.  Optic  neuritis  is  present  at  the  same  tune. 
The  fluid  analyzed  lias  been  found  to  resemble  eerebro-spmal  fluid, 
in  s„me,  if  not  all  of  the  eases,  and  there  is  great  probability  ot  its 
e«cai)e  from  the  skuil  through  the  eribriform  plate  of  the  ethmoid 
The  prognosis  is  not  good  and  no  treatment  has  hitherto  been  found 

"  Atrophy  of  the  Optic  Nerve.  .\troi)hy  of  the  oiitio  nerve  is  either 
■X  primarv  disease  (  >■  is  s.rondary  to  some  previous  atleetioii  of  the 
optic  nerV.",  like  optie  neuritis,  embolism  of  the  centra;  .rtery  of  the 
retina    or  to  retiiiochoroiditis  or  retinitis  i)igmenlosa.      (lig.  ^aa.) 


Fio,  2r.r,. 


Ophthalmoscopic  appearance  of  disk  i.i  atrophy  l.)llo\vin«  hemorrhage.    iJaeukr.! 


I'rhwini  optic  utrophy,  also  known  as  simple  or  progressive 
.itroi)hv  is  charact.Tized  l)V  gradually  increasing  i)allor  ot  the  optic 
'nerves' wit liout  signs  of  inflammation.  The  disease  is  generally 
biiiteral.  The  .-<mall  vessels  of  th.'  nerve  disai.pear,  the  retinal  arte- 
li,  ~  dwindle,  the  veins  beeomi'  funnel-shaped  at  the  disk,  and  the 
disk  a-^Mimes  a  delicate  !)lue-white  tint.  The  vessels  make  a  slight 
iMMid  it^  they  i)ass  over  the  edge  of  the  disk,  owing  to  a  slight  atrophic 
evc-iVMlion  of  the  <lisk;  the  stippling  of  the  lamina  cribrosa  becomes 
marked,  tlu-  sight  undergoes  jirogressive  diminutu.n,  percei)tion  of 
color  i'^  lost,  and  the  fi(>lds  become  contracted,  generally  concentrically, 
but  iierhaps  more  in  one  part  than  in  another.  The  most  coimnon 
cause  of  primarv  optic  atrophy  is  tabes  dorsahs.  The  atrophy  is 
often  the  earliest  sign  of  tabes  and  may  i)recede  any  otlii'r  syinpti.m 
bv  vear*  (lenerallv  where  the  sjaiial  symptoms  come  ..n  early, 
the  'oi.tic  atroj.hv  is  late  in  ai)p<-arance.  .\niong  the  other  signs 
are   smallness  of"  the    pupils,  spinal    myosis,  the  Argyll-Rolwrtson 


RETIXA,  OPTIC  yi:jlVi:,  AXD  its  cerebral  ORKIIS. 


463 


[tupil,  loss  of  the  knoo-jcrk,  and  loss  of  oquilihrium  (Romhenfs 
si/nii>t()m),  x\w  ataxk-  Rait,  while  the  patient  may  complain  of  j)eri- 
ixiic  acute  attacks  of  indigestion  (gastric  crises),  lijjhtninf;  j)ains 
in  the  limbs,  or  girdle  pains  about  the  body.  The  atrophy  of  the 
optic  nerve  may  go  on  to  comjjlete  blindness  without  the  ajipear- 
ance  of  any  of  the  other  symptoms,  the  i)atient  remaining  in  good 
iiealth.  In  some  of  the  cases  the  disease  comes  to  an  end,  the  optic 
nerves  only  are  affected;  probably  these  should  be  regarded  as  cases 
of  arrested  tab(>s,  but  generally  tlie  signs  of  ataxy  develo])  later.  In 
complete  tabetic  atrophy  the  retinal  ganglion  cells  have  Ix'en  found 
to  (lisai)pear:  Ward-IIolden  discovered  only  degenerated  ganglion 
cells  here  and  there,  even  in  the  macula.  If  this  be  so,  the  atroj)hy 
of  the  nerve  it.self  is  jjrobably  secondary  to  that  of  the  retinal  ganglion 
cells.  ()|)lic  atrojjhy  also  occurs  in  insular  sclerosis  and  general  j)ar- 
alysis  of  the  insane,  and  it  ha.s  in  a  few  rare  cases  been  found  asso- 
ciated with  diabetes  insij)i('  is.  It  may  follow  local  changes  in  the 
orbit,  as  the  jm'.ssure  of  a  tumor.  The.se  fonn.s  are  characterized  by 
their  being  one-sided  and  affecting  only  one  portion  of  tlie  nerve. 
Sim])le  atr()i)hy  is  rare  in  children;  it  is  most  conmion  after  middle 
age.  It  is  often  difhcult  to  distingui.sli  primary  atroj)liy  from  the 
atrophy  which  accompanies  very  chronic  glaucoma.  The  difference 
can  generally  lie  made  out  by  the  fact  that  in  the  latter  disease 
perception  of  colors  is  not  lost,  and  the  oi)hthalm()scoi)ic  appearances 
show  that  the  excavation  of  the  disk  is  very  much  greater  in  glau- 
<onia  than  in  primary  optic  atroi)hy. 

The  prognosis  is  generally  unfavorable;  primary  atrophy  leads 
almost  certainly  to  blindness. 

Treatment  should  be  directed  to  the  disease  underlying  the  atrophv; 
I'nr  the  optic  nerve  itself  we  may  give  strychnine  or  iodide  of 
|iotas.sium. 

I'ont-iicuritic  (itmphji  is  the  last  stage  of  an  ojjtic  neuritis.  It 
differs  in  oi)hthalmoscopic  appearances  from  primary  atrojihy  in  the 
.ippearance  of  the  disk  and  pjirts  around.  Instead  of  being  <|uite 
'  lear  and  sharply  defined,  the  disk  is  covered  by  a  light  haze,  as  if  it 
iiad  been  washed  with  Chinese  white,  the  veins  are  still  distended 
ind  tortuous,  an<l  both  arteries  and  veins  have  white  lines  along 
ihem,  owing  to  thickening  of  their  sheaths;  the  lamina  cribrosa  is 
iii<lden  by  the  remains  of  the  inflammatory  exudation  and  there  is 
■  ■■  disturbance  of  the  choroid  around  the  disk.  In  many  ca.«es,  how- 
'  ver,  it  is  impo.ssible  to  say  with  confidence  whether  the  atrophy  is 
.irimary  or  post-neuritic  from  the  ophthalmoscopic  a])pearances  alone. 

I'ost-cmholic  and  I'ost-thwmbotic  Atrophy.  These  are  ilistinguish(Hl 
'•'}■  the  obliteration  of  the  affected  ves.sels,  which  may  have 
liiunk  to  white  bands  only  c-  may  contain  .a  small  visible  column 
i  iilood.  and  by  a  certain  amount  of  change  usually  .seen  at  the  yellow 
\y\.  The  tialiin-  of  {)ost-embolic  atrojihy  can  generally  be  deter- 
iined  by  the  history  or  by  the  mode  of  on.set  of  the  affection,  that  is 
\  its  absolute  suddenness. 


464 


THE  EYE. 


r„M-rcHnUic  Atmplni.  IIV/jv  Atrnphj,  I'oM-rhowidHtc  Atrnphi.  Tlic 
t)ai>illa  ill  this  disease'  appears  to  liave  a  dirty  yellowish-re.l  (-(jlor. 
the  vessels  are  narrowed,  and  there  are  sij,'ns  in  the  liindus  ol  oh  clior- 
oi(hil  or  retinal  disease.  . 

In  filauconiatous  atrophy,  tyi)ical  plaiicontatous  excavation  ol  the 
disk,  where  the  vessels  disai)pear  at  the  niarfiin  of  the  disk  and  are  dis- 
placed toward  the  nasal  side,  is  tin'  distinRnishiiiR  featnre. 

Tumors  of  the  Optic  Nerve.  Tumor  of  the  oi)tic  none  occurs 
rarely  In  vol.  xi.x.  of  the  Tmnmctionx  <>J  the  Ophthobnohunnt 
Snriehi  of  the  rnilnl  Kim/chm.  Huller  and  -Marshall  f..un<l  only  i:}0 
cases  recorded  in  literature.     The  greater  number  of  cases  occurred 


Fio.  256. 


Coloboma  of  opilc  nerve. 


before  the  ape  of  ten  vears.  and  the  liability  to  the  disease  dimim.shed 
with  afie.  The  svniptoms  of  the  affection  are  rajud  loss  of  sight,  for- 
wan'  a'lid  outwaril  |)rotrusion  of  the  eyeball  in  the  line  of  the  axis  ot 
the  orbit,  little  or  no  limitation  of  inuv(>meiit,  and  no  pain.    1  Fig.  2,)t|.) 

The  tumor  niav  be  felt  in  s e  cases  behind  the  eye.     The  seat  of  the 

growth  is  mosl'lv  in  the  central  portion  of  the  optic  nerve,  and  it  is  not 
..nnim.m  for  tlio  <'ve  to  be  involved.  The  kinds  of  growth  found 
after  n-mov.Ml  have' been  gliomata  or  tui;;ors  of  the  neuroglia,  sarco- 
imata  or  endotheiiomata.     Tuberculous  tumors  have 


mala,  myxosarcoii 
!i!so  been  se<'n. 


(he 


Treatment.  1.  Uenioval  of  tlu'  tumor  with  iireservaimn  ol  llie  eye. 
This  may  be  done  l)v  dividing  the  external  rectus,  rotating  the  eye 
inward  and  removing  the  involved  optic  nerve,  replacing  the  eye  and 


RETINA,  OPTIC  NERVE,  ASD  ITS  CEREBRAL  ORIGIX      4(j5 

suturing  the  external  rectus:  the  external  wall  of  the  orbit  may  be 
removed  to  faeilitate  access  to  the  tumor  (Kronleiu's  operation). 

2.  luiucleation  of  the  eye  with  the  involved  nerve. 

;{.  ivxenteration  of  the  orbit. 

Having  to  deal  with  a  malignant  growth,  it  may  be  (juestioned 
whetlK'r  it  is  worth  trying  to  save  the  useless  eye.  which  is  a  great 
hindrance  to  the  easy  and  efficient  removal  of  the  tumor.  Having 
regard  to  the  life  of  the  i)atient,  it  is  wi.se  to  remove  the  growth  as 
widely  as  j)ossil)le. 

Injuries  to  the  Optic  Nerve.  These  are  caused  most  fre(|uently  by 
falls  on  the  head.  The  base  of  the  skull  is  fractured  and  the  optic 
nerve  is  ru|)tured  by  si)lhiters  of  bone,  hi  the  optic  foramen.  Sight 
may  be  lost  without  rupture  from  hemorrhage  into  the  sheath  of  the 
optic  nerve.  The  optic  nerve  is  sometimes  injured  by  foreign  bodies 
penetrating  the  orbit  without  the  eye  Ix'ing  injured.  I'he  most  famil- 
iar instance  is  by  the  ferule  of  an  umbrella  or  walking-stick.  The 
optic  nerve  is  .sometimes  divided  by  bullet  wounds  traversing  the 
orbit,  frecjuently  in  ca.s(>s  of  attempted  suicide.  In  some  of  these 
ca.seb  ra-ocular  hemorrhages  and  ruptures  of  thechf)roid  have  been 
found,  although  the  track  of  the  bullet  was  far  removed  fro-ii  the  back 
of  the  eye.  After  rupture  blindness  comes  on  at  once;  if  the  pai)illa 
appear  to  be  pale  immediately  after  the  injury,  the  nerve  has 
been  ruptured  in  front  of  the  entrance  of  the  central  retinal  arterv. 
If  the  rupture  Ix-  behind  this,  the  pallor  of  the  di.sk  may  not  come  on 
for  three  weeks  or  longer. 

Loss  of  Sight  after  Severe  Hemorrhages  may  result  from  optic 
nerve  atropiiy:  it  may  come  on  from  surgical  or  post-jiartum  hemor- 
rhage. It  most  commonly  results  from  hemorrhage  from  the  intes- 
tinal tract;  at  first  there  may  be  crdema  of  the  retina  followed  by 
atrophy  of  the  nerve.  If  loss  of  .sight  be  coming  on,  the  patient  should 
be  placed  in  a  horizontal  position  and  if  possible  intravenous  injections 
of  saline  .solution  should  be  made  without  delay.  Sometimes  the  less 
of  sight  comes  on  .several  days  after  the  hemorrhage.  The  cause  of 
tliis  is  not  clear,  but  it  is  thought  by  Leber  to  be  due  to  hemorrhage 
into  the  sheath  of  the  nerve  creeping  forward  from  the  base  of  the 
skull.  In  .some  cases  of  injury  the  blood  travels  forward  and  may 
lie  .seen  jifter  several  days  beneath  the  conjunctiva  and  even  in  the 
lids.  Treatment  should  be  rest  horizontally,  iron,  proper  feeding,  etc. 
Hyaline  Growths  in  the  Optic  Papilla. "  Hyaline  nodules  growing 
from  the  lamina  vilrea  of  the  choroid  are  very  common.  In  rare 
cases  they  ajjpear  on  the  disk  it.self;  they  are  gray  nodules  clustered 
together,  generally  at  the  edge  of  thi-  disk.  They  do  not  as  a  rule  in- 
terfere with  vision,  an<l  no  treatment  is  called  for. 

Ocular  Signs  and  Symptoms  Attending  Diseases  of  the  Brain. 

fipiic  neuritis  and  loss  of  sight  may  indicate  tumor  of  the  brain; 
ihey  are  of  value  as  showing  tJ  _>  presence  of  a  tumor  only;  they  have 

30 


4G6 


THE  EYE. 


S  1 


no  localization  value.     The  form  of  oi)tic  neuritis  known  as  choked 
disk  is  the  one  which  conunonly  attends  eerehral  tumor,  hut  the  neu- 
ritis may  also  he  coinhined  with  retinitis  witlumt  nuicli  swelliiifi,  and 
niav  resemhle  alhumimn-ic  retinitis,  even  when  the  cause  is  an  intra- 
craiiial  prowih.    In  case  of  iloubt,  examination  of  thi'  urine  should  be 
made,   ""in  meningitis  and  Iivdrocephalus  ojitic  neuritis  may  also  l)e 
l)resent.     Cvsls  and  hemorrhages,  as  a  rule,  .lo  not  give  rise  to  ocular 
symI)tom^■,  but  an  abscess  of  the  brain  may  do  so.     Optic  neuritis  m 
ceri'bral  tumor  occurs  earlv.  but  it  may  be  delayed  or  it  may  not 
occur  at  all.     The  sight  may  be  i.iiaffected  for  a  ionp  time,  but  tlu- 
field  of  vision  soon  becomes  somewhat  contracted.     In  other  cases 
ill  wlii'h  the  neuritis  is  axial,  loss  of  vision  in  the  form  of  a  central 
scotoma  ma V  occur  I'arly.     ( )ptic  neuritis  may  l)e  caused  by  a  tumor 
of  any  size  in  anv  jjart  of  the  brain.     Timiors  of  tin-  cerebellum  and 
at   the  base  of  the  brain  are  more  likely  to  produce  optic  neuritis 
than  tumors  in  other  parts,  jirobably  owiiift  to  i)rc>ssurc  on  the  yems 
of  Galen.     The  next  most  important  ocular  sign  in  disease  of  the 
brain  is  hemianopsia  or  loss  of  half  of  the  field  of  vision.      This  i> 
due  to  a  dis<'ase  of  the  chiasm,  of  the  optic  tracts,  of  the  cortical  centre 
of  vision,  or  of  some  part  of  the  l)ath  coiuiectiiif;  the  optic  tracts  witji 
the  cortex  of  the  brain     Local  di.seaseof  the  eye  producing  lo.ssof  halt 
the  visual  field  is  not  included  under  the  name  of  hemianopsia.    When 
hemianopsia  occurs,  the  fields  are  u.-;ually  both  affected,  one-half_ot 
<.ach  field  being  normal,  the  other  half  iu'ing  blind.     The  dividing 
line  between  the  two  is  a  vertical  on(>  through  the  centre  of  th(>  fiehls, 
but  usuailv  turning  a.side  a  little  at  the  fixation  point  in  each  eye  s(;  as 
to  leave  it  unafiected.     In  some  ca.ses,  however,  it  goes  through  the 
fixation  point.     It  sometimes  hap])ens  also  that  the  line  of  .separation 
is  not  <iuite  vertical,  but  somewhat  irregular,  so  that  the  s( cing  half 
of  the  retina  passes  over  the  middle  line.     The  blind  i)art  is  generally 
absolutely  bliiiil,  but  in  some  cases  color  i)erce|)tion  only  is  lost,  so 
that  we  have  a  condition  of  hemianopsia  Tor  colors  or  hemiachroma- 
to|)sia.     Ill  .some  cases  the  defect  is  sectorial,  and  in  otlier  rare  cases 
it  is  tlie  upper  or  lower  halves  that  are  defective.     The  most  freciuent 
form  is  one  in  which  the  corresponding  halves  in  each  eye  are  want- 
in<r   for  instance,  the  right  half  of  each  field  may  be  blind,  miplymg 
the  loss  of  function  in  the  left  half  of  each  retina,  or  if  the  left  half  of 
the  field  be  blind  the  right  half  of  each  retin.a  will  be  functionless. 
This  is  called  homonymous  hemianopsia.    (Figs.  I'u  and  I'oS.)    Many 
cases  of  double  homonymous  hemianoiisia  have  been  descnbed  due  to 
disease  of  the  cortical"  visual  centres  in  each  hemisphere.     Most  of 
the  ca.ses  have  begun  with  loss  of  vision  in  corresponding  halves  of 
(>ach  eye,  followed  at  a  later  date  by  loss  of  vision  in  the  other  halves, 
whereby  total  blindness  was  i)roduced.     In  a  few  of  the  ciises  the 
macula  Was  left,  .so  that  there  wa.s  fairly  good  vision  while  looking 
ahead,  but  the  ])atients  haii  no  power  of  direding  their  movement.^ 
owing  to  the  small  size  of  the  visual  field  floss  of  orientation).     Loss 
of  the  outer  halves  of  each  visual  field  or  loss  of  function  of  the  two 


BETISA,  OPTIC  NERVE,  AM)  ITS  CEREIiliAL  ORIGIN.      4«7 

iKisal  halves  of  tho  rotina  is  known  as  bitemporal  hemianopsia.  Nasal 
lii'tiiian()i)sia  is  blindness  of  the  inner  half  of  eaeh  visual  field,  and 
i:-  due  to  a  want  of  function  on  the  temporal  side  of  each  retina.    To 


Len^lded  hemianni«ia. 


Fig.  258. 
Left  Eye 


IxKtiitsA  bemlanopaU. 


468 


rUK  EYE. 


\i 


oxi)laiii  tho  cause  of  tho  honiianopsiii  in  those  atfectidus,  it  wu!  he 
lu-Irf^sary  to  p.  <«v."r  afresli  tlie  course  of  tiie  visual  fil.res  from  tlic 
retina  to  tilt' cortex  of  the  brain.  •    i         r 

Tlie  nerve  fibres  from  tlie  corresponding  or  homonymous  halves  o 
c-ich  retina-tiiat  is,  from  the  nasal  half  of  the  riRJit  and  the  temporal 
half  of  the  li'fl  retina-pass  tiiroU(jh  the  chiasma  and  umte  to  lorni 
the  left  optic  tract ;  simiiarlv  fibres  from  the  temporal  half  of  tiie  riftht 
and  luusal  half  of  the  left  retina  l)as.s  through  the  chiasma  to  iorni 
the  ridit  ol>tic  tract.  The  fibres  from  each  tract  pass  into  the  basal 
eaiiKlia  the  optic  thalamus,  the  anterior  corpus  <,uadnReminum, 
and  the  external  peiiiculate  body;  thence  thnuigh  the  posterior 
I)art  of  the  internal  ca])sule,  and  tho  optic  radiations  to  the  visual 
centre  This  i^  situat>'d  on  the  mesial  surface  of  the  occipital  lolx" 
ill  the  region  having  the  middh-  part  of  the  calcarine  hssure  at  its 

^Lesions  of  the  Chiasma.    The  most  u.'^ual  sign  of  atTections  of  the 
chiasma  is  bitemporal  hemianopsia.     This  is  duo  to  mvolvemont  of 
the  decussating  fibres  at  the  anterior  or  posterior  border  of  the  chi- 
asma    Tiieso  fibres  supi.lv  the  nasal  halves  of  each  retma,  which 
'ire  conseiiuentlv  bliixl.     The  affection  (jf  sight  begins  by  a  limitation 
of  the  outer  jwrt  of  each  visual  field,  or  one-half  may  be  afTectcd 
bef<«re  the  other,  according  to  the  position  of  the  lesion.     The  lo.s.s  of 
sight  may  for  a  time  be  onlv  a  color  blindness,  but  later  on  light  and 
form  seiise  are  involved  also;   the  lo.ss  goes  on  to  total  bitemporal 
hemianoi)sia.     In  m:>.!iv  of  the  ca.ses,  owing  to  advance  of  tho  disease, 
the  uncrossed  fibres  become  affected  too,  and  the  result  Ls  total  blind- 
ness.    It  has  been  demonstrated  by  Nettleship  and  others  that  chi- 
asmal disca.<e  fretiuentlv  begins  as  a  central  scotoma,  and  as  such  may 
bo  mistaken  for  toxic  amblvopia.     It  is  believed  in  such  cases  that  tho 
disease  starts  in  the  anterior  part  of  the  chiasma.  where  the  macular 
fibres  are  situated.     It  is  common  in  most  of  tho  caso.«  to  have  a 
certain  diminution  in  central  vision.     Tho  optic  nerve  becomes  atro- 
i)hic    there  is  generallv  great   headache,  sometimes  loss  of  mental 
power;  optic  neuritis  is  not  often  present,     .\ffections  of  the  outer 
side  of  the  chiasma  prodiu-ing  nasal  h(>mianoi)sia  are  very  rare;  hori- 
zontal hemianoi)sia  may  bo  caused  by  pressure  on  the  chiasma  above 
or  below.     The  causes  of  chiasmal  diseas(>  are  acromegaly,  tumors 
of  the  pituilarv  bodv,  meningitis,  fro(iuently   syi)hilitic,  periostitis 
of  thi'  bodv  of  "tlie  sphenoid,  tubercular  mas.ses,  syphilitic  gummata, 
cvsts  and  exostoses,  and  hydroce])halus  jiroduced  by  distention  of  the 
tiiird  vcMitricle.     The  treatment  must  be  in  accordance  with  the  dis- 
covered cause.     Much  good  may  oft(>n  be  done  in  syphilitic  cases  l)y 
apitropriate   troat:nent.  . 

Lesions  of  the  Optic  Tract.  Th<"  characteristic  symptom  of  lesion 
of  tlu'  optic  tract  is  homonymous  lateral  hemianoi)sia.  This  may  fie 
comi.lete  or  partial,  involving  only  a  (juadrant  of  each  retma,  as  in  a 
case  related  bv  Honschen,  in  which  there  was  a  defect  of  tho  field  of 
vision  in  both  left  lower  ([uadrants,  caused  by  a  tumor  pressing  on  the 


warn 


mmm 


RETIXA,  OI'TW  XERVt:,  AM)  ITS  CEHEUBAL  ORIOIS.      469 


uiUMT  part  (.f  tho  right  oj)tic  tract.  Tho  defect  may  bo  relative  also — 
that  is,  there  may  Ix-  half-vision  for  color  only — form  and  light  perce))- 
tion  iH'ing  unaffected.  ( )\viiig  to  proximity  of  the  trunks  of  the  nerves 
at  the  base  of  the  brain,  there  may  be  paralysis  of  tlu'  parts  sui)j)liecl 
i)y  these  nerves  owing  to  pressure  from  a  tumor  of  the  tract.  Optic 
neuritis  may  be  |)resent  in  localized  meningitis  or  in  tumor,  and 
primary  optic  atrophy  is  som<'times  met  with;  both  these  manifesta- 
tions are  often  more  marked  in  one  eye  tiian  in  the  other.  Homony- 
Mioiis  lateral  hemianopsia  is  shown  by  blindness  of  the  correspond- 
ing halves  of  the  retina,  for  instance,  the  temporal  half  of  the  left 
retina  and  the  na.sal  half  of  the  right.  Wernicke's  .sign  or  the  hemi- 
opic  pui)il  is  frequently  present,  and  is  of  great  value  in  localizing  the 
.seat  of  the  affection:  it  consists  in  the  fact  that  light  thrown  u|)on 
the  blind  half  of  each  eye  |)roduces  no  pupil  reaction  at  all,  while 
light  thrown  upon  the  acting  half  of  each  retina  gives  rise  to  non^al 
pu|)il  reaction.  Afferent  impulses  proceeding  centrally  from  '  le 
retina  are  interrupted  at  the  .seat  of  the  disea.se  in  the  tract,  and  lo 
not  pass  to  the  basal  ganglia  and  third  nerve  nucleus,  while  lesions  of 
tiie  visual  path  above  the  basal  ganglia  producing  homonymous 
hemianopsia  do  not  interfere  with  the  path  of  the  impulses,  which 
|iass  from  the  retina  to  the  basal  ganglia  and  thence  to  the  third 
nerve  nucleus.  It  is  conceivable,  therefore,  that  there  might  be  .sym- 
metrical le.sion.s  in  the  hemi-sphere,  which  j)roduced  double  homony- 
mous hemianopsia,  and  therefore  total  blindness  of  each  eye,  and  which 
yet  left  the  pupillary  light  reflex  unaffected.  The  hemianopic  pupil 
icnction  is  not  ea.sy  vo  obtain,  inasmuch  as  it  is  difficult  to  keep  the 
lijrlit  passing  to  one  side  of  ihe  retina  from  illuminating  the  other  half 
t(i  a  certain  extent.  But  it  is  generally  jKissible  to  establish  a  differ- 
ence between  the  reflex  action  of  the  pupil,  when  light  is  cast  from 
opposite  sides  on  to  the  retina  in  di.'seases  of  the  tract.  (For  the 
method  of  api)lying  the  test,  see  page  34.;  Symptoms  of  disea.se 
(if  the  optic  tract  may  l)e  produced  by  the  pressure  of  tumors  of 
iicif^hboring  narts,  of  the  temporosphenoitlal  lobe,  optic  thalamus,  or 
cnis  cerebri. 

Lesions  of  the  Basal  Oaitglia  or  Primary  Optic  Oang^Ua,  External 
Geniculate  Body,  Optic  Thalamus,  and  Anterior  Corpus  Quadri- 
geminum.  These  ganglia  undergo  degeneration  after  removal  of  the 
<  ye:  also  after  lesion  of  the  occipital  lol)e,  degeneration  can  be  traced 
ilnwn  to  them:  the\  are  therefore  in  the  direct  line  of  traasmission  of 
impulses  from  the  eye  to  the  brain  cortex. 

Exterrml  Geniculate  Body.  All  the  fibres  of  the  optic  tract  enter 
the  external  geniculate  body,  and  a  lesion  here  always  gives  rise  to 
hemianopsia.  It  is  probable  also  that  its  upper  and  lower  parts  supply 
the  u])per  and  lower  parts  of  the  retina,  respectively.  If  so,  homony- 
iiiKUs  quadrant  hemianopsia  may  be  due  to  di.sease  of  the  external 
'^rciiiculate  body. 

()l>tic  Thalamus.  Lesions  of  the  posterior  part  of  the  optic  thala- 
mus, the  pulvinar,  have  in  many  cases  been  found  in  association  with 


470 


rilE  EYE. 


hcniiunopsia,  Init  in  an  r<nml  nunilH-r  d'  caw's  lioinian<)i)siii  has  not 
hiTii  lounil.  It  is  prolKiliic  thai  tiic  lesion  of  liw  o|'ti<'  tiialanms 
itself  lia.s  not  given  rise  to  hemianopsia  except  indin-ctly  from  press- 
ure on  the  optie  traet. 

CorimniQiKKlriiieininn.  It  is  not  certain  that  tumors  ot  the  cor- 
pora .lua.lrinemiii'a  give  rise  to  loss  of  sight.  A  few  «l()U»)tful  eases 
have  ijeenreeonleil  in  whieh  there  was  blindness  from  lesions  m  thu 
situation,  hut  then-  is  a  far  larger  numlnT  of  eases  in  which  tumors 
of  tiie  corpora  (luadrigeniina  produced  no  blindness  at  all.  (l'<>r 
oculomotor  atTeclions  following  lesions  of  the  corpora  (luadrigemina, 
see  page  ISO.)  •       i  i:i 

Lesions  of  the  Internal  Capsule.  The  cours*'  of  the  visual  hbres 
fr.  m  the  external  geniculate  body  to  the  optic  radiation  is  not  yet 
known.  Fibres  are  traced  to  the  external  geniculate  body  through 
the  posterior  third  of  the  posterior  limb  of  the  internal  capsule,  and 
it  is  a.sserted  that  a  lesion  of  this  part  of  the  internal  capsule  causes 
hemianojjsia.  On  the  other  liand,  Henscheu  lias  shown  that  lesions 
of  this  part  do  not  necessarily  cause  hemianopsia,  and  that  when 
they  are  associated  with  it,  the  external  geniculate  boily  or  the  optic 
tract  is  interfered  with  at  the  same  time. 

Lesions  of  the  Optic  Radiations.  It  is  unknown  with  accuracy 
how  large  a  jtortion  of  the  optic  radiations  is  occui)ied  by  the  visual 
fibres.  According  to  Henschen,  only  the  central  portion  is  so  occu- 
pied. Other  writers  agree  with  him  that  the  optic  radiations  contain 
many  other  fibres  than  visual  ones.  The  importance  of  this  lies  in 
the  fact  that  in  a  'I'sion  of  the  optic  radiation,  although  we  may  get 
hemianopsia,  we  get  also  other  symi)toms,  which  may  aid  us  to  recog- 
nize the  lesion  and  to  distinguish  it  from  a  cortical  one.  A  subjective 
sensation  of  blindness  is  caused  by  a  lesion  of  the  radiations,  in  the 
form  of  positive  scotoma,  but  it  is  not  present  in  a  lesion  of  the  cortex. 
If  tile  lesion  extends  lieyond  the  visual  fibres,  various  other  syiiii)tonis 
are  present,  such  as  iiu.id  l)lindness.  word  blindne^  r  alexia, visual 
aphasia,  dvslexia,  amnesic  color  blindness,  or  visual         ucinations. 

Alexia  nr  Word  Blindness.  In  this  affection  persons  are  unable 
to  read  words;  the  print  or  writing  is  ])erfectly  well  seen,  the  letters 
themselves,  except  in  rare  cases,  can  tx-  made  out,  but  the  power  of 
combining  them  is  entirely  lost.  The  patient  can  write  (|uite  well, 
but  is  unable  to  read  anytiiing  he  lias  written  unless  he  is  allowed  to 
go  over  it  with  a  i)en.  In  some  cases  even  individual  letters  cannot 
be  recojrnized,  but  ilgures  can  as  a  rule  be  read.  Word  blindness  may 
Ix-  combined  with  an  inability  to  write. 

Alcsid  w  '  Aqraphin.  This  alexia  is  due  to  interference  with 
the  fibres  ])assing  from  the  visual  memory  to  the  siH'cch  centre,  and 
has  a  distinct  localizing  value  as  the  lesion  has  Ikm-u  recorded  from 
post-niorlem  examination  in  five  cases  in  tlie  left  (KTipiia!  lobe. 
Alexia  with  agrajjhia  if.  thought  to  be  due  to  a  lesion  of  the  centre 
for  visual  memorj-  in  the  left  angular  gyrus.  The  a.'^.sociation  of  alexia 
with  right  homonymous  hemianopsia    is    to    be    explained  by  the 


IlKTLSA,  OPTIC  SERVK,  ASD  ITS  LEIIEUHAL  ORlUlN.      471 


ncaiiHss  t)f  tln'  visual  t'cntrc  ami  pii'lw  to  the  lesion  which  cuu.>»(' 
alexia. 

Iliislfsia.  In  this  affectum  there  is  no  loss  of  sight,  but  a  .Hiinjile 
inability  of  the  patient  to  rea<l  continuously.  A  few  wonU  only  can 
be  read,  then  the  book  is  thrown  aside:  the  effort  inuy  1m'  n'|K'ated 
after  u  time,  but  power  of  continued  reading  is  absent.  In  most  casen 
dyslexia  !>as  In-en  a.ssociated  with  hemianopsia  and  other  cerebral 
symptoms.  It  is  caused  by  degeneration  of  the  cerebral  vessels  and 
generally  has  a  fatal  termination:  it  apjK'ars  to  have  little  value  as  a 
localizing  sign. 

Visual  Aphaxia.  The  |)atient  cannot  rememlxT  th(>  names  of  things 
seen,  althougii  (|uite  familiar  with  the  things  them.selves,  but  can  re- 
niemlM-r  their  names  if  he  can  n-cognize  the  things  by  some  other  .sense 
than  that  of  sight,  as,  for  instance,  if  he  can  touch  them.  Conversa- 
tion of  patients  suffering;  from  visual  aphasia  has  certain  well-marked 
peculiarities-  the  general  avoidance  of  names  and  the  use  of  circuitous 
methods  of  spe<'ch,  in  order  to  make  up  for  the  defective  power  of 
expression.  Right  homonymous  hemianop.sia  is  almost  always  \)n's- 
eiit  and  sometimes  alexia  and  agrajjhia.  The  lesion  is  believed  to  be 
in  the  l(>ft  occipital  lolie. 

Loss  of  Color  Memory — Amnesic  Color  Blindness.  The  patient  is 
able  to  perceive  the  colors  and  to  match  them  correctly,  but  is  unable 
to  give  them  their  names.  This  has  always  been  found  associated 
with  right  homonymous  hemianopsia,  and  is  believe-l  by  Wilhrandt, 
who  de.scrilM'd  it,  to  lie  an  indication  of  disease  of  the  occipital  lobe  on 
the  left  side,  preventing  communication  In'tween  the  color  centre  for 
vision  a:.d  the  sj)eech  centre. 

Visual  hallucinations  sometimes  occur  in  the  l)lind  side  of  the 
field:  objects  are  seen  in  the  blind  area  which  are  not  in  view  at  all. 
This  is  thought  to  be  due  to  irritation  of  the  centre  for  visual  memory 
in  the  occipital  lobe,  but  a  ca.se  has  been  published  by  de  Schweinitz 
ill  which  hallucinations  occurred  in  the  blind  side  of  the  field,  due  to  a 
(ruiuma  pressing  on  the  right  optic  tract.  \'isual  hallucinations  are 
always  accompanied  by  right  homonymous  hemianopsia.  Hallucina- 
tions of  vision  due  to  focal  brain  di.sea.se  are  generally  Jis.sociated  with 
oilier  signs  of  focal  brain  di.sea.«e.  and  may  be  distinguished  from  other 
\'su:il  h  lliicinations,  such  as  those  occurring  in  delirium  tremens  or 
lever,  by  their  occurring  in  the  filind  jiart  of  the  visual  field. 

Mind  Blindness  or  Visual  Amnesia.  The  sight  is  perfectly  good, 
intelligence  is  not  affected,  the  patient  is  able  to  read,  but  he  lias  lest 
tiie  power  of  recognizing  objects  seen:  if  they  lie  presented  to  him  by 
one  of  his  other  senses,  he  at  once  recognizes  them  Pcojile,  even  most 
intimate  friends,  are  not  recognized  by  their  ajipearance,  but  are 
known  at  once  when  they  begin  to  speak.  This  failure  is  due  to  a 
le>iion  of  tlie  centre  for  visual  memory,  which  is  supposed  to  lie  distinct 
fidin  the  visual  centi  although  situated  close  to  it  in  the  occipital 
lobe.  It  serves  for  the  storing  up  of  pictures  in  the  niemorv'  of  ob- 
jects or  scenes  that  have  fallen  upon  the  retina,  and  whenever  a  picture 


472 


THE  EYE. 


is  fnriiiod  on  the  n-tinsi  the  .stores  of  the  visuiil  mcinory  optitro  art- 
liiounht  out  iitid  raimcki'd  for  coinparisoiis  or  tin-  new  picturi"  is 
storcil  awav  for  futun-  uw.  Hoiiionyinous  licmiunopsia  is  present  in 
the  majority  of  cases  of  mind  blindness.  It  oeeurs  in  |M'rsons  iH-yoiul 
middle  age,  when  the  lesion  has  In-en  found  to  l)e  hemorrhages,  softon- 
iuRs,  or  tumors:  it  occurs  also  in  general  paralysis  '>f  the  insane. 

Lesions  Affecting  the  Cortical  Centre  of  Vision.    AceorditiR  to 
the  most  recent  nwearclies  of  Ilenschen,  th  s  lesion  is  placed  about  the 
mid.lle  part  of  the  c.ilcarin:-  ti.ssure.  the  upiK-r  edRe  of  the  fissun'  rep- 
resenting the  upper  homonymous  quadrants  of  the  retina  ami  the 
lower  edge  of  the  fissure,  the  lower  homonymous  (luadrants,  the  macula 
centre  lying  in  the  fliM)r  of  the  fissure.     Other    hser\ers  think  the 
visual  centre  extends  much  more  widely,  even  covering  the  whole 
mesial  surface  of  the  occipital  lob<',  but  they  agree  in  giving  special 
imi)ortance  to  the  calcarine  fissure.      Destri   tion  or  lesion  of    the 
cortical  visual  centre  leads  to  absolute  blindne^..  of  the  (•orresjM)mliiig 
halves  of  each  retina,  iiUd  con.setiuently  to  homonj-mous  hemianopsia 
of  the  op|M)site  half  of  the  field  of  vision.     If  the  lesion  Iw  confined  to 
the  cortex,  there  is  complete  absence  of  any  other  sign,  such  as  paraly- 
sis, ansesthesia,  word  blindness,  mind  blindness,  visual  aphasia,  visual 
hallucinations,  and  the  hemianopic  pupil.    For  instance,  there  is  com- 
plete absence  of  sensation  in  the  blind  side  of  the  field,  but  the  patient 
is  not  conscious  of  the  defect  Jis  of  a  dark  area,  as  he  may  lie  in  lesions 
f)f  other  parts  of  the  visual  path.     If  the  lesion  be  bilateral,  of  which 
many  cases  are  on  record,  the  symptoms  arf»  bilateral  hoinon\Tnou9 
hemianopsia,  which  means  complete  loss  of  vision.     In  small  lesions 
less  than  half  the  homonymous  fields  may  be  lost  and  partial  |H'rij)h- 
eral  or  more  rarely  scotomatous  defects  may  be  left.     But  these  par- 
tial homonymous" defects  should  lx>  upmI  with  caution  for  localizing 
|)uri)oses,  as  homonymous  fM'ripheral  coiu.actions  of  the  fields  of  vision 
are  found  in  patients  without  lesion  of  any  part  of  the  vi.sual  path. 
Sometimes  the  blindness  is  incomplete— that  is,  |>erception  of  light  may 
be  retained  in  the  blind  part  of  the  field      In  other  slighter  cases  again 
only  the  color  .sen.se  in  that  half  of  the  field  may  be  lost  (hemiachro- 
inatopsia),  light  and  form   sei  <>  b'ing  perfect     \'ariou.s  degrees  of 
loss  may  be  present  in  different  parts  of  the  affected  fields.     It  is 
unknown  whether  the  centre  for  colors  is  different  from  those  for  form 
and  light,  or  whether  the  different  colors  'i  ivo  separate  cells  devoted 
to  them:  but  there  are  cases  on  record  of  homonymous  hemianopic 
losses  of  ]jercei)tion  of  one  color  which  would  give  suiJiM)rt  to  ♦his 
view.     Probably  there  are  not  separate  centres  for  light,  form,  and 
color,  but  a  loss  of  the  latter  indicates  a  less  .serious  injury  to  the 
centre  than  when  its  other  functions  are  lost.     It  has  l)een  stated  that 
in  most  cases  the  dividing  line  iM^ween  the  two  halves  of  the  fields  is 
not  a  prfectly  vertical  one,  but   th.at  it  <!eviatps  so  as  to  include  the 
whole  of  the  fixation  pf)int  in  each  .seeing  half  of  the  field.  Two  expla- 
nations may  be  given  of  this:     (1)  That  the  whole  of  the  macular 
region  of  each  eye  is  represented  in  the  visual  centre  of  each  siile,  so 


HETIXA,  Ol'TlC  yERVK,  A.XD  ITS  CEREBRAL  ORIOIX      473 

that  carli  macula  Iuik  a  (IduMp  ncn-o  supply.  nn<l  if  (iim>  viHual  ornfre 
is  (lest n •>•(•(!,  it  Mill  retains  its  nerve  8Up|)ly  to  the  v.-iial  eentn- 
«pf  the  opiHisite  side.  C2)  Tlie  other  explanation  ftiven  for  retention 
of  the  whole  central  vision  in  lesion  of  one  visual  centre  i.s  that  the 
centre  for  the  macula  in  the  cortex  is  more  vascular  than  the  rest  oi 
the  visual  centre,  an<l  receives  nutrition  fnmi  anast«)mo8es  even  when 
parts  aroiMKJ  are  cut  off. 

It  lias  Ix-en  supjjosed  by  .some  writers  that  there  is  a  higher  visual 
ciiitre  :  1  the  anpilar  gyrus  in  wliich  the  whole  of  tlie  op|M)site  field 
of  vision  is  repn'senfed,  that  of  the  same  side  fn'ing  al.xo  n-presetited, 
hut  in  a  lesser  degree  of  intensity.  Lesion  of  this  centre  is  snid  to  cans*- 
Miiihlyopia  of  the  opfHwite  eye  by  lowering  the  function  of  the  whoh- 
ntina  and  n-ducing  the  size  of  the  visual  field  generally,  without  pro- 
ducing hemianopsia  (croxxeri  nmblyopm).  It  also  pnxluces  a  slight 
constriction  of  the  field  of  vision  of  the  .same  side.  Ferrier's  experi- 
iiients  on  animals  sup|M)rt  the  view  of  the  existence  of  a  centre  for 
vision  in  the  angular  gyrus,  but  the  evidence  in  favor  of  it  in  man  is 
very  slight,  and  many  writers  do  not  believe  in  the  existence  of  crossed 
amblyopia. 


CHAPTER    X. 
DISEASES  OF  THE  CRYSTALLINE  LENS. 

Bv   KDWAUD  C.   KLI.KTT,  M.D. 

Anatomy.  Tl.c  crvstallinc  l<>ns,  ..r,  as  it  is  eoiimiunly  called,  the 
Ion.  i.  a  l.in.-ivcx  traiisi-ainit  b.-tly  which  lies  in  the  anterior  por- 
ti„n'..f  th.'  ev,  and.  t..seti>er  with  its  suspensory  hga.nent,  servos 
to  separate  th.^  vitn-ous  chamber  l.elnnd  from  tiie  aqu.M.us  chan.heis 
in 'front      (Fig.  2.19.)     The  posterior  surface  is  the  more  convex. 


Fia.  259. 
Curnra 


Ills 


Anterior  Chamber 


The  antrrior  segment  of  the  eye.    <M.»lHi«l  fmin  v.mf^  A.mtomy.) 

The  l.Mis  is  con.pos.Hl  of  a  harder  central  portion  known  as  tl"'  ""cleus 
•  a  \  .ofter  outer  portion  known  as  the  oorfx.  The  l.oun.hir>  hn.' 
1 ;  lien  t^hese  two  .or.ions  is  not  sharply  defined,  tl.-  •;-  --^-V; 
i„.  i,s  greater  density  from  a  l^roc-ss  which  consists  esMmtial>  n 
loss  of  thii.l,  and  this  being  a  pr.,gressive  process    he  •«;"■<'- 

reases  in  si7,e  at  the  expense  <.f  the  cort.'x  m  proportion  t..  the  aj: 

;   ,;:  i,  dividual.     The  nucleus    has  a  >.llowish  coh.  -  --^-a-i 
to  tlu-  cort.'X,  and  also  a  pr<>at.>r  refractiv  power.     In  .ilderl)   pu- 
ns these  properties  fre.,uen,ly  make  the  lens  as  -'^'- ;'-^-^^.^, 

pupil    present    a   gravish   or  opaMue  appearance,   .lue   to   incnas.  1 

re  ecti  m  of  light  from  th.-  surfa.r  of  the  lens  (increased  lens  reflex  . 

m   t   is  mav  be  mistaken  for  opacity  of  the  lens,  allli.-.ugh  the  v  s,,. 

fs  n.!t  hnplSed  bv  it.  and  exail.ination  with  ...Hected  light  (ophthal 

nioscopo)  shows  tiu'  lens  to  1k'  perfectly  clear. 
(  474) 


smsm^mmmmmsm 


m 


D/SKASES  OF  TIIH  VHYSTALLISi:  LES.S. 


475 


Tlic  li'iis  .s  C()iii|i()S('(l  (if  prismatic  liln-cs  joined  tojifthcr  liy  a  small 
amount   of  cement  suhstanec.     (Fig.  2(50.)     These  i;rismatic  fibres 


Xoruittl  lens  tilirts  cui  hiiigUudiimlly,    x  lOU.  (Fr<;p«red  by  Dr.  E.  S.  Thomson,  in  ihe  laboralory 
nf  the  Manhattan  Ejreaud  Eur  Ucspilal.) 

lie  elongated  epithelial   cells,   and   are  arranged  in   hundi.s,   tliese 
uindles  iH'inp;  so  placed  that  tlieir  lines  of  union  form  a  stellate  figure 

Fio.  261. 


*4fcr^ 


^y 


Sectors  in  eryttalline  lens     (TtMiT.) 

idiating  from  the  centre  of  each  surface  of  the  lens,  and  often  visihle 
n  ohli(|ue  illumination  in  the  normal  eye.     (Fig.   261.)     Besides 


476 


THE  EYE. 


% 


i 


the  nucleus  and  cortex,  we  distinguish  the  poles  of  the  lens;  that  is, 
the  centre  of  its  anterior  and  jjosterior  surfaces,  known  resjiectively 
as  the  anterior  and  the  i>()Sterior  poles.  The  circumference  of  the  lens 
is  known  as  the  equator.  . 

The  average  size  of  the  lens  is  9  nun.  in  diameter  and  4  mm.  in 
thickness  at  tlie  central  or  thickest  part.  From  the  centre  it  slopes 
awav  gradually  until  the  two  surfaces  meet  at  the  thin  edge  ore(iuator. 
The  lens  is"  eiiclos<'d  in  a  delicate  structureless  lining  inemhrane 
of  perfect  trans) )arencv,  known  as  the  capsule.  This  is  divided  into 
two  portions:  that  oil  the  anterior  face  being  called  the  antcTior 
capsule,  that  on  the  jjosterior,  the  posterior  capsule.  The  ant<'rior 
capsule  is  lined  on  its  lenticular  surface  with  a  layer  of  epithelial  cells, 
from  which  new  lens  fibres  are  develo|)ed. 

The  lens  rests  in  a  cup-sha|)ed  cavity  of  the  vitreous,  called  the 
fossa  patellaris,  or  hvaloid  fossa.  In  front  it  is  separated  from  the 
pupillary  border  of  the  iris  bv  a  thin  layer  of  the  aiiueous  humor, 
this  lavtV  being  so  thin  that  the  pupillary  border  of  the  ins  and  the 
anti-ri(>r  lens  capsule  mav  lie  considered  as  being  in  contact.  The 
lens  is  held  in  place  bv  its  suspensory  ligament,  called  the  zone  of 
Zinn.  Tliis  is  a  fibrous  structure  which  ari.ses  from  the  jwrs  ciharis 
retina'  as  far  back  as  the  ora  serrata,  the  surface  of  the  ciliary  body, 
and  the  ciliarv  processes.  It  leaves  the  wall  of  the  eye  at  the  ciliary 
proc»s.-ies.  and  ilivides  into  two  layers,  an  anterior  and  a  posterior, 
which  unite  with  the  anterior  and  posterior  portions,  respectively, 
of  the  lens  capsule.  The  space  between  these  t\^  layers  of  the 
susi)ensorv  ligament  is  known  as  the  circumlental  si)aee,  or  canal  of 
Petit,  ami  is  more  or  less  completely  divided  into  two  i)arts  by  a 
delicate  septum  running  from  the  ciliary  processes  to  the  cijuator 
of  the  lens.  The  anterior  laver  of  the  suspensory  ligament  jiresents 
numerous  small  openings  whereby  the  canal  of  Petit  communicates 
with  the  postiTior  chamber,  both  lieing  lymph  spaces  and  both  con- 
taining aqueous  humor.     (Fig.  259.) 

The  lens  is  an  ehistic  body  capable  under  certain  conditums  ot 
changing  its  shape,  as  is  described  in  the  account  of  the  function  of 
accommo(lation. 

The  l(>ns  does  not  contain  any  bloodvessels,  but  derives  its  nutri- 
tion i)v  imi)ibitioii  from  the  fluids  .surrounding  it.  The  absence  of 
bloodves.sels  prevents  it  from  i)res(>nting  phenomena  of  inflamma- 
tion, and  the  way  in  which  it  is  nourished  oxplains  why  inflamn'atory 
coiulitions  of  the" choroid  exert  a  deleterious  l.ifluence  on  it. 

Embryology,  ^'erv  <'arly  in  the  tlevelopinent  of  the  embr\'o  the 
outer  layer,  or  ejnbla.st.  is  "thrown  into  a  longitudinal  dorsal  furrow 
whose  sides  close  over  to  form  a  tube,  the  medullary  tulx'.  From 
the  anterior  end  of  this  tube  are  thrown  out  i)rocesses  on  each  side, 
called  the  i.rimarv  optic  vesicles.  Ivich  of  these  vesicles  is  C()n- 
verted  into  a  cup  bv  the  anterior  wall  receding  against  the  posterior 
wall.  The  layer  of  epil.last  over  thi.'  -up-shaped  cavity  thickens, 
dips  into  thccup,  and  this  portion  gradually  b'conies  cut  off  from 


DISEASES  OF  THE  CRYSTALLISE  LESS. 


477 


tlio  rost  of  tlic  ppihiast  ami  forms  an  i>  lated  mass  of  pijihlastio  tissue 
lyiiifj  in  the  cui)  of  tlie  optic  vesicle.  From  tliis  mass  of  tissue  tiie 
lens  develops.  This  nia.«s  of  epil)Iastic  cells  is  composed  roughly 
of  two  layers  of  cells,  an  anterior  and  a  povsterior.  From  the  j)osterior 
layer,  by  a  process  of  elongation,  the  lens  fibres  are  formed,  the 
anterior  layer  of  cells  remaining  as  a  thin  la-  of  cells  just  under 
the  anterior  capsule.  F-om  the  most  e(|uatoiu..iy  situated  of  these 
cells  additional  lens  fibres  develoj).  The  lens  attains  its  full  growth 
about  the  eighteenth  year,  after  which  time  the  formation  of  new 
fibres  continues  much  more  slowly,  at  a  rate  to  compensate  for  the 
dimhmtion  in  size  of  the  central  portion  from  contracti(m. 

It  will  be  seen  that  at  one  time  the  rudimentary  lens  occupies 
nearly  the  whole  of  the  rudimentary  eyeball.  At  the  time  of  birth, 
however,the  lens  has  become  reduced  to  almost  its  normal  relative  size, 
although,  as  stated,  further  changes  occur  until  the  eighteenth  year. 

The  lens  capsule  is  developed  from  a  layer  of  me.sobla.stic  tissue 
which  surrounds  the  plug  of  epiblastic  tissue  when  it  grows  into  the 
optic  cup  to  form  the  lens. 


FlO.  262. 


Fio.  263. 


no.  264. 


Kidney-shaped  leiu,  coloboma  Inward. 
(Baas.) 


I.«ntic(>nu0  Anterior. 

(WlSSTER.) 


Dislocation  of 
the  lens. 


Congenital  Anomalies.  Congenital  anomalies  of  the  lens  may 
alTcct  its  size,  shape,  j)()sition,  and  transparency. 

Anomnlief  of  Size.  Congenital  absence  of  the  lens  (aphakia)  has 
been  noted  a  few  times.  It  results  either  from  arrest  of  development 
or  from  disease. 

The  lens  varies  in  size  at  different  ages.  The  only  anomaly  of  size 
usually  recognized  is  that  in  which  the  lens  is  too  small  (microphakia). 
riiere  is  often  a  relaxation  or  absence  of  the  su.sj)ensory  ligament  at 
the  same  time,  which  permits  the  lens  to  change  its  position. 

Aitomaiie.'i  of  .v/irt/jc  are  of  two  sorts:  (1)  cololK)ma  lentis,  and 
2)  ienticonus. 

Coloboma  of  the  lens  is  the  name  applied  to  a  condition  in  which 

ijic  edge  of  the  lens  jiresents  at  some  point,  usually  downward,  a 

'"caiized  flattening   or  a  distinct  notch.     (Fig.  262.)     It  is  due  to 

in  arrest  of  development.     This  apj)eiirance  varies  in  shape  and  posi- 

ioii,  and  while  usually  single,  the  edge  of  the  lens  may  be  notched 


478 


nil-:  EY^:. 


ill  scvcnil  plan's,  or  s.Tnitcd.     Tliis  aiuniialy  is  often  associatc.l  witli 
coloboiiia  of  liic  uis  and  clioroid. 

Lcnticoniis  is  a  condition  in  wliicli  a  more  or  ii'ss  pointed  projection 
exists  on  the  anterior  or  jiosterior  suiiace  of  the  lens.  (!•  i«.  'IM.) 
The  projection  is  transparent  as  a  rule,  hiit  an  o|.acity  may  exist  at 
its  apex.     The  cause  is  olisciire. 

Inomilirs  of  i><»<ili<'ii  are  grouped  under  the  name  ot  ectopia 
ieiitis  or  displacements  of  the  lens,  ilxcept  in  the  rare  eases  where 
there  i-  an  anv-l  of  devi'lopmeiit  of  the  whole  orjiaii  and  liie  lens 
remains  in  its  fietal  position,  in  the  vitreous  chamber,  the  di>location 
occurs  in  the  .lirectioii  of  the  e(iuator,  and  is  <lue  to  faulty  dev.lop- 
meiit  and  conse.,uenl  \,eakness  of  some  i)art  of  the  susjiensory  iifia- 
ineiit  This  weakness  fieiierallv  exists  in  tlie  lower  jiart  ot  the  eye 
hi  the  position  of  the  fu'tal  cleft,  and  the  dislecation  i<  in  the  <ipi)osite 
<nrectioir.  that  is.  ui)ward  and  inward  or  upward  and  outward.  (l'i<:. 
•_'t>4  )  The  whole  lijiament  may  be  absent,  permittiiif:  tlii'  lens  to 
pass  thron-ih  the  pupil  and  lie  in  the  anterior  chamber.  This  con- 
dition is  usuallv  bil.iteral  ;'iid  syinmelrical.  but  may  be  unilateral. 
It  is  also  frequentlv  hereditarv.  wlien  the  aiioma  y  i^'  found  m  suc- 
cessive paierat ions' of  a  familv.  The  displacement  v,  ries  much  in 
de<'ree,  so  that  the  patient  mav  see  either  through  tlii'  le  is  or  through 
th^  part  of  the  pupil  which  contains  no  lens,  or,  according  to  the 
ix.sition  of  the  he.id.  either  through  the  lens  or  unobstructed  inipil 
at  will.  The  lens  is  at  first  clear,  and  remains  so  in  the  majority  ol 
i'ases  but  mav  become  o])aqui'  in  time.  Sometimes  it  is  fixed  in  its 
abnormal  position,  and  sonietiines  freely  movable,  depending  on  the 
condition  of  the  suspensory  ligament. 

The  treatment  of  ectoiiia  lentis  may  often  be  satisfactorily  con 
ducted  bv  means  of  correcting  li'uses.  If  the  dislocated  lens  is  so 
situated  as  to  allow  vision  always  through  that  body,  or  alwavs 
through  the  unobstnicti'd  pupil.  glass(-s  to  crrect  the  retraction, 
concave  as  a  rule  in  the  form<'r  case  an.l  strongly  convex  m  the  latter 
(just  as  in  aphakia),  will  often  give  useful  vision,  hi  other  cases 
it  will  be  imix.ssible  to  secure  satisfactory  vision  m  this  way,  am 
the  lens  must  be  remove.l  by  the  operation  of  solution,  to  be  .lescribed 
later.  This  treatment  results  in  absorption  of  the  lens,  leaving  the 
eve  aphakic,  and  iniuiring  strong  convex  glasses,  as  will  be  men- 
tioned in  considering  the  treatment  of  cataract.  W  heiv  the  lens  l)e- 
comes  opaMue.  it  is  usuallv  advisable  to  remove  it  by  tli<'  same  means 
Aiinwtdirs  of  Iron-^ivirnini  include  the  various  iorms  of  congenital 
cataract.  These  are:  1.  .\iiterior  jxilar  cataract.  2.  Posterior  polar 
cataract  :i  Lamellar  or  zcmular  cataract.  .\  detaih'd  description 
of  these  and  the  metho.l  of  treating  them  will  be  given  in  consider- 
ing the  sub'iect  of  opacities  of  the  lens. 

Wounds  and  Injuries.  Injuri.'s  tothelens  areof  two  kinds:  I'lrst, 
the  ]ru^  is  .'.isplaced  frr.ns  it^  normal  position,  cnstitutmg  traumatic 
luxation  of  the  lens.  Secon.l.  the  lens  is  the  seat  of  a  penetrating 
wound  which  is  usually  followed  by  traumatic  cataract. 


DIHEASKS  in-   THE  CRYSrALI.lSE  LESS. 


479 


'I'nmiiiMiic  (lis|)l:icciiicnts(^f  tlic  lens  arc  the  result  nf  injuries  to  the 
sus|iriisiir_v  li«nnieiit.     The  (lis|.hu-eiiieiit  iTiny  he  partial  or  {■oiuplete. 

Partial  .lispi;ieeiiieiits  of  the  lens  (suhhixatiou)  result  from  an 
injury  whosectTeet  is  so  localized  as  to  rupture  only  a  portion  of  t!  .• 
Mi>pcns(iry  li<;ainent,  and  without  leaving;  its  normal  position  the 
rdirc  if  ijie  lens  nearest  the  seat  of  nii)turc  tilts  forward,  causing 
a>tit:iiiatism  and  consociuent  disturhance  of  vision.  The  lens,  as  a 
•Mile  in  these  cases,  remains  transparent,  and  the  treatment  consists 
I  correctinjr  the  resultinji  astigmatism  l)y  jiiasses.  Considerahle 
-|Mintaneous  improvement  m;iy  occur,  or  the  lens  may  become  opa(iue, 
when  it  is  dealt  with  as  if  the  opiicity  resulted  from"  other  than  tpau- 

Flu.  L'65. 


Ml!  liual«l  upon  the  clllar.v  IkmIv.  The  lens  Is  becoming  catoractous  nnd  is  twun.l  down  by 
■  ms  tissue.  From  an  eye  which  eaiiseil  syrap.uhetic  irritation  in  the  fellow  eye.  x  15.  (Pre- 
.■•I  tiy  Dr.  K  S.  Thomson,  in  the  laboratory  of  the  Maiihiittan  Eye  and  Ear  Hospital.) 


itic  causes.     ( Kif;.  2fio.)     'l"he  lens  may  in  its  now  ])osition  cause 
inuch  inflammatory  disturbance  as  to  result  in  the  lo.ss  of  the  eye. 
Complete  dislocation  of  the  lens  follows  an  injury  which  causes 
•iiplete  ru|iture  of  the  susi)en,sory  lijraineiit,  tluispermittiiifi  the 
i-  to  leave  its^b<>d  entirely.     Tlie  capsule  of  the  lens  is  generally 
'  ruptured.     The  dislocation  may  occur  in  one  of  .several  directions: 
forward  into  the    anterior  chamber.     2.  Backward  into  the  Vit- 
us clunnber.     3.  Through  a  ruptum  in  the  coats  of  the  eyeball 
'the  capsule  of  Tenon  or  under  tl  ^  conjunctiva.     Owing  to  the 
-licity  of  tiie  latter  membrane,  it  w   1  sometimes  not  yield  to  an 
iiy  which  ruptun  •,  the  sclerotic,  choroid,  and  retina,  and  the  lor- 


I 


4«0 


THE  EYE. 


l)a.s.siiig  through  a  nii)turo  in  these  coats  lodges  under  the  ronjunctiva, 
which  stretches  to  accoiinnodate  it.  .      ,     ,.         ,  ,• 

Tlie  symptoms  of  dislocation  of  the  lens  are,  m  the  hrst  phice.  dim- 
ness of  vision.  Hv  removal  of  the  lens  from  an  eye  whose  retraction 
is  hvperopic  or  moderately  myopic,  rays  of  light  are  no  longer  focused 
on  or  sufiicientiv  near  the  retina  to  i)ermit  of  clear  vision.  Other 
conditions  svhicli  result  from  the  injury  may  also  contnhut(>  to  cause 
dimness  of  vision,  such  txs  vitreous  hemorrhages,  rupture  ol  the 
choroid,  hemorrhage  into  the  anterior  chamber,  etc.  There  are  two 
conditions  in  which  dish.cation  of  the  l.>ns  would  cause  improvement 
instead  of  .leterioratio.i  of  vision.  These  an-  when  th(>  lens  is  oi)a(iue 
an.l  when  the  eve  is  highly  myopic.  In  both  of  these  conditions 
oi)erations  for  tlie  removal  of  the  lens  are  resorted  to  for  the  purpose 
of  imi>roving  vision,  bv  reiiKJving  a  mechanical  obstruction  to  .sight 
in  the  iivst  instance,  and  by  changing  the  refraction  oi  the  eye  in  the 

second  instance.  .        ,       ,        -i.  i         „„ 

If  the  lens  is  dislocated  into  the  anterior  chamber,  it  can  Ix;  seen 

as  a  clear  or  opatiue  disk,  as  the  case  may  be,  in  this  position,     (big. 

266.)     If  clear,  the  iris  and  pupil  can  be  seen  through  it.    It  is  apt 


Fio.  266. 


Opaque  leru  dijlocated  Inlo  Ihe  anterior  chamber. 

to  excite  inflammation  in  the  eye,  and  invariably  does  so  in  that 
part  of  the  cornea  with  which  it  is  in  contr.ct.  It  may  also  cause 
glaucoma.    It  should  be  removed  from  the  eye  by  solution  or  extrac- 

"if'  dislocated  into  the  capsule  of  Tenon,  which  is  very  rare,  or 
under  the  conjunctiva,  the  lens  can  he  seen  in  its  new  position,  and 
its  absence  from  its  normal  position  is  indicated  by  the  fact  that  th-' 
refraction  of  the  eve  is  highly  hyperopic  and  the  catoptric  images 
camiot  be  sc^en.  If  not  itself  disturbnl  by  the  injury,  the  ins  is  sejni 
to  be  tremulous  on  movement  of  the  eye,  because  it  no  longer  has  its 
normal  support  behind.  The  pnivity  of  this  conchtion  does  not 
pertain  to  the  lens  or  its  new  po.sition,  but  to  the  rupture  of  the  coats 
of  the  eye  and  vari.-s  with  the  .>ite  and  extent  of  thi?  rui)turc. 

The  lens  may  be  left  alone.     If  it  is  deemed  advisable  for  an v 
reason  to  extract  it,  this  should  not  be  attempted  until  the  sclera 


DISEASES  OF  THE  CRYSTALLISE  LESS. 


481 


wound  has  liealod,  as  wp  would  othrnvisp  conv»Tt  a  simple  scleral 
wouikI,  to  l)orro\v  an  analogy  from  general  surgery,  into  a  compound 
one,  and  through  this,  protrusion  of  the  other  coats  or  ocular  con- 
tents may  occur,  adding  greatly  to  the  gravity  of  the  injury.  When 
the  scleral  wound  has  healed,  the  lens  may  be  removed  through  an 
incision  through  the  conjunctiva  (and  capsule  of  Tenon  when  neces- 
sary), placed  as  far  as  possible  from  the  scleral  scar. 

Dislocation  into  the  vitreous  cliambe-  is  by  fur  the  most  common 
form  t)f  traumatic  dislocation.  The  lens  loos,  :;>(1  from  its  attach- 
ments sinks  downwanl  and  backward  into  the  vitreous,  where  it 
may  be  made  to  rise  and  be  seen  through  the  |)upil  by  up-and-tlown 
movements  of  the  ball  .similar  to  those  practised  for  the  study  of 
opacities  in  the  vitreous  (ocular  ballott«>ment).  It  was  formerly 
the  custom  to  treat  cataract  by  depressing  the  lens  downward  and 
backward  into  the  vitreous,  and  we  have  abundant  records  of  the 
effect  of  this  form  of  dislocation.  Sooner  or  later  the  lens,  acting 
as  a  foreign  body,  will  e.xcite  inflammatory  and  tlegenerative  changes 
in  the  vitreous,  choroid,  or  retina,  which  destroy  or  greatly  impair 
The  sight.  It  may  also  cause  glaucoma.  For  these  reasons  this 
nu^thod  of  treating  cataract  has  been  abazuloned,  and  for  these  rea.sons 
it  is  desirable  to  remove  the  lens  from  the  vitreous  if  possible.  The 
operation  is  dangerous  on  account  of  the  tendency  of  the  vitn  aa 
to  escape  from  the  eye  when  an  incision  is  made' into  the  cornea. 
The  lens,  too,  is  far  from  the  corneal  incision,  and  must  usually  be 
brought  for\var(l  by  means  of  a  delicate  wire  loop.  To  facilitate  the 
capture  of  the  lens,  it  hiis  been  suggested  to  operate  with  the  patient 
lying  face  downward,  this  favoring  the  seeking  by  the  lens  of  its  nat- 
ural position,  or  the  lens  may  be  coaxed  into  this  position  and  fi.xed 
tliere  by  a  two-pronged  needle  or  biilent  thrust  into  ttie  eye  through 
the  sclerotic  behind  the  ciliary  process,  and  thus  Ix'hind  the  1.  ns. 
\\\\\d\  it  holds  in  place  by  pressure.  The  ste|)s  in  the  removal  of 
tlie  lens  will  fje  sufficiently  detailed  in  speaking  of  the  treatment  of 
cataract. 

In  whatever  f)osition  the  lens  may  be  ilislocated,  it  almost  invariably 
becomes  ojjaijue  sooner  or  later. 

WmmdK  of  the  Lens  and  Traumntie  Cataract.  It  is  very  nearly 
true  that  a  wound  of  the  lens  means  traumatic  cataract:  but  trau- 
matic cataract  may  be  due  to  other  injuries  than  wounds  of  the  lens. 
In  other  words,  traumatic  cataract  may  occur  without  rupture  of 
the  lens  capsule.  This  is  not  common,  but  it  has  been  observed 
that  contusions  and  concassions  of  the  eye  may  be  followed  either 
immediately,  or  after  some  days  or  weeks,  by  the  formation  of  opaci- 
ties in  the  lens.  These  opacities  may  be  statioaarj-  or  progressive, 
although  there  is  very  seldom  any  clearing  up  of  them  observed,  and 
It  is  certainly  not  to  be  expected.  This  form  of  lenticular  opacity 
w  more  apt  than  any  other  to  remain  stationary,  or  if  it  progresses 
It  does  so  at  a  slow  rate.  The  prognosis  to  the  eye  from  this  form  of 
'•ataract,  per   se,  is  therefore  good.     Progressive  opacities  of  this 

.SI 


482 


THE  KYK. 


cliaractcr  rfiiuirc  removal  of  the  lens  by  operation,  citlier  l)y extrac- 
tion or  l)V  solution.  The  clioice  l)et\ve<Mi  these  methods  will,  as  a 
rule,  depend  on  the  consistenry  of  the  lens  as  estimated  by  the  age 
of  the  jiatient,  solution  beinj:  adapted  to  patients  under  twenty- 
five  or  thirty  vears,  and  extraction  to  patients  over  that  age. 

We  take  advantage  of  the  possibility  of  causing  opacity  of  the  'ens 
by  contusion  without  rupture  of  the  ca])sule  in  the  operation  ot 
massage  of  the  lens,  which  is  sometimes  performed  to  hasten  the 
maturation  of  a  cataract,  to  be  described  later. 

Traumatic  cataract  from  rupture  of  the  capsule  of  the  lens  usually 
result.s  from  a  i)enetrating  wound.  The  formation  of  this  variety 
of  traumatic  cataract  deiieiids  on  the  fact  that  if  the  afpieous  humor 
comes  in  contact  with  the  fibres  of  the  crystalline  lens  it  causes  them 
to  swell  and  become  opacjue,  and  in  time  completely  d'  solves  the 
lens  after  it  has  undergone  the  i)rocess  of  swelling  and  opacification. 


Fio.  267. 


Traumatic  cataract.  ,h„v  ,  splitting  up  of  flbres  and  formation  of  spherical  tna^.  There  are 
numerous  swollenrtbn*  which  show  iransver^rtriatlons.  ■  100.  (Prep.re.1  by  Hr.  h.  >.  ThoM9o>, 
in  the  laboratory  of  the  ManhatUn  Kye  atul  V^t  Uoepltal.) 

(Fig  'tlT  I  Rui>ture  of  the  caj)sule  and  traumatic  cataract  may 
result  from  a  contusion  ..f  the  eye,  but  for  the  purjiose  of  stu.ly  the 
process  is  observed  best  where  it  follows  the  operation  of  needling 


the  lens.     Here  a  wound  is  made  in 


the  cai).sule  and  lens  with  a 


needle  thrust  through  the  cornea.  By  ot)li.|u<'  illumination  and  a 
magnifving  lens  the  n-nt  in  the  capsule  can  be  seen  at  onc.>:  but  the 
ti-u'k  r;f  th<  wound  in  th<'  substance  -f  the  lens  is  not  usually  vi.sible 
f„r  several  hours.  As  the  a«iueoiis  gains  access  to  the  lens  through 
the  rent  in  the  ■aiisule,  the  portions  nearest  the  oi)eniiig  iM-coine 
opaque  and  swt.llen.  aiul  are  apt  to  be  extruded  into  the  anterior 


DltlKASES  OF  THE  CRi'STAlLISE  LESS.  4^3 

rliiiinlxT.  as  thfTc  is  not  room  for  them  in  their  swollen  rondition 
uitlini  the  eapsuie.  \\e  ean  tlius  find  one  or  more  masses  of  opaciue 
lens  matter  !yin<:  in  the  anterior  chamber.  The  process  continues 
more  and  m  nv  of  the  lens  breakmg  down  and  Iwing  pushed  out  int<! 
I  lie  anterior  chamber.  Sometimes  when  the  wound  of  the  lens  i.'^ 
<iiiall  the  ari'M'ous  humor  filters  in  alon^  the  wound  path,  and  finds 
Its  way  from  this  alonR  the  intersjmces  between  the  lens  fibres,  show- 
iti^t  as  Ix-autiful  festoons  of  opaijue  lines,  sometimes  respnibli'iig  the 
skcm  hpures  seen  in  the  process  of  karyokinesis. 

In  the  process  as  described,  the  ab.sorjj/on  of  ihe  lens  is  supposed 
lo  advance  m  a  gradual  way  to  its  compk  tion.  It  very  often  hap- 
pens that  the  wound  in  the  capsule  is  .so  large  that  a  considerable 
l.ortion  of  the  lens  is  subjected  to  the  influence  of  the  acjueous,  and 
liccomes  swollen  at  once.  In  this  case  the  auRmentation  of  the 
nilra-<K-ular  contents  is  so  great  that  the  tension  is  increa.sed  and 
■rlaucomatous  .symptoms  apjx-ar. 

Penetrating  wounds  of  the  lens  are  necessarily  complicated  by  a 
wouml  of  .some  coat  of  the  eye,  generally  the  cornea,  through  which 
I  lie  wounding  body  reaches  the  lens.  Fre(iuently  the  iris  is  al.^o 
wounded,  and  the  ofTending  substance  may  go  through  the  lens  to 
tli<'  deeper  parts  of  the  eye.  The  wound  may  be  .so  extensiyp  that 
liie  injury  to  the  lens  becomes  of  minor  importance  comi)ared  with 
llie  serious  nature  of  the  injury  to  other  structures. 

We  h.aye  spoken  only  of  traumatic  cataract  resulting  from  tlie 
.iction  of  the  a(iue()us  humor.  In  a  few  cases  it  has  been  obseryed 
that  the  posterior  cap.sule  alone  was  ruptured,  and  opacity  of  the 
l<iis  resulted  from  the  action  of  the  vitreous  humor.  The  action  of 
ilie  vitreous  in  this  respect  is  very  much  less  intense  and  rapid  than 
'lat  of  the  atiueous,  but  it  should  be  remembered  that  traumatic 
•  alaiact  may  follow  a  rupture  of  the  jxisterior  capsule. 

W'iiere  the  injury  is  wrought  by  a  small  f  vign  body,  this  .some- 
iiiiies  lodges  in  the  lens.  Its  princii)al  eficci  is  the  production  of 
cilaiact,  the  j)reseiice  of  the  foreign  body  adding  very  little  to  the 
^lavity  of  the  ca.se.  liven  if  the  foreign"  body  is  infeVted,  the  lens 
I'liiig  peculiarly  resistant  to  infection  from  pathogenic  germs,  sup- 
puration in  the  eye  does  not  necessarily  follow. 
Wiien  the  wound  of  the  capsule  is' small,  it  may  clo.sp  so  (juickly 

'"'  '^o  < ipletely  after  the  wound  is  made  that  the  lens  sub.stance 

-  not  exposed  to  the  action  of  the  intra-ocular  fluids.     This  is  analo- 
L  us  to  the  manner  in  which  the  corneal  wound  clo.sps  behind  the 

'"•'  '"  ♦•if'  operation  of  discission,  and  the  aqueous  humor  does 

'   iT  escape. 

A  rare  form  of  traumatic  cataract  is  that  caused  by  heating  of 
■  ai|ueous  humor  in  ai)plyiiig  the  actual  cautery  to  the  cornea  in 
■■  !taiii  diseases  of  that  menihr.Uic. 
Treatment.  The  treatment  of  traumatic  cataract  consists,  in  the 
1  place,  in  an  effort  to  secure  mechanical  and  surgical  cleanliness 
'lie  wound  on  the  surface  of  the  eye.    Any  protruding  i)ortions 


484 


■nil:  K  VK. 


,.f  iris  or  ..th.T  ..f  til.-  ..fular  rcnt.-nts  an-  ropiar.-.l  or  oxcis.-.l  and  tlio 
conjunctival  sac  Huslu'.l  with  u  n.il.l  antiseptic  suiution  llns  part 
„f  the  trcatnu-nt  is  .icait  witi.  in.lctail  under  tin-  licad  of  Wounds  of 
tlie  Cornea  and  Iris.  Atropine  is  instiil.-d.  and  the  patient  i-iit  to 
ix-d.  Tlu"  object  of  tlie  atn.i.ine  is  to  !)hice  tlie  eye  at  rest,  aii.l,  by 
vvithdrawinp  the  iris  int..  the  p.-riphery  ..f  th.;  anfrior  chamber  o 
alK.w  r...m.  f..r  the  swllii-.e  ..f  th.-  l.-ns  ihe  s..!uti..n  n.-n.'ra  1> 
used  is  of  ti>e  strength  ..f  four  Rrains  ..f  sulphat.'  ..f  atr..pu..-  t.;  tlie 
ounce  .)f  .listille.1  water,  tii.'  sohiti..n  an.l  .In.pp.-r  \mn^  st<;rihz.-.  . 
It  is  a  K.....I  l>lan  to  inc-.rp..rate  some  non-irntatinR  antis<'ptic,  such 
as  boric  acid,  with  th.-  solution:  otherwise  it  is  .liHicult  to  ke.-p  the 
s.,luti..n  sterile,  as  the  r.'ceptade  containiiiR  it  is  frequently  ..penod 
and  th.>  solution  .•xp..s,Ml  t..  the  air.  .\  light  antiseptic  .Ir.-ssing 
an.l   ban.lage  are  appli.'.l,  at   least    until   the  exfrnal  woun.l  has 

'^  "iTn'action  is  excessive,  it  is  controlled  Ix'st  by  the  application  of  ice 
c.,mi.resa.'s  an.l  the  internal  administration  of  cal.mu-l  in  .l..ses  ot  ..nc- 
t«Mith  ..f  a  grain,  combine.l  with  bicarbonate  of  sodium,  every  h..ur 
until  fr.'e  purgati..n  <.r  "  t..uching  ..f  the  gums'  mak.'s  it  a.lvisable  to 
discontinue  it.     .\s  calomel  is  giv.-n  in  this  way  for  Us  antiph -gistic 
etlect.  an.l  ..ften  fails  to  purge,  a  saline  cathartic  ha.l  b.'st  be  als.> 
given,  an.l  the  patients  general  1        h  an.l  secretions  k.;pt  in  g..od 
c..n.lition.     rn.ler  this  treatm.-nt      ..umatic  cataract   will  ..ft.-n  be 
Era.luallv  dissolve.l.     Kxcessive  swelling  of  the  lens  may  occur,  pro- 
ducing glaucoinat..us  svmi)t..ms.     The  eye  bec.im.-s  the  seat  ..f  inten.>-e 
pain  whi.'h  ra.liates  to  the  fn.ntal.  temp.md,  malar,  an.l  <'ven  ..ccipital 
region.     Conjunctival  inj.'ction  is  marke.l.  and  palpati.m  reveals  an 
increas.'.l  intra- >.'ular  t.>nsi..n.    Th.'s.-  sympt..ms  an-  r.'a.lily  .-xplaine.l 
bv  finding  the  anteri..r  chamber  fille.l  with  th<"  swollen  an.l  ..j.a.pie 
lens  matt.'r      This  c..n.liti..n  necessitates  evacuation  ..f  part  .)r  al 
of  the  leu-  ,.  'itter  bv  the  oi)erati..n  of  simi)le  linear  extraction,  which 
will  be  d.'scribe.!  in  c..nsi.lering  th.'  tr.-atment  ..f  cataract.     It  i.s  best 
t.,  rem..v.'  all  of  the  lens  matter  that  can  be  rem.)ve.l,  since  this  n..t 
onlv  more  effectuallv  reliev.-s  the  glaucomat..us  symptoms  but  reii.lers 
th.'ir  r(Turn-n,'.-  l.-s's  pn.babl.-  an.l  hastens  th.-  cur.-  .>!  the  con.liti.m 
by  l.-aving  ..nly  a  small  ain.)unt  .)f  the  lens  to  be  .lissolved  by  th.' 

a.iueous  hiim.ir.  _  ,,       i  **„, 

\n..th.'r  p..t.'nt  reas..ii  for  evacuating  th.'  sw.illen  lens  matter 
when  c.nsi.lerable  in  amount  was  m.'nti..n.'.l  in  sp.'aking  ..t  .lisloca- 
tion  ..f  the  Umis  hit.,  the  ant<'ri..r  chamber,  namely,  that  pressure  ot 
the  lens  on  the  p..st.'ri<.r  surfac  of  th.'  crnea  may  excite  inflamma- 
tion or  ev.'n  sL.uglnng  ..f  that  m.-mbrane.  .  „  ,  ,,  I 
In  s..m.'  cases  of  traumatic  cataract,  especially  where  the  wouiu, 
is  imall  the  l.'ns  b.'c.mes  opa.|ue,  but  is  m.t  absorbed.  I  iider  thesr 
circumstances  it  sh..ul.i  be  rem..v.'.t  In  s..lution  or  extraction  m  Av 
same  manner  an.l  for  the  same  reas..ns  as  if  .l.'aling  vyith  a  monocular 
cataract  .lue  t<.  other  than  traumatic  causes.  In  chil.lren  a  cataraci 
in  one  eye  if  let  alone  for  a  long  time  may  produce  amblyopia  trom 


DlStW.SfCS  Of  THE  CRYSTALLiyE  LESS. 


486 


<lisii.xc,  and  tlic  (ipcration  wlicii  ultiiiiatdy  pcrforineil  may  not  be 
tdlldwcd  liy  a  good  visua'  result. 

rrauinatic  cataract  may  he  followed  hy  the  formation  of  a  second- 
ary capMilar  cataract,  or  after-cataract,  wliich  must  be  dealt  with 
hy  capsulotoniy. 

Opacities  of  tbe  Lens.  All  opacities  of  tlie  lens  and  its  capsule 
are  included  under  the  name  cataract.  This  name  is  a  relic  of  the 
lime  when  the  nature  of  these  opacities  was  not  understood,  and  no 
distinction  could  be  made  betwwn  the  dilTeient  kinds  of  opacities. 
I  sape  has  established  the  name  so  firmly  in  our  nosology  that  it  will 
probably  be  permanency  retained,  and  great  confusion "wouhl  follow- 
any  attempt  to  abandon  il. 

The  following  classification  includes  the  forms  of  cataract  met 
with  clinically: 


I'apaular  opacitiei. 


lenticular  opaclllea. 


Aiiteriur  Citpiiular. 

rotterlor  cnptulir. 
Secondary,  or  after^calaract. 

Stationary  (partial). 


I'rotrreMlve, 


\  Congenital. 
'  Acquired. 


I  Zonular  rutarart. 

1  Circumscribed  opacltlea. 


Nuclear. 
Cortical 


Ciipsulnr  ralnrnctx  are,  as  the  name  implies,  opacities  confined  to 
the  ca,isule  of  the  lens. 

Anterior  capsular  or  polar  cataracts  are  of  two  kinds,  conveniently 
considered  as  congenital  and  acquired.  We  have  seen  that  the 
anterior  capsule  has  an  epithelial  lining  on  its  lenticular  s'lrface. 
.\ntt>rior  capsular  cataract  consists  in  a  proliferation  of  these  e|)i- 
tlielial  cells,  which  become  elongated  and  form  a  mass  of  o])a(iue 
li.-;sue  resembling  fibrous  tissue,  lying  between  the  clear  cajisule  and 
tlie  clear  lens,  neither  of  which  is  affected  by  it.  fFig.  268.1  This 
mass  is  not  fibrous  ti.ssue,  for  it  develops  from  epithelial  (epiblastic) 
<i'lls.  In  the  congenital  form  of  ant(>rior  cajisular  cataract  the  con- 
ilitioii  is  due  to  some  develoi)meiital  error  not  yet  determined.  In 
the  acquired  form,  which  arises,  as  a  rule,  during  childhood,  the  first 
step  is  an  ulc(>ration  of  the  cornea,  which  ])erforates  and  allows  the 
.niueous  humor  to  escape  and  the  lens  to  fall  forwartl  and  apply 
itself  to  the  opening.  By  contiguity  infiammatitm  is  set  up  in  the 
•apsular  epithelial  ceils,  and  they  proliferate.  Closure  of  the  corneal 
'i|iening  and  reaccumulation  of  the  atjueous  humor  results  in  replace- 
Mient  of  the  lens  to  its  natural  position.  \\e  can  see  the  corneal 
"pacity,  suggesting  the  cau.se,  anil  sometimes  a  thread  of  tissue  m.".y 
iie  seen  connecting  the  corneal  opacity  with  the  lenticular  one.  In 
'lie.se  ca.ses  there  is,  in  addition  to  the  epithelial  nia.ss  beneath  the 
.■il>sule.  usually  a  plug  of  connective  tissue  deposited  on  'he  anterior 
urlace  of  the  caiisule  (pyramidal  cataract). 

Posterior  capsular  or  jiolar  opacities  have  a  very  different  origin 
ml  are  always  congenital.     In  fo-tal   life  a  bloodvessel,  the  hyaloid 


I 


4S8 


THK  KYK. 


V  i 


artiTV,  runs  tlirmipli  the  vitri'inis,  cunni'ctiii)!  itic  optic  disk  aini  llif 
|i()slcri(ir  siiifacr  uf  tin'  lens.  This  usually  atr<i|(liii's,  iiul  sniiii'tiiMcs 
a  rcuuianl  uf  lissuc  rcniaius  at  the  site  uf  tlii'  junctiirt'  of  ihr  livalniil 
artiTV  and   the   [itwU'rior  surface  of  tiic  lens,  and  this  constitutes 


Kli. 


I     ^1 


"11 


Epithelial  pniliferatiim  (at  A  Ai  bcncHtll  tho  c«p«iile.  Krum  »  i;\k  <'t  ch(ir..lilal  Mirc.nitt.  r„ 
stiow  the  histol(«y  of  aiiterinr  <Hi»\ilar  culHrart.  ■  Imi.  il're|iarcii  hy  Dr.  E.  S.  Thu.vi>os,  in  tlie 
laUjratury  of  tlie  Mttiiliaiwu  Eye  aii'l  Ear  llinpltal.) 

posterior  capsular  cataract.  (Fip.  I'fiO.)  As  will  he  seen,  it  differs 
from  anterior  capsular  cataract  l)y  lyinj;  on  the  surface  of  the  capsule 
farthest  from  the  lens,  and  in  heiiifi  fibrous  (inesohlastic)  instead  uf 
epithelial.  Sonietinies  the  hyaloid  .artery  does  not  disajipcar,  l)ut 
remains  in  its  entirety.     Capsular  cataracts  are  stationary. 


I*))sterior  i>f)lHr  cntHract. 


11  it 


Ijnlindar  rt/wc/7(t'.s  are  far  more  co,  '  on  than  capsular  oi)acities, 
so  nuich  so  that  the  word  cataract,  unless  ([ualitied,  is  usually  taken 
to  mean  an  opacity  of  the  lens  itself. 

I,enticul.ar  opacities  are  caused  by  anylliiiij;  th;it  intertVres  witii 
the  normal  growth  of  the  lens.  In  this  way  errors  of  development, 
such  as  faulty,  delayed,  or  imperfect  development,  .-ienility,  ccmstitu- 


lUslAshs  or  THE  <  hystm.i.im:  less 


w, 


lii.n;il  <lisf;i>cs,  :iii<l  ntli.r  .liscascs  (if  tlx'  rvc,  csii.'cially  tli.'  .Ii-<fafi»..s 

ol  III.'  iivciil  tract,  wlii.li  is  .vsjiccially  ( ('•.■riif.l  in  tin-  niitritidn  nf 

iIm'  .-vc,  act  as  causes  uf  cataract.  TJic  l.nv-uradc  clii.niid;,!  inflarii- 
iiialit.n.  .Irscnl..-(|  in  tli.'  living  as  •■rli..rni,lal  .lisiinliarwr.  •  hn.iiKlit 
.iliuui  hy  cyi'stniiii  atlcn.liiiK  iinccirrcctcci  or  iiiipn.|i.iiy  currccicil 
rrrursuf  rdnicticn.  is  Ik'M  ti.  he  a  i»itciit  caws.'  ..f  lonliciilar  cataract. 
The  writer  lias  staled  the  causes  in  the  toreRoin^r  nuinn.T  I.ecaiise 
iliat  idea  hesl  explains  the  {rreal'-r  relative  frc.|iienev  of  c;ifaract  in 
ihe  illiterate  and  ignorant  ehisses— c.  ,/.,  the  iienn.fa.'e— in  whnni 
errurs  ..f  refraction  are  rel.atively  raiv  and  iis<'  of  th.-  eves  in  a  manner 
ral.Milated  to  cause  eyestrain  very  iiinisual.  Cataract  is  coniriion 
111  irlaxi, lowers  and  others  whose  occiliialiori  ex|i(i-.  s  tli'iii  to  lii>;li 
leiii|ieratures,   |)rol)al)ly   I ause  these  excessive   temperatures  cjtuse 


Plo.  ro. 


IVftliininc  CBtamct.  The  nucleus  Is  begluning  to  shrink,  and  a  numbtr  of  separation-  in  the  fibre 
■.■.hown.  Thf«e  se|«rat:on.«  are  lilk«l  with  Kranular  matter  which  staiti^  .teeply.  x  lUU  iPre- 
ircd  hy  Dr.  K.  S,  Thomkon.  in  the  lahoratory  of  the  Manhattan  Eye  and  Ear  Hospital.) 

■'lilar  conditions  of  the  choroid.  The  manner  in  which  these  eau.<*ps 
't  is  understood  best  when  we  consider  the 

Pathology  of  Lenticular  Opacities.  The  lens  grows,  as  we  havo 
■  "11.  hy  the  formation  of  new  fibres  from  the  laver  rtf  epithelial  cells 
Inch  underlie  the  anterior  cap.sule.  These  cell.s  become  fibres  by  a 
;oces.s- of  elongation,  and  p.  to  make  up  the  cortic;il  porti<m  of  the 
IIS.  The  tendency  of  the  (■.•insular  enitlielium  to  !:!ke  on  thi--  filin-.U'J 
nicture  has  been  >een  in  considering  .anterior  capsular  cataract. 
'le  nucleus  is  the  oldest  part,  and  hy  contraction  and  lo.ss  of  fluid 

idiially  becomes  more  dense  and  smaller.     If  the  growth  of  tho 


488 


r//A'  A)A". 


lens  is  arrested  l.v  senility  or  by  any  otlier  eaiise  wiiieli  interferes 
with  its  jrrdwtii,  the  nueieus  continues  to  siiriiil<,  and  small  spaces  are 
created  bv  its  drawinfr  away  from  the  cortex.     (Fip.  270.)     These 


;  ii 


senile  catamct.    The  cortex  i.  homogeneous.    Deeper  in,  the  fibre.  »«  "l-^f*  'hjough  shrink- 
ing of  the  nncleuK.  and  the  -pheres  of  .Morgagni  are  forming     .  100.    (Prepared  by  Dr.  f.  S.  THo« 


son,  in  the  laboratorj-  of  the  ManhatUn  Eye  and  Ear  Hospital) 


F;n.  272. 


Senile  cat«r..ot.    ■^pnniti..n  of  tihres  and  formation  of  spheres  of  MorKSgni.     ■    '-W.    (Prepare.1 
Ml  ir.  K  s  THoMsos,  in  the  lalK.ratory  of  the  Ma.ilmltan  Eye  and  Ear  H<»^pilal.) 


DISEASES  OF  THE  CRYSTALLIXE  LENS. 


489 


Spaces,  thcicfiiro,  as  a  rule,  lie  in  tho  jxTinucloar  rcgioti,  ospocially 
toward  the  ('((uator.  Tlicsc  s|)af('s  l)ec()iiie  filled  with  an  albuminous 
fluid,  like  serum,  which,  while  clear,  appears  opacjue  as  compared  to 
the  filires,  on  account  of  the  difference  in  the  index  of  refraction  of 
the  two.  Thus  the  first  appearance  of  cataract  when  seen  in  its 
period  of  development  is  of  opaque  lines  running  from  the  circum- 
ference, liy  obliiiue  illumination  these  lines  api)ear  gray,  but  by 
reflected  light  they  appear  black,  as  they  interfere  with  the  light 
icHected  back  from  the  fundus.  The  albmninous  fluid  in  the  spaces 
fietween  the  fibres  coagulates  to  form  drops,  called  the  spheres  of 
Morgagni.     (Figs.  271  an<l  272.)     The  lens  fibres  next  to  these  spaces 

Flo.  273. 


Senile  caWraci     Tlie  Hbre«  are  beginning  to  break  up,  ind  the  lent  looki  granular  ami  homogene- 
<'U.>.         luo.    iFre|«red  by  Dr.  K.  S.  Thomon,  In  the  laboratory  of  the  Manhattan  Eye  and  Eur 

IlivpiUI.) 


Iiccome  clouded  by  minute  fatty  drops,  and  swell  and  become  more 
;in(l  more  ()i)a(|ue  by  fatty  degeneration  and  imbibition  of  the  fluid. 
(I'igs.  27-'i  and  274.)  This  j)r()ce.ss  may  1k>  arrested  by  the  removal 
of  the  cause,  and.  (>xce|)t  in  senile  cataract,  the  lens  resumes  its 
norinal  growth.  The  nucleus,  being  more  (len.s(>,  is  usually  the  least 
.itTccted  by  the  process,  and  in  many  cataracts  it  is  yellow  and  com- 
|iaiMtively  clear,  while  the  cortical  portion  is  milky  and  opaque.  If 
llie  cataract  i)rogres.-<cs  to  complete  opacity  of  the  lens,  the  same 
lliiid  is  secreted  betwi'«'n  the  lens  and  the  capsule,  and  tends  to 
;ji;ir:itc  llictn.  i  Figs.  27.T  and  27(5.)  Thi,-;  makis  rcninvai  uf  the 
liiis  easier,  and  explains  why  we  prefer  to  delay  the  extraction  of 
;in)gres.sive  cataracts  until  they  are  fully  opa(|U('  or  "ripe."     When 


4yo 


Senile  rataract.    Showing  leparatlon  of  Hbres  and  granular  di-bria.    Fibres  cut  transvirscly      ■   liio. 
(Prepared  by  l>r.  E.  S.  Thomson,  la  the  laboratory  of  the  Ma.'-.attan  Eye  and  Ear  Hospital.) 

KiQ.  275. 


(Hlaraot  following  irldocyclUiB.  Showing  •nftenlDg  of  the  cortex  anil  wparation  i>r  the  onier 
layers  nf  Ihe  nucleus.  <  l.'i.  (Prepared  by  Dr.  E.  9.  Thomson,  In  Ihe  laboratory  if  the  Manhaiinu 
Eye  and  Fm  Hospital. j 


DISEASES  OF  TUE  CRYSTALLISE  LESS. 


491 


tliis  stage  is  readied,  the  whole  lens  contracts  until  the  increase  in 
size,  due  to  swelling  of  the  fibres  of  the  cortical  portion,  is  lost,  and  the 
lens  regains  its  original  size.  The  degeneration  of  the  Hhres  con- 
tinues until  the  cortical  portion  is  converted  into  a  jjultaceous  opatjue 
mass,  which  becomes  finally  perfectly  fluid,  and  in  this  fluid  the  still 
firm  nucleus  floats.  This  condition  is  known  as  hypennature  or 
.Morgagnian  cataract.  The  fluid  portion  may  become  clear  and  the 
lens  in  a  measure  regain  its  transjja.ency,  but  not  its  consistency, 
and  some  improvement  in  vision  takes  place.  The  luicleus  never 
entirely  disappears,  although  it  becomes  progres.sively  smaller.  V\w- 
lesterin  crystals  may  form  in  the  fluid  part  of  a  hypennature  cataract. 


Fig.  276. 


^iiitc  cataract.  The  cortical  layers  beneath  the  capsular  epithelium  are  Boftencxl,  and  .several 
iHrge  swollen  nucleated  celU  show.  Below  these  are  a  few  vacuoles  between  the  libres.  •  2tX). 
Irtpated  uy  Dr.  E.  8.  Thom!"— .  in  the  laboratory  of  the  Manhattan  Eye  and  Ear  Hospital.) 


The  symptom 

acuity  of  visio, 
li'iis  differing  in 
lyo])ia,  or  mu. 


Act  consist  i)rincipally  in   diminution  of  the 

.tie  early  stages  the  presence  of  areas  in  the 

ive  index  from  the  lens  itself  may  give  rise  to 

>ision,  but  this  is  not  verv  common.     The  eve 


surgeon  is  usually  consulted  on  account  of  dimness  of  vision.  If  the 
opacity  is  peripheral,  it  causes  very  little  inconvenience  a.s  long  as 
the  central  jiortion  of  the  lens  remains  clear.  Such  a  person  .sees 
lii'st  with  a  contracted  i)ui)il  wlien  the  opaijue  jjortifnis  are  hidden 
tM'hind  the  iris.  On  the  other  hand,  if  the  ojiacity  is  central,  the 
patient  .sees  b(>st  when  the  pu])il  is  dilated — e.g.,  iit  night — when  the 
ii'traction  of  the  iris  permits  the  pa.s.sage  of  rays  of  light  through 
:'ni-  dear  peripheral  portions  of  the  lens.  .\s  the  o])acity  progresses  the 
vision  is  jioor  under  all  circumstances,  and  the  |)U|)il  assumes  a  notice- 
iliiy  gray  or  white  color.     The  vision  is  never  entirely  lost  from 


4;t2 


THE  EYE. 


uncomplicatPtl  cataract;  that  is,  tlie  patient  can  always  not  only  per- 
ceive light,  but  can  tell  the  direction  whence  it  conies.  If  a 
patient  with  cataract  is  unable  to  determine  the  location  of  a  lightetl 
canillc  at  a  tlistance  of  fifteen  feet  in  a  moderately  darkened  room, 
we  inav  be  sure  that  some  lesion  of  the  retina  or  optic  nerve  is  present, 
and  that  removal  of  the  cataract  will  not  be  attended  with  anything 
like  a  perfect  restoration  of  vision. 

The  imi)air;nent  of  vision  which  is  observed  in  the  development 
of  a  cataract  is  sometimes  due  to  another  cause  than  opacity  of  the 
lens.     It  freijuently  happens  that  prior  to  the  development  of  any 
consideraiile  opacity  the  increasing    density  of  the  lens  renders  its 
refractive  index  higher  and  its  action  as  a  lens  stronger.    The  result 
of  this  is  to  make  the  eye  myopic,  and  this  is  the  condition  which 
constitutes  so-called  "second  sight."     A  previously  emnietiopic  or 
hyperopic  eye  becomes  myopic,  and  if  the  patient  is  at  an  age  when 
jiresbyopia  has  appeared— anil  this  is  usually  the  case,  since  this  con- 
dition is  seen  oftenest  preceding  the  development  of  senile  cataract — 
he  finils  that  he  is  enabled  to  dispense  with  his  presbyopic  glasses 
and  read  with  the  unaided  eye.     The  dist  nt  vision  is,  however, 
reduced.     Careful  examination  of  such  an    ye  will  seldom  fail  to 
show  commencinjr   ataraetoas  degeneration  of  the  lens.     An  attempt 
to  correct  this  ner\-  aci;'i'r;-d  myopia  by  glasses  is  not  very  satis- 
factory, for  although  the  patient  may  read  the  letters  on  a  test-card 
with  much  greater  fluency,  for  some  reason  the  gla-sses  do  not  seem 
to  render  him  much  practical  aid  in  vision.     The  writer  luis  frequently 
seen  cases  of  this  character  in  whom  gla.sses  would  raise  the  distant 
vision  froi)'.  20  100  to  20  50,  or  more,  but  who  preferred  to  be  without 
them.     For   their   influence  in  relieving   eyestrain   and  promoting 
nutrition  of  the  eye,  tlu-se  glasses  should  be  carefully  fitted  and  worn. 
The  course  of  cataract  is  variable.     We  may  except  the  diiTcrent 
forms  of  stationary  cataract,  in  which  there  is  no  tendency  to  change, 
and  speak  only  of  i/fogressive  cataract.    The  tendency  is  for  the 
opacitv  to  advance,  but  this  occurs  at  a  very  variable  and  uncertain 
rate.     We  are,  therefore,  not  able  to  jirognosticate  with  any  certainty 
the  length  if  time  which  a  given  case  will  take  to  arrive  at  maturity 
and  he  ready  for  operation.     The  process  may  advanci    apidly  for  a 
while,  and  then  remain  stationarv  for  years,  or,  after  a  long  period 
in  which  no  i)rogress  is  made,  suddenly  advance  rapidly.     In  case 
both  (-yes  are  affectcfl,  we  can  argue  with  some  degree  of  confidence 
that  the  last  eye  to  be  affecteil  will  run  the  same  course  as  the  first 
one  did.  but  there  are  many  excejitions  to  this.     A  plain  statement 
of  all  thi'se  facts  had  better  be  made  to  the  patient  or  the  patient's 
friends  at  first.     In  a  general  way,  it  may  be  said  that  alxiut  two 
years  is  an  average  time  for  a  senile  cataract  to  arrive  at  maturity, 
while  the  jirogressive  forms  of  cataract  in  younger  jieople  are  apt  to 
advance  more  rapidiv  and  on  the  whole  with  greater  uniformity. 
The  value  of  this  staiement  lies  in  the  fact  that  we  may  inform  the 
j>ati(>nt  that  it  is  not  likely  that  the  eye  will  be  ready  for  o|)eration 


DISEASES  OF  THE  CRYSTALLiyE  LESS. 


493 


in  less  than  two  years,  nor  is  it  apt  to  be  longer  than  three  or  four. 
But  this  statement  should  be  made  only  as  a  mere  apjiroximation, 
!<ince  there  is  no  way  of  arriving  at  a  more  accurate  prognosis. 

Progressive  cataracts  follow  a  course  in  their  development  which 
admits  of  division  into  four  well-defined  clinical  stages: 

1.  Incipient  cataract.  In  this  stage  second  sight  may  be  present, 
but  the  opacity  is  recognizable,  especially  with  the  ophthalmoscope. 
No  other  changes  have  yet  occ^/red,  and  vision  is  present  to  a  useful 
degree. 

2.  Intumescent  or  swollen  cataract.  The  lens  is  now  more  opaque, 
although  clear  areas  may  still  be  found ;  but  the  fibres  are  swollen,  the 
lens  is  larger  than  nonnal,  the  iris  is  pushed  forward,  and  the  anterior 
chamber  is  shallow. 

3.  Mature  cataract  The  lens  has  resumed  its  normal  size  and  is 
opaque  throughout. 

4.  Hypermature  cataract.  The  cortical  portion  has  undergone  soft- 
ening, or  even  liquefaction,  vtu'i  may  have  cleared  up  to  some  extent. 

DiagnosiB.  The  diagnosis  of  cataract  is  to  be  made  by  careful 
examination  with  both  oblique  illumination  and  with  the  ophthalmo- 


FlO.  277. 


I 


Niiclrar  caunct.  1.  Section  of  Itni;  opacity  densett  at  centre.  2.  Opacity  as  seen  by  tram- 
mitted  light  (ophtbalmcacoplc  mirror),  with  dilated  pupil.  3.  Opacity  as  seen  by  reflected  light 
I  focal  illuminatloD).    The  pupil  is  luppoeed  to  be  dilated  wiih  atropine. 

(jcope,  and  should  aim  to  determine  not  only  the  presence  of  lenticular 
opacity,  but  also  the  precise  location,  stage  of  development,  and  kind 
uf  cataract,  together  with  the  cause,  if  possible,  and  the  condition  of 
all  of  the  other  ocular  structures.  It  is  important  to  examine  the 
lens  with  the  pupil  fully  dilated  by  means  of  a  mydriatic.  It  is 
extremely  important,  in  ciises  seen  early,  to  make  a  careful  examination 
(if  the  fundus  of  the  eye,  since  the  opportunity  to  do  this  may  soon 
he  lost,  and  a  knowledge  of  the  conditions  within  the  ball  is  highly 
advantageous  in  arriving  at  an  intelligent  opinion  as  to  the  cause  and 
course  of  the  cataract,  as  well  as  the  chances  for  a  good  visual  result 
following  operation. 

By  oblique  illumination  opacities  in  the  lens  appear  as  gray  dots, 
iiia.sses,  or  streak  against  a  black  background.  (Figs.  277  and  278.) 
If  small  and  situated  deep  in  the  lens  or  very  near  the  eijuator,  ♦hey 
may  not  be  visible  at  all  by  this  method,  and  their  density  is,  ass  a 
rule,  not  easy  to  determine.  Opacities  in  the  anterio  layers  of  the 
cortex  or  op  the  anterior  capsule  are  easily  seen  in  this  ..ay,  and  we 
c!in  also  judge  of  the  depth  of  the  anterior  chamber  and  the  condition 
•f  the  iris  as  to  color,  motility  of  the  pupil,  etc. 


4Jt4 


rilK  EYF.. 


. 


we  (Ictcniiiuc  wIk'ii  a  cataract  is  iiiatun'  by  concpiitratiiiR  light 
oil  it  fruiii  the  side  (ohliciiic  iiluiiiinatioii).  If  the  cortex  is  not 
<>pa<iut'.  tlic  iris  tiirows  a  very  inarivPtI  siiadow  tiirouph  the  clear  outer 


Fill.  278. 


C'ortic*!  catmract     Referencra  aa  iu  preceding  llgure. 

layers  on  the  opatiue  central  portion  of  the  lens.     (Fig.  279.)     If 
the  lens  is  fully  opa(|ue  (mature  cataract),  no  shadow  is  thrown. 

liy  ophthalmoscopic  examination  opacities  appear  black  against 
a  red  background,  and  on  the  wholi'  are  more  easily  seen.  We  can 
judge  very  well  of  their  density  by  this  method  according  to  the 
degree  of  blackness.  Faint  imclear  opacities  can  be  ilet«cted  which 
escape  being  seen  by  oblicpie  illumination  altogether.  Kxcept  in 
patients  whose  eyes  show  glaucomatous  tendencies,  the  jnipil  should 
always  be  dilated  with  a  weak  antl  evanescent  mydriatic,  such  as  a 
2  per  cent,  or  4  per  cent,  cocaine  solution, or  a  1  per  cent. euphthalmine 
solution,  or  a  combination  of  the  two  in  a  5  per  cent,  or  1  per  cent, 
.solution.  Otherwise  peripherally  located  stria',  the  form  in  which 
senile  cataract  often  commences,  will  be  hidden  from  view  by  the 
iris.     (Fig.  27.S.)     The  dilatation  of  the  pupil  also  enables  us  to  judge 


i 


;,.  ■■^Imdow  of  the  iris  seen  from  in  front  In  Innnature  cataract     /.    Eqiialii  aource  of  light.     L  L, 
Shadowof'the  iris  upon  the  lensseen  in  fichematic  cnwt-section.    L.  EqnulB source  of  light.  (Ft'CH>«.) 


of  the  condilioti  of  the  pupil  as  to  its  motility  and  the  presence  of 
posterior  synechia'.  The  extent  of  central  opacities  may  be  clearly 
defined  th'iiugh  'he  dilated  pupil,  and  the  condition  of  the  fundus 
stuilied  througli  the  clear  periphenil  portions  of  the  lens. 

Tlie  liiciUlnii  uf  llij-  Djiaeity,  if  small,  can  be  made  out  liv  ophthal- 
moscopic examination  by  observing  the  motion  of  tlie  opacity  in 
regard  to  the  Miotion  of  the  pupillarj'  edge  of  the  iris.  If  the  opacity 
is  on  the  anterior  capsule  of  the  lens  or  in  the  anterior  portion  of  the 


DJSJiA.SES  OF  THE  CIlYSTAhLlSE  LESS. 


4!»o 


cortex,  it  will  aiipcar  to  move  in  tho  sanio  direction  as  the  eye  moves, 
I.        upward  if  the  patient  looks  upward.     This  is  determined  by 


Flu.  SO. 


Fia.  282. 


I'ingrammBtio  repreronuilon  of  method  of  detecting  location  of  lenticular  opacities  by  their 
■niiieni  in  relHlion  to  tue  movement  of  the  edge  of  the  pupil.  Fig.  2S0.  the  eye  is  lookine 
ia,Kht  aheHd.  Fig. -«1,  the  eye  I,  looking  upward.  Fi.g.  282.  theeye  is  l<x>kingdo»nw8n3.  ,  Iri, 
lens.    O.  Observer,    a.  Anterior  opacity.    6.  Central  opacity,    r   Posterior  opacltv.     Oc   Line  of 

">o!i  of  tibserviT. 


tiiiR  its  (li.stance  from  the  edge  of  the  pupil.     If  the  opacity  lies 
.ir  the  posterior  surface  of  the  lens,  it  will  ai)pear  to  move  ia  the 


496 


77//;  i:yt:. 


()j)j)ositc  (liroctioti  to  tlic  iiuivt'iiicnt  of  tlic  eye — /.  c.,  if  tlic  pnticiit 
looks  upwiinl.  tlic  upi.city  ajiiK-ars  to  nn.vc  downward.  A  c'litnil 
ojjacity— tiiat  is,  ono  (M|ually  distant  from  tlic  !\\m  surfaces— will 
move  vcrv  little  or  not  at 'all.  T'lis  is  shown  in  Figs.  280,  2S', 
and  2S2. 

Hch  Ics  notiiiR  tho  condition  of  tho  lens  and  anterior  scgnipnt  of 
tl>  wc  should,  if  the  condition  of  the  lens  perinifs,  examine  care- 

fully lor  opacities  in  the  vitreous  and  for  evidences  of  disease  in  the 
optic  nerve,  retina,  and  choroid.  The  latter  lieing  the  nutritive  coat 
of  the  eye,  the  presence  of  any  disea.se  of  it  will  throw  light  on  the 
cause  of  "the  lenticular  diseiuse.  I'A-idence  of  disease  of  the  optic  nerve 
or  retina  will  govern  us  in  arriving  at  a  prognosis  as  to  the  visual 
result  to  be  attained  by  oiK-ration. 

If  a  view  of  the  fundus  cannot  be  obtained,  the  condition  of  the 
deeper  structures  shouUl  be  determined  by  measuring  the  Held  of 
vision.  This  can  be  done  even  in  mature  cataracts  by  means  of  two 
lighted  candles.  It  has  Ijeen  stated  that  cataract  alone  never  causes 
loss  of  the  ability  to  perceive  light :  hence,  in  the  abscMi'-e  of  other 
disease  of  the  eye  a  fairly  normal  visual  field  can  be  demonstrated 
by  the  candles.  Not  only  .should  the  limits  of  the  field  be  mapped 
out,  Init  the  central  region  studied  in  the  .same  way  for  the  existence 
of  scotomata,  the  presence  of  which  would  modify  the  prognosis 
materially. 

The  con<lition  of  th(>  conjunctiva  should  be  noted  for  evidences 
of  present  or  past  inflanunation,  and,  above  all,  should  we  carefully 
examine  into  the  condition  of  the  lacrymal  apparatus,  both  at  its 
ocular  and  nasal  extremities,  and  determine  if  the  appanitus  per- 
forms its  drainage  functions  ])roperly  and  is  free  from  inflanunation. 
The  lacrymal  apparatus  is  probably  the  most  fruitful  -source  of  post- 
operative infection  of  the  eye. 

The  eyeball  should  be  palpated  to  determine  if  '  iiderness  exists 
and  if  the  intra-ocular  tension  is  increased  or  diniiiiislud.  The  sig- 
nihcance  of  these  conditions  is  stated  elsewhere. 

The  general  condition  of  the  patient's  liealth.  secretions,  urine,  etc., 
nuist  all  be  looked  into  before  our  investigation  and  diagnosis  are 
completed. 

Prognosis.  The  jirognosis  of  cataract,  except  from  ojierative  treat- 
ment, is  for  permanent  blindness.  From  time  to  time  other  treat- 
ments are  exploited,  but  none  so  far  ailvanced  ])osses.«es  any  value. 
.Ma.s.sage  of  the  eyeball  through  the  clo.sed  lids  ha.shad  some  supi)ort 
from  reputable  ]irofessional  sources,  b\it  has  practically  been  aban- 
doned as  without  value.  Other  treatments  by  the  instillation  of  cer- 
tain drugs,  such  )is  cineraria  maritima  and  other  substances,  and 
various  "absorption  treatments,"  have  emanated  from  unprofes- 
.siwnal  siiurces  or  from  charlatans,  for  commercial  rea.wns,  and  are 
also  worthless. 

Spontaneous  clearing  of  cataractous  lenses  has  been  occfisionally 
reported  by  observers  of  repute,  but  is  extremely  rare.     Ri.sley  has 


I)i.s/:asi:^  of  Tin:  cnvsr allim:  i.e.w- 


497 


c.-ill 


eel  :iltciiti()ti  to  tlic  fact  that  some,  at  least,  of  tl 


ii'i!  li'iiti. 


icsc  casi's  were 


ir  ( 


iliacilics,  l)ut  iiiflaiiiiiiatory  deposits  iM'tween  the  |k.. 
leiior  ea|)siile  ami  the  vitreous,  and  were  of  choroidal  origin.     It  is 
easy  to  understand  the  disa|i|iearaiiee  of  these  iiroducfs,  I 
few  instaiiet's  clearinf;  u|i  of  true  leiitieular  ojiacilies  has  I 
to  occur.     These  cases  are  ophtliahnoloKical  curiosities 


>ut   HI  a 


K'cn  .seen 


Cataract  is  sorneiinn 
dislocation  of  the  lens. 


'cured"  by  the  spontaneous  or  traumatic 


II 


In  cataracts  which  are  allowed  to  advance  t(    hyiKTinaturity,  the 
uhstance  .sonietinies  becomes  suHiciently  clear  *o  jx-rmit 


uid  cortical 

onie  restoration  of  vision. 


tl 


I  he  jirojin.isis  from  operation  is  pood.  In  uncomplicated  cataract 
e  operation  of  removal  of  the  h-ns  should  vield  a  good  visual  result 
m  about  ',»()  per  cent,  of  ca.ses.  The  pro^iio.sis  is  rend(>red  less  favor- 
alile  by  coni|)licatinK  (lisea,-*e  of  the  eye  and  bv  certain  depressed 
states  of  nutrition,  as  in  diabetes.  A  careful  examination,  as  was 
mentioned  undiT  the  head  of  Diagnosis,  will  lead  to  the  detection  of 
these  conditions,  and  the  prognosis  can  be  inodiHed  accordingly. 

Ill  considering  the  (uiestion  of  operation  for  cataract  on  patients 
who,  for  some  incurable  local  or  general  di.sea.se,  such  as  suppurative 
condition  about  the  eye,  trachoma,  or  diabetes,  nejihritis,  pulmonary 
phthisis,  etc.,  offer  a  bad  prognosis,  the  matter  should  be  explained 
fully  to  them  in  regard  to  the  risk  that  they  run  of  losing  the  eye, 
and  they  should  then  be  advised  to  have  the  operaf  )ii  performedi 
for  the  rea.son  that  in  the  event  of  failure  their  condition  is  no  worse 
ihan  if  they  were  not  operated  on,  that  is  to  say,  they  are  blind  hi 
either  event. 

The  clinical  varieties  of  cataract  have  been  -    ted  in  the  Drocedinc 

pag-s.  ^  ^ 

Capsular  Opacities.  1.  Anterior  cajmilar  or  polar  cataract  is 
lilher  congenital  or  is  actjuired  in  infancy  as  the  result  of  corneal 
ulceration  and  perforation.  There  is  a  subcaii.sular  hvperplasia  of 
the  epithelium,  and  in  the  ac(|uired  form  fre(|uently  a  depo.sit  of 
lymph  on  the  anterior  surface  of  the  capsule,  forming  what  is  some- 
I'.iies  called  inramidal  cataract.  From  this  a  filament  of  organized 
lymph  may  sometimes  be  seen  to  run  to  a  small  corneal  opacity. 

2.  Tosterior  capsular  or  polar  opacities  lie  on  the  posterior  layer 
I't  the  capsule,  and  are  caused  by  failure  of  absorption  of  the  ti.ssue 
uiicre  the  fu'tal  hyaloid  artery  joins  the  lens.  Sometimes  the  hyaloid 
iitrry  persists,  and  may  be  filled  with  blood  or  may  have  its  "lumen 
■■l>hterated  and  api)ear  as  a  connective-tissue  filament  running  from 
I  III'  optic  disk  to  the  lens. 

■{.  Secondary  or  after-cataract  is  the  name  applied  to  portions  of 

lie  cajisule  left  behind  in  the  pupillarj-  s[)ace  after  removal  of  the 

'••lis.     I'nless  the  lens  is  removed  in  ifs^eajisule,  a  secondary  cataract 

ilways  remains.     This  may  be  .so  thin  as  not  to  interfere  with  vision, 

id  then  is  (.f  litJe  clinical  importance.     On  the  other  hand,  it  may 

■  i|i"itc  dense  and  augmented  by  particles  of  lens  m.-itter  enclosed 

32 


I 


498 


77//;  i:Yh:. 


lH>tWf..n  the  postcru.r  capMilc  ai.-l  tin-  nM.uiins  of  ihc  antcnur  .-apsu  <■. 
a.ul  furtli.T  \h\rknm\  l.v  a  .l.'p-.sit  ..f  lyn.i.l.  tl.r.mu  ..ul    ......  tl.c 

iris   .luring   tl..'   iril=s   wliich   ..IKm.    follows  op.-ration    for  oatarar  . 
(FiK   -'Sa  )     If  ilK-  c'litral  portion  of  th.-  secondary  cataract  is  sul- 


Kemainsof  k...  afler  a  normal  catanu-  extraction.    Showing  swollen  lens  nhre.  .urronn.le,    by 

irir.^"'l"a,v  e.nrtau-.    Fron,  an  eye  which  wa»  enucleate,!  .,n  the  tenth  day  for  lr„  .Hy.l  .  s 

15     a'llp^r^l  b"l,r  E  S  TnoM«.N,  h.  the  laboratory  of  tbe  Manhattan  Kye  and  K.ar  Momh.hI.) 

ticicntly  <.pa<ni.-  to  int.'rf.'rc  witli  vision,  it  ro.iuircs  treatment   by 

tiie  operation  of  capsiilotoiny.  .  •         r     i      i  f 

Lenticular  Opacities.     1.  Stationary  opacities  of  the  lens  are  oi 

^'T«rrirc'iins.ri!..'.l  opacities  of  llie  lens  may  f.^ll.'W  a  penetrating 
wountl  confine,!  ,o  a  small  area.     We  cannot  count  "»;•"';"•;»•';:; 
this  character  remaining  stationary,   but  the  clinical   tact    is   tha 
thev   sometim.'s  .lo,  an.l   may   even   .lisai.pear.     It    has  l.eeii   sal- 
tha"t  in  some  of  these  cases  the  wound  in  the  capsule  is  mmute  and 
i.Ktantlv  doses.  keei>ing  out   the  a.iueous  humor.     Ihe  opacity  >> 
„„,„  a,.;,  to  mechanical  disturbance  of  the  lens  hbres.     (  ircumscri bed 
opaeities  of  (Uher  than  traumatic  origin  are  sometimes  s,...,,,  and  an 
,;i.„,„ute  explanation  of  them  is  hard  to  give.      Ihe  most  c.muiH 
rorin  is  that  in  winch  opaque  ....  .-s  a.ul  spicu  a'  ex.s    >•'";";'• 
^,,„,  i„„„,.  ,|„„hant   of  the  lens,  a-  descnb.Ml  by  .  .   h.    Hiomps  -. 
This  i.  the  form  of  senile  cataract  which  is  most  apt  to  remain  i.aiti.il 
for  a   I"...'   time.     Other  forms  are   i.unctate  opacities,   which  are 
,      "•"'-""  ,        .,,.,.,„,..;,:,,„.  .,t,.!.ir(.i>acities,  which 

niu  ti|.l<'  and  iii;iy  ,,rcupy  .l!:uM^t  au\  w.-tti  .n.  -i. .  .ir  <  -  "  '•.,,,. 
.,re  imusu.al  in  the  pt.sfrior  central  reg.on  an.  ofte..  a>s...i..  .  I 
i^th  n-tinitis  pigm..n...sa  .,r  chon.i.lal  .lisease,  -'''v-tr-usopacit  s^ 
central  cataract,  an  .-i-acity  lying  n.-ar  the  centre  ..f  the  lens,  an.l 


JUSKAst's  OF  rill-:  cnYsT.xLLisi:  i.i:.\s. 


49U 


spindle  or  axial  cataract,  which  coiisi.sls  dI'  a  fiisit'i 


rill  opacity  ruiiriinj; 


iVoiii  i)cl'orc  backward  through  the  centre  of  the  lens,  with  lli"e  lliickesi 
portion  at  the  centre. 

(/<)  Zonular  cataract  is  a  common  form  of  coii>;enilal  or  infantile 

IKS  a  cataract 

lis  arrest  of 

ceases  to  projjress, 


cataract.     From  arrest  of  development  or  growth  of  the  It 
■  I'jtins  to  form  in  the  perinuclear  rejjion.     The  cause  of  tl 


development  orpowlh  hein>;  removed,  theojiacitv 
llie  surrouiidinj;  and  sub.s<'(iuently  formed  lens  siih.stance  liei'n«  clear. 
The  condition  is  tlien  that  of  an  opa<|ue  shell  Kiiif;  in  the  lens,  en- 
closinj;  a  clear  nucleus  and  enclo.sed  hy  a  layer  of  clear  corte.x.  A 
repetition  of  the  process  at  a  later  d;ite  may  "result  in  the  formation 
of  a  .second  opa(iue  zone,  .sejiarated  from  the"  first  hy  clear  lens  tissue. 
Zonular  catanict  niav  l)e( 


ome    i)roKres.sive  by  flie  overlving  laver 


liecolim 


IK  opaque.     This  may  be  foretold   when  p(  rijilu'ral  oj 


picula-  are  .seen  lyinji  ii;  front  of  the  opa(| 


from  their    relation   to  tl 


ue  zone 


Th. 


i|ue 


le  opa(|ue  '^one  are  ci 


led 


ri.l 


spiculii 


('!> 


Hy 


>les  an  immature 


ol)lii|ue  illumination  this  form  of  cataract  re.seml 
projrressive  cataract.  The  ophthalmoscope  shows  the  centre  to  hi 
slijihtly  clearer  than  the  peripheral  |)ortioiis  of  the  opa(|ue  area,  and 
surroimdiiiK  the  opacity  a  clear  area  through  which  a  bri>;lit  reflex 
is  obtained  and  the  fundus  can  be  .seen.     {V\g.  2.S4.)     The  upj)ear- 


Klil,  2>« 


l.aiiitllarcalaracl     1,  J, :!   A«  Ixfaru.    4.  .Suows  hlnjlii  gmynewof  the  uiidilatwl  pupil  owini;  to 
the  layers  of  o|tt('lly  being  deeply  seated. 


■mce  of  clearness  in  the  centre  is  due  to  tin-  fact  th.at  the  opa(iue 
layers  are  further  .separated  here,  while  ;it  the  edye  of  the  o|)acitv  the 
iwo  ojiaque  layers  are  .so  clo.se  that  they  have  t!;.-  etfect  of  one  "thick 
i.iyer.     Zonular   catanict    is   associated   .so   (  with  a  history  of 

lonvulsioiis  due  to  rickets  that  they  .are  penerally  believed  to  l")ear 
I  causal  relation  to  it. 

''•)  .\iit<'rior  and   posterior  cortical  opacities  are  sufficieiitlv  de- 
■iril -d  by  their  name.     They  are  lenticular  opacities,  in  coniradis- 
iiiction  to  .anterior  ;iiid  posterior  c.apsul.i.-  cataracts,  and  their  .special 
.uis!-  is  not  uiid(  r.^iood. 

1'.   I'ropr.  ssive  cataracts  include  the  vast  m.ijority  of  opacities  of 

lie  lens.     W  aile  sometimes  .«(.(.ii  in  young  adults,  tli'ey  usuallv  afTect 

Tsons  over  forty  years  of  age,  and  constitute  what  are  .siM)ken  of 


."ilMt 


rill  I  VI' 


i    -!        • 


i\ 


•1,  -.nil.'  cMlaiu't-.      ll   iiiu>l   lint   !■■  i'^W    M.u  ili.ii   pr-.-nsMv.'  ral 
•  Hart-  1I1MV  1...  sell  in  iiilalu-v  -  in-     rA.  at        v     ,',■.     \WU  -i-  \\m-  aj;.-  nl 
tl.irlv   vrals    ••ataia.'ls  ,.arlakr  -i   tlir    rliaia.l.liMirs  ul   ll..;  li-mml 
Irn-   ill'llial    llirv  ,,lr  •■oinpo-r,!    iai-civ  of  ll,r  .u.t.T  M.M    rnMlcal   l"-!-- 

li.Mis  iii.l  Hi  iviaiurlv  liiilf  mi.'l.iH.  S.nil.'  rat  iiart-.  on  tl,r  ulhii 
|,..|i,.l  'law  iclativrlv  laiv;.  r  mi.'lri,  ali<l  aiv  call'  hafil  .ataniHs.  .n 
,li-tiiirii.iii  iL.tii  iuvciiil.'  ur  soil  ..IK'S.  '  .■  I"  1-  ,.,uays.  .  y;ii  m  tli«- 
as:,.,!,  a  lavcf  ,.f  M.ll.Tr..rtrx  aluMI..!  t!,     :,  ,   '     1-.  .  'Imtiull  ^i'l>  1-  !'>^. 

:„  a   '■•.■. I. Val   lailr,   ti U\vv  the  |.ali.-l  I.     •    .ml.    iv,   u-'  Oi>tlli;iui>l. 

-ull  rn.iii  liani  .■alaia.-t>,  wli.'ii  matiitv  Ia  'if  t  ■  'li^'i  ll"'  ''"'""T 
.„,.  ,,|-  .,  „„„,.  iiiiilniin  aii.l  mval.T  w  iir,,.--.  .'I  .1.'  lli-  l:ill''i-  'iiay 
!„■  ...lit.'  l.f..\vi.,  ilii.'  t..  tlif  larj;.T  l.f..«  nu<  ••••i-.  \  v.  r,>.  laij:.'  ■•'i>'l 
,|aik  iiu.'I.Mis  .-aiiM's  wliat  i<  .-all.'.l  Ll-'.-'-  .ataiaci ,  a:,.,  mi-  .'atara.'! 
i.iav   !..■   all   im.'l.'.i.-   an.i    ii.-vn-   I..MM,-nr     i..m:  >  n\'-      .iM.a.'ts 

lM.ss.'s.-    Inlir    lailiv    w.'ll-Wcliii.Ml    >la,ur-     as    I,.,-     ..■.•!,    ii     nf. i 

I.   |iiri|,i,'iit.     •_'.   lunmi.'-ccni      ;!.   Mat^i'-.      t.   il- i..  ruialtuv. 
Complicated  cataract  i-  i  '■  i.'fm  appli..!  i.    cat    act-    !.■.•. m- 

|,;ini.'.|  l.\   Mih.T  intra  .Mailar  di^.a-,'  <.f  su.-li  a   iialiliv     -  t"  'A-^''  I'.sc 

In  c.iini.Hcali.iUs  .luriiis:  llif  |HTlnMMaMi'..  .,1'  llir  ..|..T: i    h.r  lli.'ll- 

ivniuval.     Tlnis  fi.riical  .ii.acitics  wlii.!,  .  .Ii-ciiir  ilic  vi.v         ilif  t-l'l 

,,1  ,,|„-iali iiiti.-  a.llH-i'.iis  whi.'h   I'iiid   tin'  I.  lis  in   \      ■■>■,  i\u\'.>'y 

,,l  111.'  vitr.'c.ii-,  ivn.liiiii^'  its  isca|M'  lik.'ly  .liiiini;  tln'  oicran..ii.  af. 
ciuiiilKih-  111.'  .'xi^trii.'.'  ..I  wliicli  w.HiM  justify  ilu'  naiiH'  .'t  ('..inpli- 
cal.'.l    <'!•   cMiiiilical.'   •■alaiacl.     <  »ii    lli.>   otlwr   liali.l,    runjilii.-livili-. 
,|a(•^\o(■v<lili^,    .i|.tic    ii'fv-    atropliy     .tc,    may    i^ili  at.     M'ii..iisly 
ajiaiiist   tlir  suci'i'ss  of  ilic  "|H-rati.)ii.  Imi   ciist.iiii  iln.-s  iH''  sanctiDii 

tfii'   il.'si;:iiati f   .'alaiai-ls    acciiiii|'aiiifil    liy    liicsi'    .-"ti     'i'.iis   as 

(•iiiM|ilifalc  catai'ai-t , 

A  siu'i-ial  f.ifiii  .if  <Miiii|ilicat.M'atafact  is  tliat  \\\\\<\i  isscii  I'..  i..\viii.i 
ii.'fil.rt.il  iritis,  Tli.^  impil  i-  ^..ntractcl  to  a  i-iui.  ami  tlii-  small 
,,|iriiiii}r  1-  lillci  with  an  .■xinLiif  so  intiinat.'ly  a.lli.ai  lit  -.  tlic  i^ap- 
stilc  whicli  is  als.i  opa.iu.'.  a-  !•■  '■niistitiit.'  a  capsnlMr  cat  iiaci .  Thr 
irir.  i-  fiv.|inMilly  l).>iiii.l  to  tli.  .apsul.'  I)\  iliis  ii.iiiIh  >•  .'V.T  its 
\vlii>l.  r\\r\\\.  a"...l  •''  lens  is  oft.'ii  .ipa.|ii.'.  Iriii-  ..t  in-  \.'rii\ 
i>  fiv.|ii.'iitlv  acc.inj.aiii.Ml  hy  .■yclitis.  as  a  result  >'i  wlu'li  tl  n.na- 
lu'ular  t.•ll^il>n  is  lowered. 

Etiology  of  Cataract.  To  rcs.'rve  until  now  a  con-i.'.iati.in  of  Uif 
caiiM's  ..f  cai.-.ra.'t  is  iner.  ly  t..  r.rite  as  caii-.'s  ■  ..iiditi,.iis  wlms.' 
iiiiiihis  .^irnniih  lias  l..'.'n  .lisciiss.Ml  aii.l  will  r.'adii  or  imd.^rstood. 
C.l.p'nital  i-ataraets  ar.'  .lu.'  t..  d.'f.M'ti  vi^  d,\ .  |o|  in.Mit,  wIimIi  in 
turn  i-  .111.-  to  --oinc  local  or  ^'.nei-al  .lis.;:-'  ■■<  '.lie  m.itli.T.  Syplnli-. 
tiilM't-culosis.  or  ..till  '■  diatlietic  .•onditi.m  i  ^-  a.'t  in  il.is  way.  'In.- 
d.f.'ctive  d.  velopin.-nt  ..f  one  or  iiioiv  ol  ilie  pn.din-ts  ol  twin  r 
tri;'ieprei;iiaii.'y  niaye\pP-<  itself  in  this  form,  .■.'ithniis.di  seld.iiii  in:i.s- 
so.aate.l  with  oijiri  ph\-ir.ii  and  pi)s-:'i!y  loriital  dti-vt-^.  Tr:-^^^  ^' 
.■ith.'r  .lirectlv  ..r  in.lirectly  to  tli.>  len-  i-  a  eause.  <irn.ral  di- 
whieh  affect  tlu'  nutrili.-ii!  an.!  -milily  tliro.i:.h  a  Minilar  .■e>sati 
trr'iwlh.  have  been  .liscu.ssed  a.-  .•aiis.'s.      Local  .liseas.s  ol   t!" 


/'/sA'|h/.v  1)1    fin-:  '  i;ysi hum:  /,/■;' 


»>1 


*liniikihi.'  lenH  in  u  cn-f.-  of  irl-j 
tiiry  )ii 


Tiiov-s,  ill  Ih'     ubipin- 


I 

5    ■ 


1  l)lulii>is  lin;i)i  loUiiwinif  inilocyelitls.  l."i       ITcparfil   'v  lir   E. 

in  the  lalM)ratory  ol  the  Mantmtlaii  Kyeand  I'-tir  llii«i>ilal 


502 


Till-:  i:ye. 


i.art'iculnilv  clionmlal  .liscasc.  arc  I'niitful  causes.     (Fij:.  2^^->.)    Cho- 
roidal caiaVact  is  a  wcll-di'tiiu'd  variety,  and  is  .seen  often  in  young 


Kio.  an. 


section  from  a  c««!  <,f  phthisis,  btilhl  with  owlfled  choroid,  showing  the  lens  .■oi.vcrtcd  Int..  u 
,„■■*  of  llhroi.s  ii.s..e.  X  1.-..  iPreparcl  b.v  Dr.  E.  S.  THOiisoN.  i.i  the  Uboratory  of  the  .Manhol  an 
I.M'  and  V»j  Hospital ) 

Fiu.  2SR. 


Wrinkling  of  lens  c«i>»\ile  ami  Kinenlng  "f  cortex  -.inder  a  large  Irii  adh-wlon  ,artlflclally  fopa- 
raicli.  Fn>.naca.«e..Hrldnchorol.mi..  •:  im)  (I'reparwl  by  Dr.  E.  ».  THonsor.  in  the  lat  jratory 
ni  the  Manliattun  Kye  anrt  Kar  Hiwpilal  ) 


hisKASES  OF  ruK  chystallim:  less. 


503 


IK'rsoiis.  In  tliis  fdrin  tlie  lens  is  very  a])t  to  undergo  caloiircous 
infiltration,  and  presents  a  porcelain-liive  wliiteness.  Diseases  of  the 
eye  whieli  terminate  in  atropliy  of  tiie  ploln'  Tiearly  always  produce 
cataractous  lenses.  (Fips.  2Sfi  and  2X1.)  In  the  same  way  coiiffeni- 
tally  microplithalmic  eyes  have  opa(|ue  lenses. 

I'lyestrain  from  inicorrected  errors  of  refraction  acts  as  a  cause  by 
proikK'ing  a  choroidal  disease  of  low  tyix'  hut  long  duration,  and 
thus  interfering  with  the  nutrition  of  ti  -^  lens.  Iritis  sometimes 
causes  cataract  by  the  tracti.tn  of  the  result:  .g  .synechia'.  We  cannot 
say  whether  this  act.s  by  first  producing  a  rent  in  the  capsule,  or 
by  the  disturbance  due  to  traction  alone,  acting  just  as  a  contusion 
or  massage  of  the  lens  does.  (Fig.  2SS.)  In  chronic  glaucoma  the 
lens  usually  becomes  opa(|U(>  in  time,  due  to  nutritive  disturbances 
in  the  eye  which  result  from  the  glaucomatous  process.     (Fig.  289.) 

Flo.  289. 


Deformity  of  lent  In  a  cataract  from  chronic  glaucoma.     •   15.    (Prepared  by  Dr.  E.  8.  Thomkn, 
in  the  laboratory  of  the  Manbatlan  Kyu  and  Ear  Hoapllal.) 


Treatment.  The  treatment  of  cataract  varies  with  the  variety.  It 
will  be  convenient,  in  order  to  avoid  rei)etition,  to  dp.scril)e  in  a 
M  parate  .section  the  operations  to  be  performed  for  cataract. 

Capsular  Opacities.  Anterior  or  posterior  capsular  and  polar 
lat.iraets  are,  as  a  rule,  so  small  that  they  do  not  seriously  inter- 
fere with  vision,  .mikI  may  be  let  alone.  In  case  thoy  do,  and  treat- 
ment is  necessary,  we  have  no  means  of  attacking  tlio  oitp.^uiar  ifsion 
MJoiu ,  but  discission  of  the  lens  must  Im'  performed  and  the  case 
siib.se(|uently  managed  like  a  soft  or  traumatic  cataract.     Iridectomy, 


.")04 


Tin-:  i:yi:. 


often  (if  viiluc  in  sonic  forms  of  piirtial  cataracts,  is  nsually  valnelcss 
in  anterior  and  posterior  iiolar  cataract. 

Secondary  or  aftcr-cataraci  is  to  i)e  treated  i)y  operation  if  it  inter- 
feres witli  vision  to  any  considerai)le  extent.  Tlie  treatment  is  by 
tiie  operation  of  capsnlotomy. 

Lenticular  Opacities.  Stationary  (partial)  cataracts  reqinre  dif- 
ferent treatments,  according:  to  tlie  inipairmeiit  of  vision  wliicii  tiiey 
cause  and  the  condition  of  tlie  other  eye. 

Zonnlar  cataract  is,  as  lias  been  said,  the  most  coinmoii  variety 
of  Iciiliciilar  cataract    seen   in   children.     If  the  oi>a«iue  portion   is 
small  ill  diameti'r,  it  will  be  fouiid  that  dilatati(Hi  of  the  JHipil  will 
.so  exjMise  the  dear  ln'rijiheral  i)ortion  of  tlie  lens  as  to  permit  very 
satisfactory  vision    thronjih    it.     In   such   a  case,  while  permanent 
dilatation  of  the  pupil  by  contimioiis  instillation  of  a  mydiiatic  may 
be  piacli.sed.  it  is  inconveiiiiiit  and  not  free  from  the  possibility  ol  a 
delct<'rioiis  effect  on  the  eye  or  fjeneral  health  of  the  patient.     I'or 
these  reasons  il  is  preierabie  to  make  a  portion  of  the  clear  periphery 
of  the  lens  available  iK'imanently  for  vision  by  the  i)erformance  of 
an  iridectomy.     Tliis  should  be  done  in  an  upward  direction,  and 
the  coloboma  mad"  of  moderate  size,  but  exteiulinj:  to  the  base  uf 
the    iris.     The   refraction   should   then   be   cai. fully   coirecied   and 
leases  Riven  for  constant  use.     If  both  eyes  are  affected,  Ixjth  should 
be  operated  upon.     If  only  one  eye  is  afTected  and  the  vision  of  t!i(< 
other  eye  is  jjood,   this  ojieration   should  not  be   performed.     The 
alTected  lens  slidiiid  be  treated  by  solution  or  not   at  all.     If  the 
cataract  shows  a  tendency  to  pro<;ress,  the  oix-ration  for  solution 
(discission)  should  be  |)erformed.  as  iridectomy  will  a''nr(l  only  tem- 
porary relief.     T"  the  absence  of  any  contraindication,  the  treatment 
by  solution  should  be  i>erformed  in  all  cases    as  affordiiifi  the  l>est 
visual  result.     'tVe  can  count  on  securing  normal  or  nearly  normal 
vision,  and  can  be  sure  that   the  effect   is  permanent.     Both  eyes 
should  not  be  operated  on  at  once,  as  some  accident  or  iiiierciirn'iit 
di.sease  may  cause  tlie  h-^  of  both.     Hy  oiM'raliiif^  on  the  two  eyes 
at  different   times,  we  profit   in  the  second  eye  by  the  (  xperience 
gained  in  tn-atinj;  the  first,  as  to  the  peculiarities  of  the  patient  and 
the  behavior  of  the  eye  jus  to  reaction,  etc.     The  same  rule  .-ipplies  to 
all  double  cataracts. 

Circumscribed  stationary  lenticular  opacities  .should  be  treated  on 
the  same  iiri.iciiiles.  If  the  fellow  eye  is  good,  no  operation  is  neces- 
sary on  the  alTected  one.  If  it  is  defective  or  has  been  removed,  the 
(lueslion  of  operation  will  be  determined  by  the  amount  of  visual 
impaiinii'nt.  the  jiresence  of  eomiilications.  ami  the  help  afforded  by 
cornrtiu}:  lenses.  The  o|)eration  will  be  that  of  solution  or  extrac- 
tion, accordin-:  to  the  jiatient's  age  and  the  consequent  hardness  of 
the  lens  and  the  size  of  its  nucleus. 

i'rogre.ssive  iciilicular  opa.-iliis  should,  if  slicht,  \v  fri-:ded  by 
what  nie.ans  we  have  to  retard  tlie  progress.  Careful  correction  of 
r"fraction.  including  the  ac(|uired  myojiia.  and  nie.asures  to  iruiirove 


di.si:asics  of  the  vRYsrAiuyt:  less. 


505 


tlic  RciHTiil  lu'tiltli,  togctlicr  witli  th<>  troatincnt  of  any  proiiouncci! 
ilysfrasia,  such  as  (lialh'tos,  iu'i)hritis,  etc.,  will  often  render  excellent 
aid  in  retarding  the  development  of  a  cataract.  Correction  of  the 
refraction  lessens  the  choroidal  disturbance  caused  by  eyestrain, 
and  in  this  vay  contributes  to  iM-tter  nutrition  of  the  lens.  The 
iiiiproveinent  of  vision  which  lenses  bring  al)out  is  also  a  source  of 
I  lie  greatest  .satisfaction  in  .some  ca.ses.  There  is  ])lenty  of  evidence 
show  that  the.se  mea.sures  are  of  undoubted  value,  and  tliev  should 


til 


tried  faithfully.     We  have  .spoken  of  the  futility  of  "ali.sorpti( 


)n 


drugs.    Alteratives  undoubtedly  exercise  a  beneficial 


(reatnients    ant(  ii 
inthience  in  some  cases. 

As  in  zonular  cataract,  so  iu  progres.sive  lenticular  cataracts,  dila- 
laliiin  (if  the  jjujiil  by  mydriatics  or  the  performance  of  an  iridectomy 
may  assist  in  obtaining  temporary  improvement  of  vision.  As  a  rule, 
these  measures  are  worthy  of  trial  only  when  the  vision  of  the  other 
I  ,.'  is  .seriously  iini)aire(l  or  altogether  absent.  In  behalf  of  iridec- 
lipiiiy,  it  may  be  sai<!  that  its  performance  at  some  tune  before 
extraction  of  the  lens  renders  the  latter  operation  ea.sier  and  safer. 

Ill  some  cases  contraction  of  the  pupil  by  myotics  (pilocarpine 
aiiil  eseriiie)  will  be  found  to  improve  the  vision  when  the  centre  of 
the  lens  is  d'-ar  or  tolerably  clear. 

In  deciding  on  the  use  (,f  mydriatics  or  myotics,  it  is  best  to  test 
till'  patient "s  vision  with  the  eye  under  tlieir  influence  at  his  occu- 
pation or  in  going  around,  to  see  if  1  m  condition  is  improved,  before 
.-•uggesting  their  use  or  advis'ng  an  iridectomy,  for,  although  they 
may  help  the  jiatieiit  to  .see  li.uic  letters  on  the  test-card,  they  may 
lint  render  his  vision  any  more  u.seful  in  any  other  way,  and  their 
use  would  be  wholly  unsatisfactory. 

The  utility  of  rii)ening  '^^'Tations  for  hastening  the  maturity  of 
leiiticul.'ir  o])acities  is  (jiiesti.nable.  Most  operators  prefer  to  extract 
.111  unripe  lens  rather  than  resort  to  them. 

The  operation  of  removal  of  the  lens  in  progressive  ojiacities  is, 
as  a  rule,  best  deferred  until  maturity.  This  is  not  necessary  in 
soft  cataracts— 7.  c,  in  patients  under  thirty-five  years  of  age,  in 
whom  the  operation  of  solution  is  aj)plicable.  In  senile  cataracts 
it  is  best  to  wait  until  maturity.  The  lens  is  tlien  removed  by  extrac- 
lion.  When  the  patient  has  a  mature  cataract  in  one  eye  and  the 
lens  of  the  other  eye  is  clear,  it  is  well  ♦(>  advise  removal  of  the 
1 -liariict  for  the  following  reasons:  it  improves  his  field  of  vision  by 
•  iiabling  him  to  .see  at  lea.sf  large  objects  on  the  affected  side,  and 
iliis  prevents  him  from  beinf  .-'n  into  or  from  running  into  objects 
iiid  other  persoas.  The  ey  ■•  i>  from  accident  to  the  other  or  the 
development  of  cataract  or  '  ■•  li.spase  in  it,  be  at  some  time  his 
niain  de[)endence,  and  tlie  \  .  will  be  I)etter  if  it  is  allowed  to 
lie  (>xercised  by  removal  of  the  tens  than  if  it  is  excluded  from  the 
visual  act  for  years  maybe  In- the  cataract.  Amblyopia  from  di=use 
Mi.iy  develoj)  in  an  eye  which  is  affected  with  cataract,  particularly 
ill  children. 


506 


Tin-:  EYi:. 


t'oiii]>li(':iti'(l  cataructs  arc  a  law  unto  ihcinsclvcs.  In  pcnoral,  if 
tlic  other  eye  ])o^^! >,-;(-  ^oiui  vision,  coniplicatcd  cataracts  had  better 
l)e  let  alone.  If  ii.e  imIkt  eye  docs  not  possess  and  cannot  Im-  made 
to  ol)lain  useful  vision,  i(|»eiation  should  he  resorted  to,  even  if  the 
chance  of  success  is  small.  Solution  or  extraction  should  be  per- 
formed, according  to  the  af;e  of  the  patient. 

The  operative  treatment  of  cataract  comprises  several  operations. 
For  hasteniiifj  maturity  in  unripe  cataract,  various  ripeiiiiif;  opera- 
tions have  been  devised,  i-'or  the  removal  of  opaipie  lenses,  the 
operation  may  be  that  of  depression,  or  solution,  or  extraction.  For 
tile  membranous  oi)aciti<'s  classed  as  secondary  or  after-cataracts, 
the  operation  of  ca])sulotomy  may  be  done.  For  occlusion  of  the 
pupil  after  the  rem()\al  of  the  lens,  various  operations  on  the  iris, 
such  as  iridectomy,  iridotomy,  etc.,  maj'  1k'  re(|uired. 

General  Considerations,     See  Chapter  XI\'. 

Thk  ()I'EH.\tk).\  of  DKi'KK.ssiox  was  formerly  extensively  practised, 
but  was  abandoned  liccause  the  eyes  were  sub.se((uently  lost,  eitlier 
from  glaucoma  or  iridochoroiditis,  cause-.',  by  tlie  lens  acting  as  an 

fin.  ■y» 


FiXHtion  forceps. 
V\a.  '.w. 


<»C 


Uayes'  kiiifu  acudle. 
Fig.  jy;). 

Brua'l  (oracenteBia  needlu. 


irritating  substance.  The  o])eration  consists  in  displacing  the  lens 
downward  iUid  liacKward  into  (he  vitreous.  Tiie  instruments  re(|uircii 
are  a  wire  speculum  (Fig.  290),  toothed  fixation  forceps  (Fig  291), 
and  a  broad  needle  (Fig.  293).     The  lids  Ix'ing  separated  by  the 


VISt'AHEil  OF  Tin:  CRYSTALLISE  LESS. 


O07 


spcdiluin,  tlio  conjunctiva  and  subconjunctival  tissue  arc  grasped  with 
llic  fixation  forceps  to  steady  tiie  eye,  and  the  needle  entered  either 
at  the  margin  of  the  cornea  or  in  the  sclera  behind  tiie  iris.  It  is 
jtlaced  against  the  posterior  surface  of  or  thrust  into  the  lens,  and 


Fin.  -.'31. 


struight  cataract  neeille 


l\v  a  Icver-likp  action  forces  it  ilownward  and  backward.  The  needle 
is  then  carefully  and  ([uickly  witlulrawn.  The  innnediate  results  of 
this  o|)erati()n  are  brilliant,  unless  the  lens  rises  to  its  normal  j)osition 
again.  The  ultimate  results  are  usually  loss  of  the  eye  from  subse- 
(|uent  inflanunation  or  glaucoma.  The  operation  is  only  justifiable 
in  those  so  feeble  from  age  or  disease  that  they  would  i)robably  not  do 
well  uniler  the  o])eration  of  extraction,  but  to  whom  it  is  desired  to 
give  some  sight  during  their  short  remainder  of  life. 

TiiK  ()PEU.\Tio.\  OF  soiATiox  or  (liscis-Hioii  is  apj)licable  to  catiiracts 
in  young  people.  The  age  limit  is  variously  stated  as  from  fifteen 
to  thirty-five  years.  We  would  prefer  it  on  patients  under  thirty 
years  of  age.  The  operation  eon.sists  in  making  an  opening  in  the 
anterior  capsule  and  lens,  and  submitting  the  latter  to  the  action 
in  the  acjueous  humor.  We  have  seen  that  this  causes  the  lens 
tihres  to  become  opa(iue,  swell,  and  ultimately  absorbed.  Anterior 
and  posterior  capsular  cataracts  (if  they  re(|uire  treatment),  zomilar 
cataract,  progressive  juvenile  cataracts,  and  other  ojjacities  of  the 
lens  in  young  people,  ;'.re  to  be  treated  by  this  operation. 

The  |)upil  i.s  first  fully  dilated  with  atropine.  The  lids  being  sepa- 
rated and  the  eyeball  fixed,  as  in  the  preceding  operation,  a  small 

I die,  or  a  knife  needle  (Fig.  292),  is  thrust  through  the  cornea  well 

toward  the  peripher>',  and  carried  to  the  centre  of  the  pujnllarj-  space. 
The  point  of  the  needle  is  entered  through  the  centre  of  the  capsule 
into  the  lens,  and  in  withdrawing  it  the  opening  is  slightly  enlargecl. 
The  needle  is  ijuickly  withilrawn  from  the  cornea,  without,  as  a  rule, 
losing  the  aijueous  humor.  It  is  well  at  the  hrst  operation  to  makr: 
M  V(>ry  small  opening,  since  we  do  not  know  how  the  lens  or  eye 
will  react.  Should  no  irritation  show  it.self,  and  the  change  produced 
in  the  lens  l)e  slight,  a  freer  opening  may  be  maile  in  a  few  days 
■md  in  the  same  manner.  A  generous  central  T-sha])ed  or  crucial 
incision  is  a  good  form,  and  is  followed  usually  by  rajnd  swelling  of 
I  he  l(  !is,  which  protrudes  through  the  capsular  opening  and  fills  the 
inferior  chamber  with  broken,  swollen,  and  opaijue  fibres.  These 
iiiiiy  be  removed  from  the  eye  by  simple  linear  extraction  (q.  v.). 
I'ain  in  the  eye  and  increased  tension  (glaucoma)  necessitate  this 

^peratiim  at  once,  ihhI  it  pronijitly  relir-vi-.s  these  synsploms.  If 
Miis  is   not  done,   the   lens   slowly  absorbs.     This  process   may  l>e 

iMstened    by    breaking  down    the    larger    masses    by   needling    or 


508 


Tin:  IJih. 


furthor  oijoniiip;  of  the  capsule.  ('(Hiiplctc  altsorption  requires  from 
two  to  six  inoiitlis.  iitid  (luring  this  time  the  eye  should  be  kejit 
eonstaiitlv  umler  the  intluenee  of  atropine.     A  drop  of  a  solution  of 


to  tl 


le  ounce  IS  ins 


two  to  four  firaiiis 

to  four  timi's  a  day.     On  accou 

ahsorl),  it  is  advisalile  to  remove 


tilled  into  the  eve  from  one 


nt  of  the  time  it  takes  the  lens  to 
•iome  of  it  by  siini)le  linear  extrac- 
tion wlien  possible.     The  absorpuon  of  the  lens  usually  leaves  an 

after- or  sec dary  cataract,  which   re(iuires     peration.     After  this 

the  eye  re(|uires  a  hit;h  strong  cotiv<'x  lens  to  enable  it  to  sen-.     When 

the  result  of  discission,  a 


the  lens  has  been  partially  ab.sorbed  a 
method  to  hasten  thi'  attaimnent  of  visic  has  been  jjroposed  by 
Dr.  (!.  (".  Savage,  and  is  as  follows:  A  needle  is  introduced  into  the 
eye  and  the  centre  of  the  lens  cl(  ared  by  pushing  the  fragments  towaid 
the  jieriphery.  In  this  way  a  clear  pupil  may  be  obtaii..'d  some 
weeks  before  it  would  be  availa!)le  l)y  the  process  of  absorption. 

( (perations  of  discission,  ami  capsular  operations  may  be  considered 
"office  operations,"  and  can  be  done  on  a  couch  or  with  the  patient 
sitting  in  a  chair  and  resting  his  head  against  the  body  of  the  surgeon, 
who  stands  behind  him.  Subse(iuent  rest  is  desirable,  but  subse- 
(pient  immobility  is  not  essential. 

Ripening  Operations.  These  consist  in  procedures  whose  essential 
]iart  is  till'  ajiplicatioh  of  massage  to  the  lens  for  the  ))urj)ose  of  .so 
disturbing  the  superficial  portions  tiiat  opacification  of  the  outer 
cortical  portion  is  ha.stened.  Their  main  influence  is  exerted  on  the 
peripheral  layers  of  the  cortex  anteriorly. 


McClure'.'  iris  sclMors. 


InKlrumrnlx.  Speculum  (Fig.  2!M)),  fixation  forceps  (Fig.  29\). 
keratome  or  paracentesis  needle  (Fig.  29:^),  blunt  probe  or  tnnvel- 
sliiiped  spatula,  iris  forceps  (Fig.  295),  and  iris  scissors  (Fig.  297). 


DISEASES  OF  THE  I'KYSTALLIXE  LE.VS. 


'iOit 


An  iri(lcct()iii\  or  simple  paracentesis  cdrneie  is  done,  and  mas- 
sage applied  to  the  li'ns,  either  directly  l)y  tiie  probe  or  spatula 
introduced  into  the  anterior  chaniher,  or  the  lens  is  niassajjed  throu;tli 
tlie  cornea.     Tlie  movements  are  rotary  and  very  Rentie.     Discission 


*=C^ 


CVlWlltSO^S 


Hseder's  kiilfe  (right  and  left). 


is  also  sometimes  used  for  the  purpose  of  rii)eninR  cataracts.  The 
present  vi(>w  of  the  method  may  be  well  expressed  in  Knajjp's  words: 
"  .\11  these  procedures  have  the  disadvantage  of  heinp,  in  a  number 
of  cases,  either  totally  or  partially  inethcient,  besides  adding  to  the 
removal  of  the  cataract  another  surgical  procedure  which  has  not 
always  |)roved  harmless." 

.Most  operators  prefer  to  extract  immature  cataracts  rather  than 
resort  to  any  metliod  of  .artificial  ripening. 

Extraction  of  cataract  is  tlie  term  a|)5)lied  to  o])erations  whereby 
the  lens  or  the  greater  i)ortion  of  it  is  removed  at  one  sitting.  The 
<iitTerent  pr()ce<lures  may  be  groujied  under  the  heads  of  (1)  simple 
linear  extraction,  .uid  (2)  extraction  of  hard  cataract. 

Sini])le  linear  extraction  is  applicable  to  soft  cataracts—),  r.,  in 
pi'rsons  under  !he  age  of  thirty  years — and  to  traumatic  catara-cts. 
It  is  performed  as  follows: 

The  j)upil  is  dilated  with  atropine,  local  ana-sthesia  induced,  the 
lids  separated  by  a  speculum,  and  the  eye  grasped  with  fixation 
forceps,  as  already  described.  A  narrow  keratome  or  broad  needle 
i>  entered  through  the  cornea  just  within  its  clear  margin,  and  usually 
.It  the  point  nearest  tiie  external  canthus.  By  jju.xhing  the  instru- 
ment forward,  and,  if  neces.«ary,  by  a  lateral  movement  in  with- 
dr.awing  it,  an  incision  about  .')  nun.  long  is  made.  The  instrument 
should  be  withdrawn  very  slowly  to  permit  gradual  emptying  of  the 
anterior  chamber,  as  rapid  evacuation  of  the  aipieous,  especially 
if  the  tension  of  the  eyeball  is  increased,  may  be  accompanied  by 
-ciisations  which  cause  the  patient  to  become  alarmed  and  move. 
!!'  the  npcratidii  Im  jjndertaken  a«  the  pnir.ary  "pcrati'in  on  a  soft 
I'Mtaract,  the  capisule  may  be  incised  by  the  same  instrument  which 
makes  the  corneal  incision,  by  directing  its  point  backward,  or  this 
may  be  done  with  a  cy.stotome  (Fig.   '{(K))  after  withdrawing  the 


510 


THE  EYE. 


f  i 


first  instniniont.  Frc(|U('ntly  tlic  opcriition  is  doiM  on  traumatic 
cataracts,  or  on  soft  cataracts  already  (liscissioiiod.  In  citlicrof  llicso 
events  the  anterior  ciiainl)er  will  contain  lens  inatliT.  This  is  re- 
niovi'il  i)y  opeiiiiif;  the  corneal  incision  by  nressure  on  its  jM)sterior 
li|i  with  a  (lelii-ate  s|)alula  or  spoon  (Ki;;.  ;{()4),  and  the  escape  of 
the  lens  matter  further  facilitated  hy  gentle  counter-pressure  and 
strokinn  at  the  i)oint  opposite  the  incision.  Tiiis  manceuvre  is  con- 
tinued until  the  lens  matt'T  is  evacuated  as  thorou>;hiy  as  possible. 
The  eye  is  tln'ii  bathed  with  an  antiseptic  solution,  atrojiine  instilled, 
and  a  monocular  dres>inj;  a|)plieil.  It  is  rarely  necessary  to  combine 
an  iridectomy  witii  tiiis  method.  A  modification  of  simple  linear 
extraction  consists  in  extraction  of  the  lens,  when  svifhcieiitly  fluid, 
by  suction.  A  curette  with  a  hollow  handle  and  jiartially  covered 
bowl  is  introduced  info  the  eye,  and,  by  means  of  a  rubber  tube 
attached  to  the  end  of  the  handle,  the  ojjerafor  draws  the  lens 
matter  out  by  suction  with  his  mouth.  The  same  result  is  attained 
by  means  of  a  ]>iston  syringe,  but  this  method  is  not  much  ]»rac- 
tised.  AnotluT  modification  consists  in  irriftatinji  the  anterior  cliam- 
ber,  as  will  be  described  in  treating  of  the  extraction  of  hard  cataract. 

It  occiLsionally  hapi)ens  that  a  patient  over  thirty  years  of  age 
desires  operation  on  ;i  cataract  which  is  either  congenital  or  a])i)eared 
during  cliildhood.  It  should  be  treated  as  if  it  had  developed  but 
reci'Utly;  that  is,  by  extraction,  as  if  it  were  a  hard  cataract,  which 
it  will  have  by  this  time  become,  if  not  manifestly  hypermature. 

I'lxtraction  of  hard  cataract  may  f)e  performed  in  one  of  three 
principal  ways:  1.  After  a  preliminary  iridectomy.  2.  Combined 
with  an  iridectomy  done  jus  a  step  of  the  operation.  3.  Without 
iridectomy  (simple  extraction). 

1.  KxTHACTiox  .\KTKK  I'ltKi.iMiNAHV  TuiDhXTOMY.  This  is  probalily 
the  safest  of  all  methods  of  extracting  a  hard  cataract,  but  has  the  dis- 
advantage of  subjecting  tiie  patient  to  the  danger  and  inconvenience 
of  two  openitions  involving  opening  of  the  eyeball.  With  much  to  be 
said  in  its  favor  on  the  .score  of  safety,  it  is  practi>'<ed  comi)aratively 
.seldom.  'l"he  iridectomy  is  to  be  done  as  described  in  Chapter  \'II., 
about  six  weeks  before  the  extraction  of  the  lens,  which  should  not 
be  undertaken  until  all  signs  of  irritation  foh  ving  the  first  operation 
have  di.sippeared.  The  teehni(|ue  of  the  extraction  will  be  ti.e  same 
as  to  be  i)resently  described. 

2.  KxTiiAcriox  wrr!i  ikidf.ctomv  is  the  l)est  operation  for  those  of 
limited  experience  with  the  cataract  operation.  Its  difficulties  and 
dangers  are  fewer  than  those  of  the  simple  method  and  are  easier 
to  avoid.     It  is  usually  iierformed  ;>;  follows: 

Inslnimrnts.  A  (iraefe  knife  (Fig.  L'OS)  (it  is  well  to  have  two 
at  hand),  a  stop  s|>eciilum  (Fig.  2(H)).  lid  elevator,  fixation  forceps 


(Fig.  291;.  iris  foreej-.-  {Fig.  2!).")),  iri.- 


=iv  {I'ig.  207 


i.i..-.* 


knife  (l'"ig.  W7]  or  scissors  for  enlarging  the  corneal  wound,  cysto- 
tome  (Fig.  ."^fX)),  silver  s|)atula  (Fig.  .304).  spooTi  (Fig.  'M)'2),  wire  loop 
(Fig.  Wi),  and  blunt  hook  ( l"ig.  ;5()1  >.     Tlie  lids  may  l>e  se|)arated 


JJIHEASEii  OF  THE  LU)iSlALLlME  LESS. 


611 


with  a  six'diluiii  or  hy  a  lid  clfvator  uimUt  the  u[)Imt  lid,  hcM  l)y 
an  assistant,  who  draws  down  tlio  lower  lid  with  the  finger  of  the 


Kki.  XO. 
Uimefc'n  cjritolome 


Fio   Wl. 

Tjrreiri  blunt  hook. 
Kli;.  3IV2. 

lel'i  len^  » 
Fill   nns. 

I^cvis'  wire  loon. 
Fin.  304. 

Spatula,  ahell  or  silver. 
Fiu.  3I». 


Weckefa  Iris  Kisiora. 
Fig.  set. 


'  incision  in  cataract  extraction.  l*tiucture  and  counter>puncture  have  beei  made  The  sec- 
I'"  -111  paiwln  its  whole  extern  exa<:tly  through  the  transparent  margin  of  the  cornea,  the  knife 
lUMiiiiing  in  the  same  plane  throughout.  (Slightly  modlfled from  de  Schwelnlu,  Diaeaaea  of  the 
':.ve,  third  edition.) 

Fid.  :W7. 


Deamarrcs'  secondary  knife,  stniight. 


612 


TIIK  KYE. 


otliiT  liand.     As  it   is  often    iicrcssnry   to  o|M'ratc  wWlioiit   skilli'd 
assistance,  or  witiioiit  an    issistaiit  to  wlmni  tlie  operator  is  accus- 
tomed, it   is  desiralile  to  !iel  in  liie  liahit  of  operatinn  without   an 
assi>tant.     It  is  |irefei:il)l<    to  liave  no  assistant  ratiier  tiian  a  poor 
one.     Tlie  operator  stands  l)eliind  tlie  patient.  Iiol.lin^  the  cataract 
knife  ill  the  ri,i.'lit  hand  anil  tixat'oii  forceps  in  tiie  left  for  the  rijiht 
eye,  and  rivf  virsii  for  tiie  left.     The  eye  is  jiraspeil  l>eh>\v  the  cornea 
with  fixation  forceps,  and  if  a  lid  elevator  is  used,  these  forceps  may 
now  serve  to  hold  tlie  lower  lid  out  of  the  way.     The  incision  is  to 
he  made  in  an  upward  ilirectioii.     The  eyehall  is  rotated  dowiiw.ard 
and  the  point   of  the  cataract   knife  entered  just   within  the  dear 
inarjtin  of  the  'oiiiea,  and  at  a  point  which  is  the  temporal  extremity 
of  a  line  parallel  to  a  tan>i<'nt  to  the  corni'al  summit,  and  dividing 
the  cornea  into  two  portions,  the  upper  |)ortioii  of  which  is  one-third 
of  the  cornea.     The  knife  eiitiis  the  cornea  at  right  angles  to  its 
surface,  and  as  .xoon  as  the  point   is  seen  to  have  pt-iietrated  the 
cornea  the  handli-  is  depressed  until  the  point  of  the  knife  is  directed 
str;iiglit  across  the  :interior  chamher  from  the  site  of  the  ptincture. 
and  the  surface  of  the  iilade  lies  i)arallel  to  the  surface  of  the  iris. 
The  knife  is  pushed  forward,  emerging  from  the  cornea  at  a  point 
(counter-puncture)  diametrically  opposite  the  juiiictiire.     (Fig.  -Wy) 
Ip  to  this  time  the  ai|neoiis  humor  is  preserv(>d.  and  the  point  of 
the  knife  seen  through  it  lies  farther  backward  than  it  seems.     The 
handle  of  the   knife  should   he  carried   well   backward  toward   the 
external  canthus.  or  the  iHiints  of  punctun'  and  counter-puncture 
will  Mot  correspond,  and  an  irregular  wound  will  be  made.     As  soon 
as  the  point  emerges  from  the  eye  the  blade  is  piishe<l  firmly  inward 
and  niiward  to  its  full  length,  and  then  drawn  back,  still  pressing  it 
ii|iwartl.     The.-^e  two  cuts  will  sometimes  sever  the  cornea  throughout 
its  extent,  but  fre(|uently  a  bridge  remains  re(|uiring  further  to-and-fro 
moNements  of  the  knife  to  divide  it.     The  knife  should  be  helil  with 
lis  bl.icle  parallel  to  the  plane  of  the  iris  throughout,  and  if  this  is 
done  a  sinooih  corneal  incision  results,  with  a  small  conjunctival  flap 
at   the  a|ie\  of  the  corneal  flap.     The  knife  is  now  Laid  aside,  and 
the  fixation  forceps  turned  over  to  an  assistant  or  dis|(eiised  with  if 
the  patient  is  docile.     The  surgeon  takes  the  iris  forceps  in  his  l"ft 
hand  between  the  thumb  and  index  fiiigiT,  and  the  iris  scissors  in 
the  right   hand.     The  closeil  iris  forceps  are  gently  insinuated  inl<i 
the  wound,  passed  to  the  pupillary  border  of  the  iris  opjiosite  the 
centre  of    the  wound.  oiK'Hed   slightly,  and  made  to  grasj)  the  iris 
at   the  pupillary  bordiT.     They  are  then  witiidrawn,  bringing  with 
them  a  i<M  of  the  iris,  which  is  drawn  out  of  the  wouiul  as  far  as 
possible  .-hkI  cut  otT  smooth  with  the  cornea  by  means  of  the  scissors. 
The  tixaiion  fiice|)s  niay  or  may  not  now  be  reapi)lied.     The  cysto- 
tome  is  tlic!!  v.:  ■•m!u("  1  flatwise,  carried  In  the  centre  "f  the  pupillarv 
space  and  turii'ii,  so  iliat  its  point   '-  directed  toward  the  capsule. 
This  is  then  ff  'ly  cut.  not  torn,  in  >ucli  a  ni.iiiiier  as  to  give  a  siif- 
ticient  opening  I      the  lens  toe.^caiie.     -  une  o[)erators  make  extensive 


DISEASES  or  TUE  VKYSTMLISE  LkSf>. 


5i;j 


iiTcciilar  iiu'isidiis.  others  inakc  incisions  in  die  .-'i:i|)c  of  a  cniss.  the 
IfltiT  A,  an  inverted  a.  'T  like  the  (;re<'k  letter  -.  Kn.i|.|i  makes 
:i  i-aiisular  incisiim  parallel  {.■  the  corne.il  iiieision  '  |ieri|ili(  ral  caii- 
sulot(iiriy).  The  eystotoine  is  Hirneil  ami  withilrawn  carefully  flat- 
wise anil  tlie  surireon  t;ikes  the  s|ioon  in  one  haml  and  the  wire 
loop  in  the  other.  The  speculiiiii  or  elevator  inav  l)c  reinoxed  at 
this  time,  (lentle  pressure  is  ma<le  witii  one  of  ih.>e  instruments 
just  helow  the  eiljre  of  the  eonie.i,  the  l>ressure  heinj;  first  ii.ickward 
and  then  Upward.  The  lens  lilt.s  and  presents  its  r,\(ro  in  the  corneal 
wound,  whicii  >;;ip.s  from  the  pn'ssure  lieiovv.  If  it  does  not.  it  is 
!ri;ide  to  do  hi  liy  pnssure  on  its  upper  lip  wi'li  the  instrunient  held 
in  ;he  othi'r  h;iiid.  My  coniinuin'r  the  upw.ii  I  pressure  the  lens  is 
-lowly  delivered  from  the  eye  ( Fijr.  ."JOS)  and  caught  .vitli  ene  of  the 
instruments  held  hy  the  operator,  and  removed  from  the  e\c.  If 
the  spcculinn  or  (levator  lias  not  .dre.idy  heen  nrnovi'd,  it  should 
lie  removed  now,  and  the  patient  allowed  to  rest,  with  the  a.— urance 


Flu.  ant. 


Flu  .WO. 


li'i.  308.— nellvcry  of  the  Itiis.  The  lens  is  i.rcwn'.ii'K 
lit  the  wound  (eapsulotomy  has  U*'n  jif-rfiinnt'il!.  (lit- 
soliweiulu,  l>i!«aw»  nf  the  Kyi',  thirl  i-diiliiii.) 

Km  3IKI.— The  miimicr  of  upplying  the  drcsMugs  after 
cataract  extiaction. 


iliat  the  o])eratioii  is  over.  In  a  few  minutes  he  is  told  to  open  the 
■  ye,  and  tiie  "toilet  (if  tin  wound"  is  made.  If  any  portions  of  the 
lens  n>in!iin  in  the  eye,  they  are  coa.xed  toward  the  corneal  w.  und 
liy  stroking  th(>  cornea  with  the  Imck  of  the  spoon,  and  (leliv(>red  ius 
'he  lens  was  hy  pressure  on  the  cornea.  It  is  best  not  to  introduce 
my  instrunicnt  into  the  anterior  chainlier  to  facilitate  removal 
if  this  di'hris.  A  .slender  .spatula  is  introduced,  however,  to  ensure 
li.i'iHness  of  the  wound,  ;\vA  t"  rei>!:ice  by  »;e!it!e  stroking  tlie  edff-r-s 
if  the  cololxmia  of  the  iris.  .Ml  the  clotted  blood  and  other  material 
>  removed  from  the  conjunctiva  by  moist  pledpet.s  of  sterilized  gauze 
ir  by  the  iris  forceps,  the  small  conjunctival  (iaj)  smoothed  out,  a 

33 


flF" 


A14 


Till  /.•)•/■;. 


(Iri>!>  i>l'  Mti(i|iiiic  instillfil.   iikI  iIm   ilir-^^^iiijf^  appiird.     TIk'M'  CDiisisl 

iiiil  two  Iivrrs  iliick, 


of  ^"luarr?*  Ill  -ii'rili/.i'il  ;i:i(i/,i'  ;wii  mchr-  -■iiiirc  a 


vi't  with  li.KHNI  iiii'i'i'iiric  clilnriilc.  tli 


Hiiiall   |'"l  •      sti'iilizi'tl 


ahsiirtifiit  cuttiiii.  Iioili  I'Vo  Ix'iiiK  >'  cuvitimI.  atu'  •  '  .mlt'  Ik'IiI  in 
jilacc  liy  strips  of  isingla>  ur  atliir^i\i'  pi  islcr  applied  as  i'.-'InWM: 
Thf  first  strip  ^>us,s«'s  dvit  ImiiIi  lirfssincs  from  tciiipli'  to  tcinpli'. 
A  sccofiil  strip  j.is.-i's  fri'iii  tin'  rlitt'k  of  ihr  iipcratcii  side  Upward 
and  iliu.ird  art'oss  the  pad  omt  iIh'  oprr  Ii'd  eve  to  iiic  fonlirad 
ovtT  ilii'  snind  i-yc.  A  tliird  passi-s  fmni  Ih-'  ciicck  of  tlii'  sound  side 
across  tli<'  pad  over  that  I'vc  to  the  forrhcad  over  the  oporati'd  eve. 
(Fiji.  -Ml)  <  Ivrr  tliis  is  placed  a  mask  made  of  some  li^ht  stiff  mate- 
rial, to  protect  the  eve  from  accidental  injmy.  The  hands  of  the 
patient  may  Ih-  fastened  liy  a  strip  of  handap'tied  to  each  wrist  and 
to  the  post  at  the  foot  of  the  hed  oil  the  same  side,  these  strips  lieilift 
just  short  eiioiijih  to  prevent  the  patient  touching  th"  eyes  with  the 
liand. 

The  writer  prefers  the  almve  dressiii);  to  the  roller-liaiidajie,  because 
it  is  easier  to  ipply,  do«T«  not  necessitate  raising  the  patient's  head, 
and  is  cool,  clean,  and  eoinfortalile.  It  makes  snflicieiit  pressure,  and 
this  cannot  lie  inerea.sed  liy  tiirniiif;  the  head.  The  strinns  to  the 
mask  can  h"  e;isily  insiini.'iied  under  the  |)Mtii'nt's  head  without 
inii\inn  th'-  head,  and  should  lie  of  unequal  l''iiKth.  so  that  the 
knots  will  be  mi  the  side  of  the  face  next  to  the  operated  eye. 
In  this  position  the  patient  will  not  !!'•  on  them,  and  they  are 
acc«'ssi!ile. 

'.i.  l-;.xTHv«'Tio\  wrruoir  ikidi'ctomv.  ..r  .-iinple  extract'on,  is  the 
<iperation  of  selection  by  many  surjfeoiis  of  hiifre  experience.  It 
leaves  the  eye  mo,-e  natural  lookinjr — indeed,  in  some  cases  it  cannot 
be  told  that  an  operation  has  been  done  on  the  eye.     Hut  it  let*  never 

I II  shown  that  the  visual  results  are  better  than  by  the  i-ombined 

method,  while  its  |ierform.ince  reipiiris  more  operative  dexterity, 
and  convalescence  is  apt  1o  be  interrupted  by  certain  comiilications 
which  do  not  obtain  in  the  combined  operation. 

The  same  instruments  are  rei|uired  as  for  the  conibini'd  operation. 
Till'  operation  is  performed  in  the  same  way  u[i  to  the  -laij"  of  makiiif; 
the  iridectomy,  except  that  it  is  import. int  that  the  incision  lies 
within  the  clear  cornea.  Tne  cystotome  is  introduced  immediately 
after  the  incision  is  comp!"ted.  and  the  ca|isnle  cut  as  already  d(- 
scribed.  The  speculum  may  or  may  not  Iw  removed  at  this  time. 
,uid  the  li-ns  delivred  as  .ilrejidy  described,  i'articles  of  lens  matter 
are  coaxed  into  the  pupil  and  thence  out  throujih  the  wo'iiid,  :is  in 
the  other  iperation.  The  iris  is  then  carefully  repl.iced  by  strokin<: 
with  a  spatula.  I*'  it  I'efuses  to  stay  in  position,  but  jirolapses  in 
pite  ot  beiny.  reduced,  a  portion  of  it  should  \w  excised  i iridectomy >. 


Th.- 


Isrnised  .ir  u-.rv.  \:\-  delivery  "f  the  lens  that  V 


is  best  to  excise  the  bruised  part.  ( )therwi.se,  e.serine  fV  gr,  to  1  nz.i 
may  be  insiilleil  to  keep  the  iris  drawn  inward  from  thf>  wouml, 
and  the  dressing  aiiplii'd. 


rBt.1 


DlSKASes  <>F  TitK  ril\sT\Ll.ISK  LESS. 


5i:. 


ModificatioM  of  the   Operation,     lli--  orijrinal  (•alunict   cxtnictioii 
:is  vvliat  \^  kiii.un  u.s  ilie  li  ii'  ()|MT;iti..ii,  tlu-  incision  (•(.iiipnsing 


was  vvliat   is  known  a- 

one-half  of  tlic  lorncul  circiniilrrcnct 


varionsly  nMHiificil,  so  as 

oiK-half  of  thf  forn<-a.     A  '.\ i.  Hap  i 


riic  length  of  liiis  lias  iM'cn 
to  iiicliitle  any  portion  from  one-fourth  to 


i^  popular.     \  very  iiiiportaiii    ii 


.  r  '"short  Hiip,  "  us  it  i.'*  railed, 
liticatioii  was  (iraefe'.s  [n'riphital 


line.ir  incision, 
corneal  margin  am 


The  knife  was  eiiteicl  at  a  jioint   I  mm.  from  ilii 
'ent  to  its  summit,  and  brought 


1  2  mm.  Iielovv  a  tar 


Ixnit 


nut  at  a  -imilar  i.oint  on  the  other  .-ide.     The  inciMon  was  a 
III  mm.  long,  t.nd  hut  slightlv  curved.     Iridectomy  wa.s  always  done 
The  oiHTatiou  is  not  popular,  Inraiise  the  (    '   'metiva  is  cut  tn-ely 
and  bleeds  to  all  annoving  degree,  and  the  i.,,Mtion  of  the  woim 


I 


favors  loss  of  vitrei 


lus  and  cvcli'is.     .Mention  ma: 


l)c  iiKide  of  the 


Instead  of  delivering  i 


downward  incision,  and  of  <ine   lying  in   tlie  coriua   and   near  its 
centre.     These  are  nirelv  used. 

he  lens  by  pres.-^urc  below  with  a  spoon,  the 

1  and  the  incsMire  made  vvitli  the  Kiwer  lid. 

be  irrigated  to  remove  fragments  of  the 

iiid.      i'his  is  done  by   specially  eoli- 

I  and  flattened  points  made  of  gold 


icculum  may  Ix'  reniovei 
The  anterior  ciuimber  mav 
ns  cortex  which   remain   1 


slructed  svi-inges  haviiiir  (■mve( 


ilulion,  which  should  be  warm 


rhel>e>t  fluid  is  a  O.t)  |>er<'ent.  saluH' so  _ 

Mud  of  course,  sterile.    Boric  acid  may  U-  used,  but  stronger  solutions 

I'his  method  is  not  much  in  vogue,  lis  it 


sill 


damage  the  cornea. 


i-  somewhat  tnmblesome  and  not  s])ecially  advantageou 

iH'tween  the  simple  ami  combined  i       hods  has  been  i 


iiimisi 


.\  con 

•ITected 


une  o|ieiMlors 


follow* 


in: 


lead  of  grasping  'he  iris  at   it 


illarv  l>or(!er  with     'le  iris  forceps,  withdrawii 


idecfomv.  a  smal 
il 


id  of  iris  is  pii 


■ked 


up 


midv 


t  of  that  membrane  and  its  pu) 


)illarv  border,  draw 


uni 


■ut  off. 


so  as  'o 


leave  a  small  hole  in  the  iris. 


■aves  a  round  j)!'  lil,  and  by  jitTording  a  ] 


assage 


liumoi  from  the  posterior 


to  the  anterior  cliamber  i. 


ii' 


I  making 

the 

I. 

!  (   fion 

i/li.H)US 

inieal 

r)f  till 


^.mml,  1-  tiM.uglit  to  be  less  likelv  to  be  followed  by  prolai).se  oMIu 
iiis.  In  .ertaiii  ca.ses  where  j.rolapse  of  the  vitn'ous  is  especially 
;i|it  to  occur,  or  as  an  extraordinary  precaution  against  prolapse  ■• 


o 


f 

f  (  )     t  KIWI  ,     'H      iir*     iiii     '    .-VI  »  i»"i  ^»«">"  /       J    ■      -      .-         r-  .  . 

th.'  iris  after  the  simple  o))eration.  Kalt  has  proposed  the  cornea 
-litch.  It  is  of  tine  .silk,  and  is  inserted  before  making  the  r',,r.,eal 
Micisioii  in  the  same  nianiKT  .'is  the  beniberi  intestinal  sut-ir  i.-^  in- 
M.rted.  .\  tine  rounded  iieiMlle  is  used,  and  the  central  loo,,  >  left 
vrry  long,  so  that  it  can  be  irawn  out  of  the  way  of  the  instruments 
u^ed  during  the  o|KTatioii.  After  the  cimipletion  of  the  operation 
-he  ends  of  the  suture  .ue  drawn  taut  an<l  tied.  A  portion  ol  the 
Ulterior  capsule  mav  be  !.mo\.-d  bv  specially  devised  forceps,  or  b^ 
iris  forceps.  This  isdesirable  if  the  capsuK'  is  thickened.  An  attomi.t 
^liouKl  be  made  to  make  a  more  or  h  -  circular  cut  with  the  cystotome 
I  this  procedure  is  contemplated. 

Some  operators  omit  the  capsulotomy,  and  attempt  to  rupture  the 
iniuile  of  Zinn  aiul   remove  the  lens  in  its  capsule.    This  is  done  by 


ol« 


THE  EYE. 


pressure  with  the  spoon  at  the  inarjiiii  of  tlio  cornea.  It  renders  loss 
of  vitreous  more  proliaiile,  l)Ut  when  sueeessful  leaves  a  pei.';'ctl)' 
dear  pupil.     It  is  not  much  in  vogue. 

Choice  of  Operation.  The  safest  method  is  that  of  preliminary 
iridectomy,  followed  by  removal  of  the  lens  after  some  weeks.  The 
patient  is  suhjected  to  the  danjjer  of  two  operations,  but  the  operator 
w'll  have  ijaineil  the  patient "s  confidence  and  some  knowledge  of  his 
beliavi(.r  and  that  of  the  eye.  It  should  certainly  be  done  if  the  other 
eye  has  been  operated  on  unsuccessfully. 

The  choice  iR'tween  the  wo  i)rinci|)al  methods,  with  and  without 
iridectomy,  is  a  matter  on  which  o])inions  ditfer.  The  occasional 
operator  had  better  use  the  former  method,  since  it  is,  on  the  whole, 
easier  to  perform,  and  the  visual  results  are  (juite  as  good  as  by  the 
simple  method.  It  is  well,  at  any  rate,  to  make  the  cori'cal  incision 
as  above  described,  and  do  the  iridectomy  if  delivery  of  the  lens  is 
not  ea.sy,  or  if  the  iris  tends  to  prola|)se.  When  the  iris  is  rigid  or 
in  the  least  di.scolored,  ,:r  if  the  patient  is  restless,  or  if  the  incision 
has  been  placed  other  than  within  the  clear  cornea,  it  is  better  to  do 
the  iridectomy  :it  once,  as  the  iris  is  likely  to  jjrolapse  and  necessi- 
tate its  performance  later,  and  prolong  the  healing. 

An  operator  who  is  not  ambidextrous  should  take  his  position  in 
front  and  at  the  left  side  of  the  patient  in  operating  on  the  left  eye, 
and,  inserting  the  knife  with  the  right  hand,  cut  ujjward — /.  c.away 
from  himself.  To  av.)id  the  necessity  of  assuming  this  position, 
angular  knives  (Fig.  '2!)!))  have  been  devised,  by  which  the  incision 
is  made  l)y  entering  the  cornea  to  its  njusal  sid(\  They  are  seldom 
used. 

Accidents  during  the  Operation.  The  knife  may  be  inserted  upside 
down.  It  should  be  turnecl  in  the  wound  and  the  o|M'ration  ])roce«'(|e(l 
with,  or  the  knife  may  be  withdrawn  and  the  operation  postponed. 
.\s  (he  ai|ueous  is  lost  by  withdrawing  the  knife  and  the  iris  and 
the  cornea  lie  in  contact,  the  knife  caimot  be  reitiserted. 

The  iris  may  fall  ovit  the  edge  of  the  knife.  By  raising  the  knife 
it  may  bi' disengaged :  but  if  not,  the  incision  should  be  completed, 
the  fold  of  the  iris  being  cut  through.  Then  with  the  iris  forcejis, 
the  cut  jjortiou  of  the  iris  is  drawn  out  and  the  wound  made  as  nearly 
an  ordinary  iridectomy  as  possible. 

Loss  of  some  of  the  vitreous  liumor  is  a  commo'i  accidetit.  It  is 
rendered  less  :\yX  to  occur  by  removal  of  the  speculum  at  the  com- 
pletion of  the  capsulotoiny.  If  this  is  not  done  and  a  bead  of  vitreous 
presents  in  the  wound  at  any  stage  of  the  operation,  the  speculum 
should  at  once  Ix'  removed  and  the  i)atient  allowed  to  rest  a  moment. 
If  the  lens  has  not  been  extracted,  the  attem])t  to  deliver  it  by  ])r(»s.s- 
ure  in  tile  usual  way  would  probably  result  in  loss  of  the  vitreous. 
Therefore,  no  pressure  should  be  made  on  the  l)all,  i)ut  the  lens  should 
be  removed  by  the  wire  loop  gently  passed  through  the  wound  and 
under  the  lens.  Lo.ss  of  vitreous  usually  occurs  aftir  delivery  of  the 
lens.     Fluidity  of  the  vitreous  or  a  sudden,  voluntary  sijucezing  of 


DISEASES  OF  THE  CRYS'j.     LLINE  LCXS 


517 


Ili(>  musolos  around  the  oyo,  or  an  involuntary  contraction  of  the 
recti  muscles,  may  cause  the  loss  of  a  consiilerahle  amount  of  vitreous. 
If  this  's  not  suiHcient  to  cause  collapse  of  the  globe,  it  is  usually 
not  a  serious  matter  and  recjuires  no  treatment;  but  if  the  eyeball 
collapses,  warm  sterilized  salt  solution  (0.6  per  cent.)  should  be 
injected  into  the  eye  by  a  j)i{K'tte  introduced  through  the  corneal 
wound,  until  the  ball  resumes  its  rotundity.  This  will  generally  pre- 
vent any  permanent  ill  effect  from  the  accident.  If  the  wound  is 
too  small  to  allow  the  easy  passage  of  the  lens,  it  should  be  enlarged. 
This  can  be  ilone  by  a  blunt -pointetl  knife  (Fig.  .S07)  or  fine  blunt- 
pointed  scissors,  such  as  Stevens'  tenotomy  scissors.  Under  no  cir- 
cumstances should  the  lens  be  forced  through  a  wound  which  Is 
evident Iv  t(K)  small. 

The  lens  may  be  dislocated.  This  is  usually  done  in  the  attempt 
at  capsulotomy  when  the  capsu'e  is  thick  or  tough  antl  the  suspen- 
sory ligament  frail.  The  dislocation  is  generally  backwanl.  The 
lens  should  be  caught  by  the  wire  loop  passed  through  the  wound, 
and  gently  drawn  from  the  eye. 

Hemorrhage  into  the  eye  may  occur  from  the  cut  iris  or  from  the 
rupture  of  a  choroidal' vessel  ilue  to  lack  of  support  to  these 
tissues  which  oi)ening  of  the  eyeball  entails.  The  former  i.s  usually 
a  trivial  matter,  the  hemorrhage  ceasing  spontaneously  or  being  made 
to  cease  by  com|)resses  wet  with  hot  ^^^  ^^^ 

Mhtise-ptic  "solutions  being  applied  to 
the  closed  lids.     Blood  left  in  the  an- 
irrior  chamber  at   the  termination  of 
I  lie  operation  may  be  exjjccted  to  ab- 
sorb in  twenty-four  to  forty-eight  hours, 
llemnrrhage  from  the  choroid  is  fatal 
1(1  tiie  eye.     The  patient  at  any  time 
alter  the  completion  of  the  corneal  in- 
risiiiii,  or  even  several  hours  after  the 
o|i(Tation    is    finished,    complains    of 
-cvere    aching    pain   in   the  eye,  and 
tliere    occurs    gaping   of   the   wound, 
then  lo:  ■  of   vitreous,  and  a  free  How 
:.f  blood   filling  the  ball     nd  pouring 
Until    the    wound.      .\   compress    and 
liMiiuagi'  should  be  applied,  a  hyjioder- 
iiiicof  morphine  given,  and  the  jiatient 
made  to  sit  up.    The  bleeding  will  cea.se 
in  from  a  few  minutes  to  a  few  hours, 
hut   the  eye  is  alwavs  irretrievably  hist,  and  subseiii.ently  shrinks, 
lis.  ■"ilO.")    The  paiii  may  continue  to  such  a  degree  as  to  justify 
'iiucleatiiin.    The  accident  is  rare. 

Sniiietimes  after  the  cataract  operation  the  ])atient  will  develop  a 
niaiiiacal  con<lition,  probably  due  to  the  combined  mental  effect  of 
nervousness  from  operation,  exclusion  of  light,  and  the  lack  of  any- 


Speclmen  of  chorolilal  hemorrhage 
following  caUniet  exiraciion.  The  globe 
is  filled  with  blond,  anil  the  retina  and 
vitreous  have  been  cupelled.  The  darlt 
line  is  the  choroid,  which  has  been 
everywhere  torn  loose  ,lifc  tl«).  (Pre- 
pared by  Or.  E.  S.  Thomson,  in  the  labiv 
ralory  of  the  ManhatUn  Eye  and  Ear 
Hospital.) 


518 


THE  EYE. 


tiling  to  ocotiiiy  his  attention.  It  is  treated  by  sedatives,  allowing 
him  to  use  llie  imoi>erat('d  eyt %  and  l>y  having  someone  remain  by 
his  bed  to  talk  to  him  and  otherwise  "  kcH-p  him  company."  Patients 
aeeustonied  to  the  free  use  of  alcohol  frtMiuently  develop  delirium 
tremens  after  this  oix^ration,  as  after  other  surgical  operations. 

The  After-treatment  of  Catanwt  Extraction.  In  a  cas(>  which  runs  a 
normal  course  the  first  thing  to  be  ob.xerved  is  closure  of  the  wound 
and  reformation  of  the  anterior  chamber.  .\s  lont;  as  jjatency  of 
the  wound  ptTtnits  the  aciueous  to  How  away  the  anterior  chamlK-r 
is  empty  a  td  the  iris  rests  against  the  corncii.  Closure  of  the  wound 
is  shown  by  accumulation  of  aiiueous  forcing  the  iris  back  to  its 
normal  position.  I'ntil  this  hapiH'iis  we  nmst  feel  some  apprehension 
of  |)ossible  infection,  and,  in  the  sim|)le  o  )eration,  of  prolapse  of  the 
iris.  Closure  of  the  woimd  usually  occ  irs  within  twenty-four  to 
thirty-six  hours,  .\tropine  may  be  used  i'limediatelv  after  the  opera- 
tion in  cases  where  iridectomy  is  done:  but  after  the  simple  operation 
should  not  be  used  until  the  wound  h;is  closed,  for  fear  of  inducing 
])rolapse  of  the  iris.  The  eye  should  be  dres.sed  daily,  and  the  con- 
dition of  the  lids  ol  served  for  swelling  or  other  indications  of  inflam- 
mation. The  lids  should  be  separated  and  the  ball  ins|)ected,  too,  and 
in  cases  done  without  iridectomy  the  wound  should  be  looked  at  to 
see  if  i)rulapse  of  the  iris  has  ()ccurre<l.  As  soon  as  the  wound  doses 
the  p.itient  i";iy  i)e  allowed  to  sit  up  and  the  sound  eye  left  uncovered. 
.After  fortv-eighi  hours  inire  the  dressings  may  be  left  off  and  dark 
gin.sses  or  i  sliadi  substituted.  Coiilinement  to  the  room  is  necessary 
for  at  least  a  week,  and  atropine  •<houiil  be  kept  up,  usually  three 
times  a  day,  until  tlie  eye  is  entiii'ly  free  from  redness.  The  (n'es 
should  not  be  used  for  reading  or  other  near  work  before  this  time. 

The  immediate  or  early  use  of  atropin.-  after  cataract  extraction 
is  justitii  li  by  the  freijuency  with  which  the  operation  is  followed  by 
at  least  a  mild  di  gree  of  iritis.  We  Mini  to  secure  dilatation  of  the 
pujiil  before  tiiis  occurs,  which  is  ueniTally  about  the  second  or  third 
day,  or  later.  We  observe  injection  of  the  ball,  especially  in  the 
pericorneal  zone,  slight  pain  and  tenderness,  photophobia,  aiid  a 
tendency  for  the  iris  to  adhere  to  portiniis  of  the  cajisule  and  any 
remaining  frMgiiicits  of  lens.  In  favorable  cases  these  symptoms 
disappear  in  al)out  two  week>, 

I'atients  coinjihun  bitterly  of  p.iin  in  I  lie  li.ack  when  confined  to 
:he  bed  in  tlie  proi'c  position  fur  twelve  hours  or  longi'r.  This  may 
be  n'iicved  l>y  slippuig  a  small  pillow  under  the  sntall  of  the  back, 
or  i)y  Mirnio'!;  the  i)atient  gi'ntly  on  the  side  away  from  the  operated 
ey^  (ntii  tin  wound  closes,  only  food  which  dois  in.*  re(|uire  chewing 
sho;ild  be  .illuwfil.  and  thi-  patient  should  be  made  to  use  the  bed- 
p.in  uid  ui  nial  if  pofsible  rather  than  rise  or  sit  up.  The  open  method 
of  treatment,  cir  thai  of  placing  no  dressing  at  ,ill  on  the  eye  proposed 
by  Hjort,  has  not  foinid  followers. 

Anomalies  of  Healing.  Delayed  closure  of  the  wound  may  result 
from  entanglement  of  a  tna  of  capsule  or  other  foreign  matter  in  the 


DISEASES  OF  THE  CRYSTALLINE  LESS. 


oiy 


wound.  If  tiot  dosed  in  thirty-six  hours,  can  ful  search  should  be 
made  tor  sucii  cause,  and  th.-  particle  removed  with  forceps.  1-re- 
.,uently  the  wovuul  heals  .sh.wly  from  a  i)oor  .state  ot  nutrition  or 
from  no  api)arent  cau.se.  Conjunctivitis  with  discharfje  may  arise 
from  the  action  of  the  occlmhnp  i)anda(ie.  The  dressinps  .shoul.l  Lh- 
li.rlitened  or  left  off  entirely,  and  the  eye  fre(|uently  irrigated  with 
al)oric  acid  solution.  If  the  discharge  does  not  cease,  the  lids  shouh 
l.e  everted  and  a  solution  of  nitrate  of  silver  (4  gr.  to  1  oz.)  applied 
to  the  conjunctiva.  Kven  if  the  wound  is  open,  this  siiould  he  done, 
lis  the  risk  is  less  than  that  of  allowing  the  .lischarge  to  c<intmue. 
If  the  wound  has  closed,  the  (lanfcr  of  infection  is  lessened.  Intis 
occurs  very  fretiuently.  It  usually  yields  to  atropine,  hut  if  severe 
may  recjuire  re.st  in  ImiI.  the  adilition  of  cocaine,  leeching,  ice  coin- 
jiresses,  and  antiphlogistic  doses  of  mercury.  Ice  acts  far  bettor  m 
these  cases,  which  a'-e  >raumatic,  than  heat. 

Iridocvclitis  an  '.  iriilochoroiditis  are  to  be  treated  m  the  same  way. 
They  an-  much  more  serious  than  simi)le  iritis,  and  may  result  in 
destruction  .if  the  eye  by  sub.se(|uent  atrophy.  In  cnnmon  with 
iritis,  thev  tend  to  form  exudations  in  the  pui)illary  space,  the  mem- 
branous secondary  cataract  resulting  being  very  tough  and  dense. 
In  iridochoroiditis  in  i)articular  we  notice  chemosis  of  the  conjunctiva, 
and  in  all  the  intlammatorv  states  which  may  follow  the  cataract 
oiK-rations  the  lids  swell,  especially  at  tiie  inner  cantiuis.  In  the 
absence  of  this  .sign  an.l  discharge  we  may  feel  rea.sonably  sure  of 
liie  absence  of  undue  reaction.  _        r   i       •       i 

i'rolapse  of  tlie  iris  is  the  nu  st  common  compl'-.-ation  of  the  simple 
ni cratioi,  and  constitutes  the  greatest  objection  to  it.  It  occurs  m 
In.m  .'}  to  10  per  cent,  of  cases.  Its  (k  ■urrence  is  often  announced 
bv  a  shari)  i)ain,  but  as  often  bv  no  unusual  sensation.  I'  diseov- 
.■red  before  infiammatorv  action  has  sealed  it  hrmly  to  the  cornea, 
tiie  i)rolai).se  should  be  excised  and  the  margins  of  the  colol>oma 
dressed  back  into  the  eve.  It  is  hardly  wise  to  rei)lace  the  prolapse 
and  trv  to  hold  it  in  place  bv  eserine.  though  this  is  sometim.'s  done. 
Ii  tlie"  prolapsed  portion  is  Hrmlv  aled  in  the  wound  by  mdam- 
mation  it  mav  be  incised,  tmicheil  with  the  actual  cautery,  or  left 
.done  It  wilfeventuallv  shrink  and  Hatten,  so  as  to  have  no  trace 
I. in  a  small  pigmented  spot  in  the  wound:  but  as  .■ntaiiglemeiit  of 
the  iris  is  apt  to  leail  to  iritis  or  iridocyclitis  'Kig.  ;{n).  or  form  a 
path  for  infection,  it  should  l)e  excised  when  |)ossibh'.  Otherwi.se, 
to  let  it  alone  is  preferable  to  incision  or  the  use  of  the  cautery. 

Septic  infection  is  a  dreaded  and  u.-^ually  fatal  comi'lication.  It 
mav  arise  in  the  wouiiil  or  from  the  iris  (suiipurative  iritis  .  or  more 
rarely  in  the  vitreous.  The  tirs^  is  usually  by  infection  In.m  without 
after  operation,  the  other  two  torms  by  operative  infection.  Sup- 
puration of  th"  wound  is  most  common.  It  is  annoimced  by  pain 
■  iiid  marked  infiammatorv  svmptoiiis,  and  the  wound  is  toiind  to 
I. resent  swollen  edges  and  a  vellowish  infiltration  along  its  c(mrse. 
Till-  mav  spread  toward  the  corneal  centre  or  around  the  cornea, 


520 


THE  EYE. 


like  a  rinn.  Tlic  whole  cornea  Ixm-iiiiics  op.'Kiuo,  and  usually  slouftlis 
off.  The  eye  sul)se(|uently  shrinks.  Soiiietiiiies  the  suppuration 
is  limited,  and  healiiifi  may  oceur  with  some  remaininjj;  sijiht  or  a 
po.ssiliility  of  ohtaininn  some  hy  operation.  The  treatment  should 
consist  in  thoroujih  t're(|ueiit  cleansiii';  of  the  eye  with  1 :  10,(KH) 
mercuric  chloride  and  the  application  of  tiie  actual  cautery  or  pare 
carbolic  acid  to  tiie  line  of  the  wound.  Tiiese  measures  may  he 
repeated.  Suhcoiijunctivai  injections  of  mercuric  chloride  may  Im' 
tried,  hut  are  very  painful  and  usually  useless.  Hut  the  coinse  of  the 
condition  is  nearly  always  unchecked  hy  any  treatment.      If  th'  sup- 


l'riilai«c  nf  in-  hIIit  I'atKrii'l  i-xtractiim.  Thi'  ciiriu-nl  lip  nf  11, |.  u.iiiii.i  iv  iiilillmtuil  iiiiii  ilis- 
placi'd.  Thf  liniiT  )«rl  C.I  ihi'  iris  i»  ilrauii  up  Iry  Un' •■xinlatc,  Kiiucl.'iHiun  i.ii  llif  ir-nili  ilay  l.il- 
limiim  ilii- i-xinii'iioii.  •  l.\  (i'n'i«n'il  liy  Iir.  K.  S.  Th(jji,-c.n.  ill  tbe  labomiiio  ul  Uiu  Maiiliaii.it' 
Kyt'  HU'I  F.ar  llo-'i-ital.) 


puration  is  from  tlif  iris,  or  if  pu-  is  seen  within  liie  anterior  ( liamlici-. 
the  wouml  shouiil  III-  opened  and  the  anterior  chamber  irri^taled 
with  a  boric  acid  solution  The  introduction  of  powdered  iodoform 
or  rods  made  of  iodoform  and  >;i'laiin  ha^  been  recently  tried  in  this 
condition,  and  promises  lietler  results  than  any  other  Iri'atnienl. 
If  the  infection  is  primarily  in  the  vitreous,  injections  of  mercuric 
chloride  into  th.at  boily  may  be  trii'd. 

Traumatic  stripeil  keratitis  is  the  name  t;iven  to  a  foiin  of  corneal 
intlammation  manitested  liy  p.arallel  frray  lines  runninj;  in  the  corneal 
substance  from  the  wound  toward  its  centre.     It  is  due  to  bruisiuf: 


DISEASES  OF  THE  t'HYSTALLISE  LESS. 


;V21 


of  tho  antt'rior  Hap  In-  tin'  lens,  aiul  is  caused  by  a  too  small  wound. 
It  subsides  in  a  few  days. 

Occlusion  of  the  pujjil  l)y  the  iris  is  due  to  entanglement  of  the 
iris  111  the  corneal  wound.  It  may  occur  after  either  the  simple  or 
conihined  operation.  The  iris  is  stretched  over  the  entire  bottom  of 
the  anterii  ;•  ,  hamber,  or  a  small  jjiipillary  o|M'ninn  may  be  left  near 
tiie  wound.     The  treatment  is  by  iridotomy. 

( 'ijstoid  ( 'iaitrix.  This  is  a  bulginp  of  a  portion  or  all  of  the  corneal 
wound,  due  to  the  cicatricial  ti-sue  yieldinft  to  intra-ocular  pressure. 
The  adjacent  conjunctiva  is  sometimes  involved.  It  is  to  Im-  treated 
by  a  firm  compression  baiidajre  ivorn  for  several  weeks.  This  some- 
times fails  to  relievo  the  condition,  under  which  circumstances  the 
site  of  the  oriftinal  wound  may  be  exposed  by  tuntiiifi  u|)  a  small 
conjiuictival  flap,  the  leaking  jMiint  found  and  touched  with  the 
g:\lvanocautcry. 

(Ilaucoma  .sometimes  develops  after  cataract  extraction,  probably 
beiufi  induced  by  the  u.se  of  atropine  in  eyes  predispo.sed  to  the 
disease.  It  is  to  Ik-  treated  on  the  .same  principles  as  glaucoma 
occurring  under  other  circumstances,  but  as  a  rule  yields  to  the  use 
of  esciine  and  heat.  If  not,  an  iridectomy,  sclerotomy,  or  even  ,sym- 
IiMthc'toiii\',  may  have  to  l)e  done. 

Secondary  or  After-cataracts.  In  a  majority  of  ca.ses  there 
ii'inains  after  the  removal  of  th"  lens  a  membranous  opacity,  called 
secondary  or  after-eataract.  This  consists  of  the  posterior  ca|)sule, 
with  ]Missibly  some  of  the  anterior  capsule,  ai  d  it  may  1h'  thickened 
liy  the  deposit  on  it  of  intlammatorv  exudate  from  the  iris.  Secoiid- 
iiy  cataract  varies,  therefore,  in  lensity  from  a  filmy  membrane 
whicli  offers  no  ob.stacle  to  vision,  to  a  d(iise,  tough  membrane  coin- 
|iliirly  abrogating  useful  vision.  Provided  the  vision  is  not  better 
than  2().")0  and  the  reduction  of  vision  is  not  manifestly  due  to 
-oMii'  other  cause,  the  membrane  should  be  divided.  The  operation 
i-  known  as  (•;ipsulotomy.  It  should  not  be  done  until  the  eye  is 
.■iiiiiriy  free  from  the  redness  and  inflammation  following  the  primary 
'i|ieralioH. 

Iiisiriiiiit fits.     S[¥'cuhini   (Fig.   2!KI),   fixation   forceps  (I"ig.  291), 

neeille   .'Unl 


knife 


die  (!• 


ijr.  - 


i'li'  1 


Treatment.    The  |)Upi!  is  dilated  witii  atropine,  the  eye  aiuesthetized. 


ilie  YuU  -I'panitiil  hy  the  s| 


X'cuhin 


l)s.     .\rtifii  111  light  is  preferai)le. 


1,  and  the  eye  grasped  with  fixation 


hirci 

die  field  of  operation  bv  means 


and  sliould  be  concentrated  on 
•adiiig-glass  held  by  an  assistant. 
The  knife  needle  is  entered  near  the  corneal  margin,  and  the  membrane 
penetrated  and  cut  through  in  such  a  manner  as  to  leave  an  opening 
III  the  centre  of  the  pupil.  This  is  \ctv  well  accomplishecl  liy  making 
'he  incision  ill  the  form  of  an  inverted  a.  the  totigue-sha|M'd  flaj) 
iMing  imshed  b.'ickward  by  the  needle  before  it  is  withdr.iwn  from 
die  ev.      If  too  rigid  to  ri'inain  lient  out  of  the  way,  it  m;iy  be  par- 

bv  a  third  incision.     The  cutting  edj:.' 


ally  divicled  acrr 

t'  the  knife  needle  should  be  extremely  sharp,  and  the  membraii 


522 


THE  EYE. 


fut  throiijrh  l>y  rapiil  short  siiwiiif;  strokes.  Tliis  is  <loin'  to  avoid 
traction  of  tlic  ciliary  hody,  .vliich  would  i)rol)al)ly  cause  cyclitis.  If 
tlie  nieinliiaiie  is  too  tough  to  cut  readily,  it  siiould  Ix'  transfixed 
tii-st  hy  a  needle,  then  the  knife  needle  entered  tiiroujth  the  oi)|)osite 
side  ot  the  cornea,  and  thrust  throufih  the  nieinbratie  near  the  needle. 
It  is  made  to  cut  away  from  this  point,  the  needle  actinji  as  the  pohit 
of  resistance,  to  protect  the  ciliary  Ixxly,  or  two  ii(>edles  may  1k> 
entered  on  opposite  si<les  of  the  cornea  and  made  to  pierce  tlie  mem- 
hraiie  near  tlie  centre.  My  approximatiiifi  the  handles  of  the  points 
separat",  the  cDriiea  at  tlie  site  of  [H'netnition  acts  as  a  fulcrum, 
and  the  menil)rane  is  torn. 


Flti.  312. 


IveucKvlic  iiitiltration  of  lens.  From  a  case  of  Irldocrclills  following  a  wnuml  In  the  ciliary 
region.  ■  luo.  (I'repareil  by  i»r.  K.  3.  Thomson,  in  the  laboratory  of  the  MuiihaltHii  Kye  and  Eiir 
Hoyj'ital.) 


When  the  pupil  is  small  and  uiuhlatablo,  Noyes  proposed  to  enter 
a  thin  cataract  knife  throuf^h  the  sclerotic  behind  the  ciliary  hotly, 
and  to  transfix  and  cut  the  meniltrane  from  behind. 

If  the  ])ui)il  is  occluded  by  drawiii}.'  the  iris  over  it,  this  sliculd 
l)e  ilealt  with  by  irldotomy.  The  iiici.xion  may  be  iiia<le  with  the 
knife  needle  or  with  Wecker's  scissors  (Fig.  ;{().')),  introduced  after 
making  a  sutticiently  large  corneal  wound  with  a  broad  needle  or 
keratonie.  The  scissors  are  irtrodureil  do-^ed,  <)|M'ned  in  the  anterior 
chamber,  and  one  blade  made  to  fx-netrate  the  iris.  The  iris  lying 
between  the  blades  is  then  divided,  usually  in  a  V  or  cross-shape. 


DISEASES  OF  THE  CR  YSTALLIAE  LEyS. 


-)2S 


After  the  (•(Uiii)loti(>n  of  (•:ii)sul<»t(tmy  or  iridotoniy  atKipiiif  if< 
instilled  iiiul  the  eye  covered  with  a  dressing.  The  patient  siioulil 
he  ke|)t  in  bed  for  twenty-four  hours,  and  the  least  sign  of  iritis 
should  he  |)ronii)tly  met  hy  ieeeiiing  ami  iee  compresses.  Otherwise. 
iiiH.immatory  products  will  s<Mm  fill  the  oiK'ning  and  nullify  the  effect 
of  tiie  operation. 

Arriilenh.  The  accidents  most  likely  lo  hap|KMi  are  infection,  glau- 
coma, intense  intiammatory  reaction,  and  detachment  of  the  retina. 
The  treatment  of  these  conditions  is  given  elsewhere. 

Aphakia,  .\pliakia  is  the  name  given  to  absence  of  the  lens,  and 
is  the  condition  that  exists  after  a  cataract  has  been  removed.  Its 
principal  characteristic  is  an  increase  in  the  refraction  of  the  eye  by 
the  dioptric  value  of  the  lens,  usually  lU  I),  or  12  I).,  loss  of  all  |jower 
of  accoinnuxhition,  and  in  cases  of  cataract  extract i<jn  by  the  de- 
velopment of  corneal  astigmatism  at  right  angles  to  the  direction  of 
the  corneal  incision.  This  astigmatism  is  great  at  first,  usually  from 
.",  I),  to  5  I).,  init  as  cicatrization  progres.ses  it  diminishes,  usually 
to  1  I).  Some  patients  possess  a  sort  of  |)seudo-acconunodation,  wliich 
is  generally  jx'rformed  l)y  s(|uinting  or  partially  closing  the  lids.  The 
refraction  should  be  worked  out  l)y  the  same  means  as  used  in  esti- 
mating refraction  under  other  circumstances,  and  reading-glasses  of 
:<..">()  D.  or  4  D.  stronger  than  the  distance  correction  also  given. 
Mifocal  lenses,  or,  if  only  one  eye  is  useful,  reversible  frames,  are  to 
Ik-  given.  The  strength  of  the  correction  for  near  work  must  be 
made  to  accord  with  the  distance  at  which  the  patient  will  u.se  his 
eves  most. 

Inflammation  and  new-growths  of  the  lens  do  not  occur,  although 
th<'  lens  may  be  the  seat  of  infiltration  of  leucocytes  in  cyclitis. 
(Fig.  312.) 


m 


CHAPTER    XI. 
GLAUCOMA. 

By  K.  THKACHKU  COLLINS,  F.R.C.S.  Exn. 

TiiK  term  '•  jrlaucoiiia  "  is  dcrivcil  from  tlio  drook  word  y/.a'jxo;,  sig- 
nifyiiij;  sca-prccii.  It  was  used  hy  Hippocrates,  ami  was  applied 
oriniiially  to  affections  of  the  eye  in  which  a  green  or  preenish-grny 
reHex  was  obtained  from  the  pupil.  At  different  times  the  disease  has 
ix'eii  resrarded  as  an  affection  of  the  crystalline  lens,  an  affection  of 
the  vitreous  humor,  and  an  effusion  hetween  the  retina  and  choroid. 
It  was  not  until  the  discovery  of  the  ophthalmoscope  in  1S.")1  that 
these  several  theories  respectinj;  it  were  found  to  he  untenable. 

.Mackeii/ie,  of  (ilasRow,  in  1S;{(),  first  drew  attention  to  the  increased 
tension  of  the  eye  in  glaucoma,  which  is  now  known  to  he  its  essen- 
tial factor.  .Vs  Wits  |)ointed  out  first  hy  von  (Jraefe,  all  the  other 
.symptoms  can  he  ex|)lained  as  the  result  of  increaseil  tension. 

(ilaucoma  may  now  he  defined  as  increa.sed  tension  of  the  eye,  the 
result  of  derangement  in  the  circulation  of  the  intra-ocular  fluid. 

A  green  retlex  from  the  pupil  is  not  always  present  in  glaucoma, 
and  it  may  i)e  met  with  in  other  conditions  in  which  there  is  no 
increase  of  tension. 

A  derangement  of  the  circulation  of  the  inlra-ocular  fluid  causing 
increase  of  tension  may  occur  in  a  variety  of  ways.  It  may  occur 
in  an  eye  which  in  other  re.xjM'cts  is  apparently  healthy,  or  it  may 
he  the  result  of  some  obvious  precedent  disease.  In  the  former  ca.se 
the  glaucoma  is  termed  pri)iiiir}i.  and  in  the  !;itter  sccoiiildrii. 

The  Mechanism  for  the  Maintenance  of  Normal  Ocular  Tension. 
Thi're  :ire  three  sorts  of  fluid  within  the  eyeball,  v.-iriable  in  amount: 
blood  in  the  bloodvessels,  lymph  in  the  lym|ilialic  spaces  of  the  uveal 
tract  and  the  perivascular  lymphatic  chamieis.  ami  the  intra-ocular 
lluid  in  the  aqueous  and  vitreous  chambers.  The  amount  of  blood 
in  the  inlra-ocular  bloodve.-jsels  is  sub.j(>ct  to  constant  variation  from 
many  ciuses.  such  us  alterations  in  the  blood  pressure,  changes  in 
the  shape  of  the  iris  and  ciliary  body,  and  varying  amount  of  pres.s- 
ure  from  the  surroimding  muscles. 

The  lymph  is  ilerived  from  the  bloodvessels,  and  its  amount  is 
dejiendeiit  on  the  blocil  pressure. 

'{"he  intra-ocular  fluid  containecl  in  the  aijueous  and  vitreous  chan".- 
bers  is  of  practically  the  same  con>istency.  Its  composition  is  esti- 
mati'd  as  <K»  per  cent,  water,  1  percent,  salts  and  extractives,  together 
with  a  trace  of  albumin. 


HI 


(lL.^uco^r,i. 


■»2o 


In  the  vitn'oiis  this  fluid  i-;  loiljicil  in  a  network  of  fihri's  much  Ukc 
water  in  a  sponp',  and  is  siirrnniiileil  by  a  iiyaloid  nictnhraii  ■.  It  is 
this  arranncmcnt  which  gives  to  the  vitreous  humor  it.-  gelatinous 
(•(insistency. 

The  inlra-oculHr  fluid  is  a  secn'tioii,  anil  not  a  mere  exudation  from 
llie  hloodvessels.  If  it  were  an  exudation,  it  would  contain  a  larpe 
i|uantity  of  albumin,  like  lym|ili. 

There  is  consi(|('r;ii)le  exix'iiniental  and  clinical  evideinc  to  siiow 
that  glaucoma  is  |iroduced  I'v  the  secretive  action  of  the  .'inthelium 
covering  the  ciliary  body.  'I"he  folds  of  the  ciliary  process  ])rovi(le 
,1  comparatively  large  epithelial  coNcred  surface  overlying  a  dense 
plexus  of  bloodvessels.  Then'  arc,  moreover,  uii  the  pigmented  layer 
numerous  little  tubular  reces.s's,  presmnably  giant's,  concerned  to 
some  extent  in  the  elaboration  of  secretion. 

Ivxperimentally  it  has  In^en  found  that  after  excision  of  the  iris  and 
ciliary  body  from  the  eye  of  a  nibbit,  the  .-iccretion  of  the  aipieous 
liinnor  is  arrested  and  the  vitreou.s  shrinks.  Also,  that  subcuta- 
!ieously  injected  fluids  tnake  their  app<'ar;ince  in  the  eye  first  at  th<' 
ciliary  body,  and  thence  spread  to  the   vitreous,  and  through  the 


iipil  to  the  anterior  chamber. 


Clinically,  we  find  that  when  the  pupil  lK>comos  clo.sod  by  a  com- 
plete ring  of  posterior  .synechia'  the  a(|UPous  humor  accuiiuilates 
behind  tlie  iris,  bowing  it  forward.  I'urther,  that  all  the  vascular 
structures  within  the  eyo,  other  than  the  ciliary  body,  may  be  absent, 
nr  h;ive  their  ves.sels  occluded,  without  alt-ration  in  the  amount  of 
the  intra-ocular  fluid  or  the  tension  of  the  eye  being  noted;  whiie 
destructive  process(^s  involving  the  cili.-iry  body  cause  shrinking  of 
liie  glolx'.  Tlni.-,  the  tension  of  the  eye  and  the  intra-ocular  .-ecretioii 
liave  been  found  miaitered  when  the  following  conditions  were 
present:  congenital  an(l  traunci::c  aniridia,  embolism  of  the  central 

irterv  of  the  retina,  congenital  absence  of  the  choroid.  The  tension 
'<'-.<>  al.^o  l)«"  i;  known  to  remain  increased,  where  all  the  bloodvessels 
<ui>plying  the  retuia  and  chdroid  nave  Ixcn  cut  through,  after  the 

per.ition  of  optico-ciliary-neurot(.my  performed   for  absolute  glau- 

.■^ome  of  the  secretion  from  the  cihiry  !)ody  pa.'i.ses  directly  forward 
between  the  iris  and  lens  into  the  anterior  chamlK'r.  The  main  exit 
I'lr  tluid  from  the  anterior  chamber  is,  a-;  iirst  [Toved  by  Leber,  at 
its  angle.  It  passes  through  the  sp;ices  of  Fontana  in  tlf  ligamentuni 
pectinatum,  into  the  canal  of  Schlennn  by  a  proc(\ss  of  iiltration.  .and 

turn  there  into  the  .anterior  ciliary  veins.     .\  certain  amount.  Nuel' 

h.is  >hown.  also  escajies  through  the  iris,  entering  the  openings  on  its 

.interior  surface,  which  are  situ.ated  mostly  near  its  ciliary  and  jjupil- 

!;iry  m;i:giiis,  then  into  the  iritic  veins  by  liltnition  through  their  walls. 

.\  part  "if  the  secretion  iif  tlu^  ciliary  body  pa.sses  to  the  vitreous 

iimor.     I'roiu  tiir-  vitreous  a  small  amount  of  fluid  may  escape  along 


'  Arch,  d  Ophlalrool .  April,  1900. 


? 


29 


THE  h  YE. 


tlic  lviii|(lijitics  aniiiiul  tlic  rcnlml  rcinii!  vosmcIs  in  tin*  nptic  norvr, 
or  hy  liltration  into  tlir  Inrjjfr  vcswls  ;li('in!<('lvc«:  inosl  linwcvi  r, 
after  pcrincatiiiR  tlic  anterior  li>  iloitl  iM'inhnine  ami  sns|M'ns(irv  lijra- 
nicnt.  |)a-H>  iltrough  the  lirciiniicntal  spac'  ami  [tiipil  into  tin- 
.•interior  ciianilH'r. 

In  a  liullow  sphere  (iisiemlcii  wiili  llniil  the  aiiimnil  "f  pre  ure  on 
the  \vall>  is  (■■|iial  at  all  |M>ints.  In  the  i-ye.  whieh  is  ihvideii  into 
two  chatnlwiv.  the  aijui'ous  and  vitreous,  by  a  diaphragm  consistitifr 
of  till'  lens  and  its  sus|H'nsory  ligament,  it  is  coiM-eivalile  that  the 
pressure  in  one  or  the  otlxT  initrht  1h'  trn'ater.  In  the  norniMl  eoii- 
ditioii  this  is  not   the  ease.     The  pressine  in  the  vitn-ous  chairiln-r 


The  kuk  •    >i  ilii/     ..ivrliir  chambur  In  a  heslthy  eyi',  »hii»  tiu  Ihv  canal  i>t  Seblemiu,  tbe 
ii):auientuui  linllnalinn,  ami  lympliatic  cryptii at  tip-  < .  rl|ihery  of  Uu  iris. 

and  in  the  all! "rior  ehaniber.  measured  experiinentallx  I>y  a  nianoni- 
I'lei,  has  Imi'ii  I'luind  lo  Im'  ecpial  in  eacii  to  a  cohnuii  oi'  mercury  about 
2^  luiii.  in  heifrht.  The  ei|nality  of  pressure  is  miimained  by  the 
p(i--ibic  iree  isc;ipe  of  thiid  from  the  vitreous  into  the  anterior 
ehanil"  1.  and  irrt-  esiape  of  lliiid   from  the  anterior  chamlier  out  of 

the  <-\\ 

In  spile  of  chanfies  which  aiv  constantly  occurring  to  alter  the 
amount  of  blood  in  tlie  iiitra-ocular  blood\issels,  in  the  normal  con- 
dition the  tension  of  the  eye.  as  estimated  by  the  linger  pn'ssurc. 
remains  practically  uniform. 

My  :;  mere  aciive  secretion  of  the  ciliary  body,  or  by  a  more  nipid 
.■s(.ipe  of  iluid.  llii'  eye  has  the  |towcr  of  adajitiiig  itself  so  as  tr 
maintain  an  eijuable  amount  of  jiressure  upon  the  structures  con- 
t.ained  within. 

It  would  seem  natural  le  suppose  that  tliis  regulating  power  which 
iiioMtains  ,,  uniform  degree  of  tension  is  the  result  of  nervous  in- 


J 


(ILAUCOMA. 


527 


tliicnrcs.     (hir  knowlcflKf,  iKtwcvcr,  of  tho  infliirnri's  of  tlic  ncrvitUM 
.•-vstiin  (HI  the  tciisiitn  of  flu'  (■>•«•  is  iit  pn-sfnl  far  from  (•oiu|)l('tc. 


Hill,  ii 


I  some  r('S| 


M'cis,  (Mmtni<lictorv. 


V«'  sliould  like  to  know  if  tin-  eye,  cut  off  from  all  iiillui-nct-M  pro- 
(liiii:  to  it  from  the  (•cn-hro-spiiial  or  sympathftic  nervous  system. 


IS  rap 


if  maintaiiiinjr  normal  tension 


riie  11  suits  of  the  openition  of  opiico-eiliary-neurotomy  offer  us 
-I'liie  eviiienee  on  this  point.  When  |>erforme<|  on  an  injured  eye  as  a 
prophyiaetie  against  sympatiietir  opiillialmitis,  the  tension  fn'(|uently 
Iteeomes  iliminished.  and.  in  some  eases,  tliis  diminution  of  'elision 


Ih>  the  di 


lit 


iti 


d  not 


d  bv 


eausec 

the  affection  of  the  eye  for  whieh  it  was  perfortned.  When  i«'r- 
lormed  on  eyes  with  absolute  Rlaueonia,  when-  presumably  the  chan- 
nels of  exit  of  Huid  from  the  eye  aif  clos«Hi,  the  tension  remains 
increased. 

Nervous  intiuences  may  [iroceed  to  the  intra-oeularstnictures  either 
ihrouRh  the  trigeminus  or  through  the  syni|)atlietic  nerves. 

The  ex|)eriments  of  dividing  or  irritating  the  trigeminus  in  ani- 
mals have  not  imxluced  uniform  results.  Some  observers  have  found 
itsdivi.sion  result  in  dhninished  tension,  and  its  irritation  in  increased 
tension  (I)onders),  while  others  have  concluded  that  its  division  or 
>hiiiulation  had  no  influence  on  ocular  tension  (W'egner). 

The  operation  of  nMiioval  of  the  (ia.sseriaii  ganglion  has  now  been 
performed  a  numlxT  of  times  on  man  for  the  relief  of  neuralgia,  but 
in  the  description  of  such  ca.ses  no  reference  is  made  to  its  etTect  on 
ocular  tension.  It  is  po.ssible  that,  unless  specially  looked  for.  some 
slight  variiitions  in  tension  may  have  Im-cu  overlooked. 

In  the  affrction  known  as  herpes  ophthalmicus,  which  is  <lue  to 
a  lesion  of  the  Gas,serian  ganglion,  diminution  of  ocular  tcn.sion  is 
sonietimes  noted. 

Kxperiments  on  animals  have  shown  that  section  of  the  cervical 
sympathetic  causes  diminution  of  ocular  tension,  while  irritation  of 
it  occasions  a  transient  increase  of  tensicm  (Wegner.  .\dainuk). 

Removal  of  the  superior  cervical  ganglion  has  lu'en  i>erfornied  in 
man.  in  patients  who  had  no  ocular  affection,  without  any  alteration 
ill  llie  ocular  tension  being  appreciable  ( F'.  V.  Burghard'). 

Uemoval  of  the  superior  cervical  ganglion  in  patients  with  primary 
■_'l:iuc<iiiia  sonietimes  reduc<<s  the  tension  (.I(mne.«co').  In  some  cases 
lit'  ))aralysis  of  the  cervical  symi)athetic  from  injury  or  pressure.  ,'\ 
-light  diminution  of  ocular  tension  has  Ix^eii  noted. 

In  cases  where  symptoms  of  stimulation  of  the  cervical  synijia- 
I  lietic  arc  present,  as  in  (Jraves'  disease,  glaucoma  has  not  been  proved 
to  1m'  of  unusually  fre(|uent  occurrence. 

.^Stimulation  or  removal  of  the  superior  cervical  ganglion  causes 
several  changes  in  and  about  the  eye,  which  it  is  conceivable  would 


Bnttah  MeiiUal  Journal.  October  io,  1900.  p.  1175. 
Wiener  kiln.  NViicbenschritt,  May  4,  1899. 


MICROCOPY    RESOLUTION    TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No    2i 


1.0 


I.I 


1.25 


;-iiiiiM  m 

"  lis  illlM 


1.4 


1.8 


1.6 


j£     /APPLIED  IM^GE     Inc 


^.■i-'-'.e^fe'.    New    T^'t.  't&Oi 

i,7'6i    -.8^       <JiQO      Phone 


528 


Tin:  EYE. 


tend  to  iiiHiiciiw  the  iiitra-ooular  pressure.  Tims  its  stiimilatioii 
causes: 

I.  Dilatatinn  oj  thv  piijiil,  wliieli  inijjlit  iin|)e(le  the  exit  of  fluid  from 
the  eye  l)y  iiarniwiiifi  tlie  oritices  of  the  lymphatic  spaces  on  the 
anterior  surfac' of  the  iris,  or  by  approxinfatinf;  the  root  of  the  iris  to 
the  hack  of  the  cornea  in  the  rejiion  of  the  spaces  of  l-'ontana. 

■J.  Incnii<al  hliiod  jirtssmr.  which  diininishes  the  amount  of  hiood 
in  the  eye,  and  so  lessens  the  amount  "i  its  contents,  hut  also  |)rohahly 
increases  the  amount  of  lymph  in  the  intra-ocuhir  lymphatics. 

;}.  I Hcrmsvd  scrrcllnii  jrmn  tin;  rHiiiri/  botlij,  which  tends  to  inerea.M' 
the  contents  of  tlu'  eye. 

-1.  ('onlnirlioii  oj  the  mistridlcil  iiin  ric  fihrcs  oj  Miillrr.  which  by 
compression  of  the  efl'erent  veins  c.in\infi  from  the  eye  delays  the  exit 
of  blood  from  it. 

l{emo\al  of  the  f;an}rlii;n  jinxhices  just  thi'  r(>verse  effect:  it  con- 
tracts the  pupil,  lowei's  blood  jiressure,  diminishes  .•secretion,  and 
allows  of  relaxation  of  the  muscle  Hbres  of  .Miiller. 

.\nother  factor  callin};  for  consideration  in  the  maintenance  of  nor- 
mal intra-ocular  tension  is  variation  in  the  composition  of  the  intra- 
ocular lluid.  It  has  to  escape  from  the  eye,  as  already  mentioned,  by 
a  i)rocess  of  hitration.  Containing,  as  it  does  in  the  normal  state, 
but  a  trace  of  albumin,  this  filtration  may  readily  take  place.  Should, 
however,  the  anterior  chamber  be  |)mictured  and  the  ai|ueous  luunor 
alloweil  to  escape,  the  fresh  aiiueous  humor,  which  is  formecl  much 
more  rapidly  than  under  the  usual  conditions,  is  found  to  contain  ;» 
considerable  (luantity  of  ;dl)umin,  and  will  conso<iuently  take  much 
longer  to  filter  out  of  the  eye. 


The  Effects  of  Increased  Tension  on  the  Various  Structures  of  the 
Eye  and  Their  Respective  Functions. 

Tiio  maintenance  of  the  normal  amount  of  intra-ocular  pressure  is 
most  essential  for  the  regular  performance  of  the  functions  of  the 
different  structuri's  com|)osing  the  eyeball.  We  shall  now  proceed  to 
descriiie  the  chaiifri's  which  are  proihiced  in  an  eye  as  a  result  of  a 
disturbance  in  the  intra-ocular  pressure,  resulting  in  increased  tension. 

Sclerotic  and  Conjunctiva.  A  sudden  onset  of  increased  tension 
.so  disturbs  the  iiitra-ocular  blood  circulation  as  to  cause  for  a  time  a 
general  congestion  of  the  ciliary  bloodvessels  in  thi'  sclerot'c,  and 
often  al-o  of  those  of  the  conjmictiv:i.  Ill  the  most  acute  cases  this 
congest-on  is  acci>mp;tiiied  liy  ledema  of  the  conjunctiva  (chemosisi. 
and  sometimes  even  ledema  of  the  eyelids.  Till'  vessels  being  mostly 
engorged  witii  venous  blood,  the  injection  has  ji  characteristic  (lusky 
hue.  The  main  exit  of  blood  from  the  uveal  tr.-ict  is  by  the  verue 
vorticos^e:  the  channels  in  the  sclerotic  through  which  these  pass 
run  very  oliliquely,  and  when  the  sclerotic  is  stretched,  as  it  is  in  glau- 
coma, they  easily  heronie  clo.sed.  The  result  of  sui'li  obstruction  is 
to  ratise  considerable  enlargement  of  the  anterior  ciliary  vt'in.s,  which 


OLA  UCOMA. 


529 


„f  hl<...(l  into  tli(>  cy.'  gradually,  instead 

Wl„-..  the-  ''"-^'\";7;;;'';  \^;  "    ^^^^^^^^^^^^       hlu.,,!  circulation  to 

„f  suddenly.  ^^^\!^^^^'^'^'''yl  J^^  ^'^Av   'ind  the  violent  disturb- 

„,,  alt..n-d  c.n.lit.ons  is  "•'''*•  ''''^^r'''^  (.^Ue  place.     Indeed, 

Tl„.  ,.fT«-t,  ct  mcn.,sr.l  '"'™; '''\^  ,;  !  ^  ,1,  ■  iwot'lc  i»  an 

™s'a,u,--..'.'„-t'^  !;:"s5  i='.vS  a:'?;::;"^^r:5 

S;."';";r,r*^ » *.'  .1-  «'"'«•  '<■»'■«■»  ""■™'""  '""""■  ■" 

,|„,  ;,nten..r  lamella  "^  J"''"^'^;^,";.  1  ,,  „„.t  .vitb  between  the  surface 
-'V'l'"'"''"1^  ;;  MnS  CiaS  n^M^Jmine,  between  the  epi- 
'I'"'"''"""  "'  ,      h,     ,    channels  in  the  anterior  lumting 

„,.,Hal  cells  then.selves  and  ^ J^^J.^  j",^^^,  ,,  ,,„  epithelium. 

,„,,„brane  through   which  the  V"^\'   '"''.•  ,    ,..i,i,u!ss  of    the 

"f-iJfsSii^^  

f,.rwanl  through  '■''=';;•;•;:..'  J      ;^^^;Lv  nerve,  from  which 
mav  also  be  due  In  cnmpre,-.-nin  ui  Hu       ."(^ 


530 


THE  EYE. 


the  corneal  nerves  are  derived,  af?aitist  tlie  luird,  unyielding  sclerolic, 
as  they  pa-^s  forward  on  the  outer  surface  of  the  choroid. 

The  iia;  .  ss  of  the  cornea  wlieii  present,  ajjart  from  other  causes, 
tends  to  .nake  vision  misty.  It  is  also  the  cause  of  another  very 
characteristic  sym|)t()m  of  glaucoma,  viz. :  the  appearance  in  the  dark 
of  halos  of  rainbow  colors  'iround  lights,  the  re<l  color  always  Ixnng 
the  outermost. 

A  precisely  similar  appearance  of  halos  of  rainbow  colors  around 
lights  is  produced  by  drop|>ing  a  solution  of  the  alkaloid  erythroph- 
la'iiie,  obtained  from  an  African  arrow  poison,  into  the  eye.'  It 
causes  also  a  slight  steaminess  of  the  surfiK c  of  the  cornea,  slif4,ht 
ana'sthesia,  and  .some  blurring  of  vision,  but  <loes  not  increase  the 
tension.  One  specimen  dilated  the  pupil  and  another  contracted  it; 
with  both  the  halos  were  .seen.  lOviilently  then  they  are  not  tlu" 
result  of  |)ressure  on  th(>  retina  or  any  altt>ration  in  the  pupil.  Halos 
may  also  be  produced  by  the  instilliit'.on  of  adroi)of  erythrophla-ine 
in  the  eye  of  a  patient  who  has  undergone  extraction  of  cataract, 
which  excludes  the  lens  from  any  participation  in  their  production. 
We  are  led  irresistibly  to  conclude  that  they  are  the  result  of  the  slight 
haze  in  the  cornea. 

FlO.  314. 


Tlie  angle  ol  i  '.x  aiUerior  chamlKr  iii  a  case  of  primary  Blaiicoma,  »lii)»  liiu  closiit*  of  the  flltmtloii 
area  at  the  periphery  of  the  cornea,  liy  apposition  with  i'  of  the  ro<Jt  of  the  iris. 

In  primary  glaucoma  which  occurs  late  in  life  no  ai'im'ciable  altera- 
tion in  the  sliape  or  size  of  tlie  cornea  occurs,  \\iien,  however,  in- 
crease of  tension  is  met  with  in  infancy  or  early  life,  the  cornea,  like 
the  sclerotic,  being  still  very  elastic,  enlarges  and  becomes  globular  in 
shaiie.     Tlie  condition  is  spoken  of  as  keratoglobiis  or  buphtli  tlmos. 

Anterior  Chamber.  The  condition  of  the  anterior  chamber  in 
glaucoma  varies  with  the  position  at  which  the  primary  obstruction 
in  the  circulation  of  the  iiitra-ocul.ar  fluid  takes  jilace.  In  primary 
glaucoma  it  is  shallow;  as  will  be  shown  Liter,  this  is  due  to  an  increase 
of  tension  occurring  iiist  in  the  vitreou  lianiber,  and  the  lens  with  its 
suspensory  ligament  being  forced  forward.    .\  continueil  shallowing  of 


1  ophtlialmii'  Keview,  IS'.K),  vol.  Ix.  p.  19ii, 


ULAUCOMA. 


631 


tlu-  aiitmur  fhaiiilKT.  aiul  prossure  .,f  tlic  oiliary  processes  against 
the  root  of  the  iris,  result  in  eontaet  of  th<'  latter  with  the  hack 
of  the  cornea  and  :i  narrowiiiR  of  the  angle  of  the  chanitM'r. 

In  xoiiK  <'ases  of  secoiularv  glaucoma  ami  in  cases  oi  congenital 
.r|.,ui'oina  the  priniarv  ol)struction  to  the  circulation  of  the  intra- 
ocular fluid  is  at  the'aug.e  of  the  anterior  chninher,  where  it  gams 
.■xit  from  the  eve ;  the  anterior  chanilx'r  then  iH'Coines  .leeiK'iied. 

Iris.  Pressure  of  the  root  of  the  iris  against  the  hack  of  the  cornea 
1,.„1<  to  compression  of  both  its  bloodvessels  and  nerves.  If  the 
incn'ase('  tension  is  sudden  in  onset,  the  compression  at  first  causes 
adeina  and  venous  engorgement,  which  make  the  iris  a;)lM>ar  altered 
ill  eol,.r  Later  on.  its  vessels  become  empty  and  its  stroma  atrophies 
■iiid  shrinks.     The  pigment  epithelium  on  the  ])osterior  surface  of  the 


Fid.  315. 


■n,e  in,  and  .ili.ry  body  fn,m  a  ca«>  of  glaucoma  of  long  «an,llnK,  showing  nmrked  eetropkn.  of 
.„  ,.i«,n.nt  .,,i.h«lium  a,  .he  ..upillary  margin.  The  angle  of  the  «"'^';;^»"f  J^^J^^.^^^^th'y 
„,,,.«.,„„  or  .he  r,«,l  of  .he  ir,,  .o  the  back  of  .he  cornea ;  In  the  prei«r.t ion  "'  'f  'l^  ™«" '^^^ 
have  i«.on,e  simi.'y  ^,«ra.ed.  There  ,s  an  abrupt  hen.l  in  the  Ir.s  where  '' ™»»  '^  »«  '»  ""'*'=' 
«iil,  the  cornea.    The  s.rcma  of  the  ins  is  .nueh  atrophied,  »o  that  it  a,    ,an,  very  th>n. 

iris  is  ui.atTecte.1  bv  the  atrophy.  It  normally  ends  at  the  inipillary 
margin;  but  in  cases  of  glaucoma  of  long  standing,  by  the  shrinking 
<,!•  the  stHMua.  the  |)igm<"nt  epithelium  becomes  drawn  around  ont.. 
the  anterior  surface,  a  condition  which  is  spoken  of  as  ectropion  o 
the  pigment  epithelium.  Clinically  it  is  seen  as  a  dark  ,.igmente.l 
.,n.;.  on  the  surface  of  the  iris  at  the  pupillary  margin,  usually  ex- 
fudiiig  m..re  in  one  direct ioi  ihan  another.  It  is  most  nuirked 
uli.'iv  the  iris  has  beciine  most  atrophied  and  when  the  tlilatation 

111'  the  pupil  is  widest.  ,      ..    ,  •       „,.♦„ 

The  pressure  of  the  nerves  against  the  back  of  the  cornea  in  acute 
ease.,  of  glaucoma  paialvzes  the  iritic  muscles,  ami  the  piipil  becomes 
inactive  and  semidilate.'l.  If  the  tension  is  relieved  l«-fore  atrophy 
has  s,.t  in,  its  activitv  returns.  In  long-stamling  cases  of  glaucoma 
■nt  dilatation"  of  the  pupil  may  be  brought  about  through 


iiiTinanei 


532 


rilE  EYE. 


atrophy  of  the  sphincter  inusrh'  and  shrinking  of  the  stroma.  The 
amount  of  dilatation  is  sometimes  not  equal  in  all  directions,  so  that 
the  ])U|)il  is  often  oval  or  im-gularly  circular,  and  it  may  Ik-  displaced 
away  from  the  centre. 

When  the  cornea  and  root  of  the  iris  have  he(>n  in  apposition  for 
only  a  short  while,  their  separation  is  easily  effected.  After  a  time, 
however,  cell  exudation  takes  ])lace  and  tiiey  hecome  adherent,  and 
in  long-standing'    ases  of  glaucoma  most  intimately  adherent. 

Ill  chronic  ca.si  of  glaucoma,  wlu  re  the  onset  of  tension  is  gradual, 
and  there  has  been  time  for  compen.satory  changes  to  take  place  in 
vessels  an<l  nerves,  the  dilatation  of  the  pupil  and  atrophy  of  the  iris 
may  be  absent. 

Ciliary  Body.  Incrca.se  of  tension  early  causes  disturbance  in  the 
acconnnodative  action  of  the  ciliary  muscle,  due  probably  to  com- 
pression of  the  ciliary  nerves  against  the  sclerotic.  It  manifest.s  itself 
by  the  a;  parent  rapid  advance;  of  presbyopia,  the  patient  requiring 
stronger  and  stronger  gl;i.s.ses  for  near  work.  In  the  early  stages  of 
primary  glaucoma,  more  especially  in  acute  cases,  the  ciliary  proc- 
esses are  swollen  and  (udematoas.  "their  veins  ar(>  engorged,  and  they 
press  forward  against  the  root  of  the  iris,  .\fter  increase  of  tension 
has  lK>en  established  for  some  time,  they  Ix'come  atrophied  and  shrink, 
as  al  ")  does  the  ciliary  muscle,  so  that  in  cases  of  glaucoma  of  long 
stanuing  they  are  no  longer  in  contact  with  tlie  back  of  the  iris,  and 
a  considerable  s])ace  is  left  between  them  and  the  margin  of  the  lens. 
The  ciliary  body  receives  an  extensive  nerve  .supply,  from  both  the 
long  and  short  ciliary  nerves,  which  p(>rforate  the  sclerotic  posteriorly 
and  p;iss  forward  in  the  lamina  suprachoroidea,  until  they  break  up 
into  a  net-work  of  fine  branches,  which  is  known  as  the  ciliary  plexus. 
It  is  the  sudden  onset  of  pressure  of  this  plexvis  against  the  unyielding 
sclerotic  which  is  the  cau.se  of  the  excessive  pain  of  acute  glaucoma 
— pain  which  is  not  confined  to  the  eye,  but  referred  also  to  ether 
parts  sujiplied  by  the  fifth  nerve,  especially  those  receiving  branches 
from  its  first  division.  Certain  reflex  disturbances  may  also  be  set 
up,  which  will  Im-  referred  to  in  speaking  of  the  different  clinical 
ty])es  of  glaucoma. 

WhiMi  increased  tension  comes  on  gradually  and  is  ntit  very  intense, 
the  nerves,  like  the  bloodvessels,  have  the  power  of  adapting  them- 
selves to  the  changed  conditions,  and  in  the  majority  of  chronic 
cases  of  glaucoma  no  pain  is  experienced  by  the  |)atient  from  first 
to  last. 

Choroid.  The  efTect  of  iner'ased  tension  on  the  choroid  in  acute 
cases  of  glaucoma,  as  on  the  otlu>r  ])ortions  of  the  uveal  tract,  the 
iris  ,ind  ciliary  bodv.  is  first  to  jiroduce  a  condition  of  venous  conges- 
tion and  (vdema:  later  on,  emptying  of  its  vessels  and  a.rophy.  In 
chronic  glaucoma,  o;.  the  other  hand,  no  sudden  disturbance  of  the 
circulation  is  set  Up.  but  the  compression  of  the  choroid  against  the 
sclerotic  tends  to  empty  the  blood  out  of  the  cajiillaries.  The  fundus 
ophthahnoscopically  in  such  cases  is  seen  to  lo.se  its  uniform  red  hue, 


OLMCOMA. 


5ua 


and  ti.  pri-seut  a  tessellated  ap|.earance,  due  to  exposure  of  the  net- 
work of  larger  vessels  in  its  outer  layers.  _        . 

Itroi.hvof  the  choroi,!,  th.-  result  of  mcreascni   tension,  is  most 

.nirke.     It  the  parts  where  it  has  the  Hrniest  attachments  with  the 

i    r  s  .-x  ernal  to  it,  viz.:  around  the  optic- disk  and  at  the  seats 

f?^it  of  the  vortex  veins.     When  increa.se  of  tension  has  exjste.l 

or  i  ne  tinu-,  the  optic  dish  is  usually  seen  to  Ix-  ccircl.-d  by  a 

ylunwiih-whit;  ring,  which  is  due  to  the  atroplued  choroul  allowing 

tlic  sclerotic  to  1m' exposed  to  vi'.'W. 

Lens.  The  .lisplacen.ent  forward  of  the  lens  in  primary  glaucoma 
wmU  if  the  <'ye  is  emmetropic,  to  make  it  myopic,  as  do  also 
e  ching  of  the  walls  ami  expansion  of  the  glolK>  in  the  antero- 
; , wtV.-ior  axis.  .\  drag  on  the  suspensory  ligament  from  .l.splacement 
n  rd  of  the  lens  or  expansion  of  the  glob-  in  the  ciliary  region 
!.;,,;.ld,  on  the  other  hand,  lessen  its  refractive  power,  and  te.ul  to 
in'iki-  an  emmetropic  eye  hypermetropic.  ,  .     ,  , 

n  g  aucoma  in  llie  adu.t  hardly  any  expansion  of  the  globe  takes 
phui,  hut  it  is  stated  that  during  attacks  of  glaucoma  the  refraction 

"'iTi' glaiic."mrin' earlv  life,  where  considerable  enlargement  of  the 
gl,  .  i  i  its  mericlians  is  met  with,  the  lengthening  o  the  globe  is 
r  ,ei^  ted  for  in  part  by  the  flattening  of  the  lens,  and  the  amount 
;;;  ,;iyopia  met  with  is  not  as  much  as  might  otherwise  have  been  ex- 

'""ln"iiaucoma  of  long  standing  the  nutrition  of  the  lens  sometimes 
suffers  ami  it  becomes  cataractous.   The  opacity  of  the  lens  occasioned 
!,v  glaucoma  usually  pn-sents  a  bluish  nietallic  lustre 
■  Aqueous  and  Vitreous  Humors.     Seeing,  as  already  stated  that  u 
acute  glaucoma  there  are  at  first  venous  c.ngestion  and  ^f^^^^J 
h..  iri>  and  ciliarv  body,  it  might  scn-m  natural  to  suppose  that  theie 
V  ul    li«w.soxmlation  into  the  aqueous  and  vitreous  chambei^, 
'that  th.'  intra-ocular  fluid  would  be  more  albuminous   han  n,,r- 
,      Whether  this  is  so  or  not,  has  yet  to  be  determined  definitely^ 
Th,.  haze  of  the  cornea  in  acute  glaucoma  prevents  it  being  seen 
h„  V  much  the  obscuration  of  the  fundus  may  !«»  due  to  want  ot  clear- 
;  s  h.  the  other  nie.lia.     That  part  of  the  increased  onhiancy  n  the 
iris  whieh  is  observed  innnediately  after  opening  the  anterior  cham- 
l"r  in  operations  for  acute  glaucoma  is  due  to  escape  of  imperfectl) 
,.l,.;ira.iueous  humor,  there  can  belittle  doubt. 

Th.  .'n'enish-grav  reflex  from  the  pupil  sometimes  seen  in  glaucoma 
is  prohablv  in  in>rt"due  to  an  incn>ased  seros.ty  of  the  me.luh 

Retina."   The  imme-liat"  eftect  of  increa-sed  tension  on  the  retinal 
bloodvessels  is  to  obstruct  both  the  entrance  of  bloo  '  by  the  arterie 
•Hwl  its  ,.xit  bv  the  veins.    ronse,,uently  the  latter  become  enlarge* 
and  the  forn.eV  smaller  than  normal.     The  in^ra-ocular  pressure  and 
,he  pressur..  of  the  bloo<l  in  the  r.>tin.al  vessels  are  so  balanced,  uder 
Mornml  con  litions.  that  no  pulsation  is  to  be  observed  in  the  retinal 


arteries. 


V  hen  the  intra-ocular  pressure  is  much  increased,  or  tne 


534 


TIIK  EYK. 


artorial  pn'ssure  much  (liiiiinishod,  this  balance  is  {liaturbod;  blood 
then  can  force  its  way  into  the  retinal  art-r'  only  during  contrac- 
tion of  the  heart,  and  pulsation  in  them  l>ecot..es  visible  it)  the  vicinity 
of  the  optic  disk.  If  the  increased  top'uon  in  a  case  of  glaucoma  is 
not  sufficient  to  give  rise  to  pulsation  of  the  retinal  arteries,  it  may 
readily  Iw  elicited  by  slight  pressure  on  the  glolx'  with  the  finger. 
I'lKler  normal  conditions  a  considerable  amount  of  pressun?  on  the 
glolx'  is  recjuired  to  jjmduce  pul.satioii. 

Pulsation  of  the  retinal  arteries  has  tx-en  observeil  in  cases  of  aortic 
regurgitation  and  of  s'-ncope,  without  increa.sed  tension  of  the  eye 
and  due  to  diminishe       'ood  pressure. 

.\s  the  result  of  '  ontinued  increa.sed  tension  the  walls  of  the 

retinal  arteries  bee  sclerosed.  Hemorrhages  into  the  retina  from 
rupture  of  the  sniaii  vessels  are  met  with  fre()uently  in  glaucoma. 

.\  disturbance  of  the  function  of  the  retina,  as  the  result  of  increased 
tension,  may  be  due  either  to  diminished  blood  supply  i  to  atrophy 
of  its  nerve  fibres. 

Loss  of  vision  due  solely  to  the  first  cause  is  recoverable;  that  due 
to  the  second  is  permanent. 

If  the  tension  of  a  healthy  eye  lx»  increased  by  pn'.ssurc  from  with- 
out, as  with  the  finger  upon  the  eyelid,  vision  may  be  completely 
abolished,  it  disappearing  last  in  the  region  of  the  macula.  This 
may  be  attributed  to  arrest  of  the  circulation  in  the  retinal  vessels, 
and  possibly  also  in  the  choroidal  capillaries  from  which  the  outer 
layers  of  the  retina  receive  their  nutrient  supply.  Directly  the  press- 
ure is  removed,  the  circulation  is  re-<>stablished  and  vision  returns 

In  the  same  way  in  acute  glaucoma,  vision  may,  in  the  course  of  a 
few  hours,  be  reduced   to  mere  perception  of  light  or  completely 
abolishe<l.     If  normal  tension  is  re-established  before  sufficient  ,.  . 
has  elapsed  for  organic  changes  in  the  nervous  tissue  to  set  in,  ■ 
will  be  r(>store(l. 

The  branches  of  the  retinal  artery  which  go  to  the  periphery  cf  U 
retina  on  the  temporal  side  have  a  longer  course  to  i)Mrsiie  than  ili  )so 
distributed  to  other  parts,  because  the  point  of  entrance  of  the  oj)tic 
ner\e  into  the  eye  is  situated  to  the  na.sal  side  of  the  midille  line.  It 
is  the  capillaries,  therefore,  from  the  t(>mporal  branch  which  are 
affected  first  by  any  increa.se  of  tension. 

The  n(>rve  iibres  destined  for  the  i)erii)hery  of  .ue  retina,  which  lie 
in  the  outer  portions  of  the  optic  nerve,  are  more  liable  to  be  exi)o.sed 
to  pressure  against  the  scl(>rotic  iis  they  enter  the  eye,  than  those 
destined  for  the  central  region.-s. 

Thes<'  two  anatomical  facts  serve  to  explain  the  manner  in  which 
vision  fails  in  cases  of  glaucoma.  The  process  begins  at  the  ()eriphery, 
producing  a  contraction  of  the  field  of  vision.  This  contraction 
usually  is  noted  first  on  the  na.sal  side.  As  the  ciise  progresses,  the 
held  gradually  becomes  reduced  to  a  more  or  less  oval-shaped  area, 
extending  chiefly  to  the  outer  side  of  the  fixation  point.  I'ltitnatcly 
the  fixation  point  becomes  involved,  a  small  area  in  the  field  to  its 


OLA  VCOMA. 


536 


„ut4T  .uh-  b.-i..K  l«-ft  until  thp  l:u.t.     In  somo  chronic  cases  of  glau- 
coma ;;  rfect  cmtral  vision  may  Ik-  rotaino.1  with  extreme  contract..,n 

Flo.  SIC 

Right  Eye 


Conrentric  contraction  u  seen  In  gUucom»  simplex. 


Kio.  S17. 


106  ^ Ti 

Concentric  contr»cUon  as  «een  la  glaucoma  .implex. 


536 


THE  EYE. 


of  the  field.     In  otlirr  cases,  in  asMiciation  with  a  contracted  tield, 
some  l()s.f  in  the  acuity  (>f  central  vision  is  met  with. 


Kl(i.  31H. 

Hight  Eye 


iloncentric  oonimctlon  R!»  peen  in  Rlauct      .  siraplox. 


Km.  319. 
Ijft  Eye 


m--      '" 
'"'oncentric  contraction  rh  Been  m  glaucoma  simplex. 


tlLArcDMA. 


637 


TliouKli  the  above  is  th.-  niusl  tyi)ical  way  for  tho  Hold  of  vwioii  to 
h,  ((iiiH-  alTopted  in  plauc.ma,  cases  occur  when-  it  is  contracted  cou- 
iitrically,  or  wiiere  liiere  is  a  central  or  parairiitral  scotoma. 
Wlicn  the  ♦ieid  is  tested  l)V  an  "hject  whidi  sul)tends  a  snia'.ler  visual 
I  with  tlie  ordinal  V  |)erinletor^      s  in  tlie  nietiiod 


crl 


angle  than  enii)loyed 


«)phth«lmo«cni.i.'  appearonco  of  the  opllc  disk  In  absolute  utaucoma.     .l*KtiE«.l 


siifip'sted  i)v  Hierruni' ),  it  is  found  that  in  plaucoiiia,  whatever  1m'  tho 
situation  of" the' defect  in  the  fiel.l,  it  always  starts  from  the  blind  spot. 

The  fiel.is  for  color  usually  fail  proportionately  to  the  field  for  white 
ami  to  one  another. 

In  ey(>s  blinded  by  Bhiucoma  then>  are  found  some  atrophy  of  the 


Fig.  SJ 


Seition  of  optic  nerve  heart  of  cane  lU'pieled  In  Fig.  3a).    (Jaeoer.) 

nervous  elements  of  the  retina  and  some  increase  of  the  fibrous  tissue 
elements.    Small  cystic  spaces  in  the  tmtcrior  portion  of  the  retina, 
in  'he  vicinitv  of  tlie  ora  serrata,  are  mot  with  v(>ry  commonly. 
Optic  Nerve.     Tho  delayed  exit  of  venous  blood  from  the  retinal 

uxxl.-.,  and  c.nM-.iuent  venous   o()i;::rstiun,  probably  jjive  ri«o   to 

1  NordUk  Ophthal.  Tidsskrlft,  il.,  S,  and  ophlhalmic  Review,  180O,  vol,  U.  p.  IW. 


fiSM 


Tut:  KYH. 


some  (I'dcniatoiis  swt'lliiijr  nf  tlii'  (iptic  |iapilla  in  tnatiy  cases  nf  acute 
glaiiconia.  Hy  the  time  a  clear  view  of  tii(>  details  of  the  fiiiidiis  can 
\m'  (ihtaiiied,  this  swelliiij;  has  niveii  way  to  cii|)|)iii>j  and  atrnpliy. 
S'Veial  oltservers  have,  however,  descrilx-d  seeing  ap|«'araiices  like 
optic  iieiiritis  as  an  initial  syniptnin  in  glaucoma. 

The  position  wiiere  the  nerve  lihres  enter  the  hIhIm-  is  a  weak  spot 
in  its  walls.  There,  instcid  of  having  the  three  coats— sclerotic, 
choroid,  and  retina— there  are  only  the  fibres  of  the  o|)tic  nerve  ami 
the  laiiiin.'i  crii)ro>a.  The  latter  does  not  represent  more  than  h.df 
the  thickness  of  the  sclerotic,  and  is  compiM^il  mainly  of  yellow 
elastic  tissue. 

When  the  ten-ion  of  the  eye  hecomes  increas«Ml,  this  weak  spot  soon 
begins  to  give  and  bulge  outward. 

Tlie  sclerotic  surrounding  the  optic  disk  is  very  thick  and  unyield- 
iiij:.  -o  that,  as  the  liimina  cribrosa  becomes  curved  backward,  the 
ner\'  fibres  become  compressed  against  the  tough  resistant  edgi'  of 
the  -iclerotic  at  its  niargi';.  and  conse(|uently  atrophy.  When  they 
hecdine  atrophied  ilown  to  the  lamina  cribrosa,  instead  of,  as  in  the 
healthy  condition,  there  b<>ing  an  elevation  in  the  region  of  tlii  optic 
disk  ( the  optic  I lapilla),  a  depression  is  formed. 


Clipping  "fttit^  optK:  disk  IIS  (he  result  of  Klutiiuniit.  lH."iiiU's  (Icpresstoii  tiut  kwunl  uf  tbo  lamitia 
crihros*  there  hiis  Ipeeii  N'lne  Ititerul  eximlisinti,  so  Ihat  one  siiJe  nf  the  eup  lins  ttecume  Koniewhat 
cxnivHteil.  Ill  ttu'  pre[>aratioii  of  the  siieclineii  the  retina  hta  become  (lisplaceil  lorwiird  from 
r-oiitact  with  the  rhoroid. 

The  cupping  nf  the  optic  disk  iii  i^hitsconia  is  then  the  re';ii!t  of  tv.f. 
cau.ses:  depression  b.ickw.iril  of  the  lamina  cribro.sa  and  atrophy  ot 
the  nerve  fibres  down  to  it. 


liLAVCUMA. 


A"  111"  .lc|>rcH>»ic">  biickwanl  of  llif  1  imiiia  lilm.-a  increase-  the 
sides  of  liie  cill)  I  ..il  to  iK'eollie  .niite  steep  hey  may  Ix-eolii.  ex- 
liainled  laterally  at  the  posterior  part,  so  that  on  section  it  |)resents 
a  tiask-shaped  outlin<'. 

Oplithalnioseopieally.  a  riipiK-d  .'onditoii  of  the  optic  nerve  m 
rec<i>;riize<l.  with  the  iiidirt  ct  inetho<l  of  examination,  hy  the  parallax 
which  is  priHlueed  on  movement  of  the  lens.  The  hottoin  of  the 
cup  and  the  surromidinjr  fun<lus  seem  to  move  at  dilTerent  rates, 
the  former  more  slowly  nan  the  latter,  sr)  that  the  siirroundiiift 
fundus  appears  to  nio\'     ver  the  d.'presse<l  surface  of  the  disk. 


Fio.  S». 


I  ,l,iiic,innlrm«  oicavall..!!  taking  place  in  an  o|.tii-  nerve  with  a  phyRiological  cxcnvalinii.    (Jakgeb.) 


( »ii  examination  with  the  direct  niethiMl  it  is  found  that  a  ditTereiit 
I.  MS  is  necessarv  to  see  clearly  the  liottom  of  the  cup,  from  that  which 
i-  rciiuired  for"the  rest  of  tJie  fundus.  Thus  supposiiift  the  patient 
t(v  he  enmietropic.  a  inimis  lens  would  be  needed  to  see  distinctly 
tl,,.  h,.f,to!H  of  the  cup;  or  if  the  patient  were  myopic,  a  higher  minus 
■:1a  <s  than  that  used    )r  seeing  the  rest  of  the  fundus. 

When  the  side  ot  the  cup  is  steep  or  somewhat  overhauftiug,  the 


540 


77//;  /•;>'/•;. 


rctiiiMl  vessels  as  tliev  curl  arouiid  it  disappear  from  viinv  fora  portion 
ol'  tiieir  cdurse.  or  may  l)e  vieweil  in  a  t'oresliorleiied  maimer.  If 
tiiey  disappear  from  view  for  a  portion  of  tiieir  ('onrse,  there  seems 
III  !)('  a  i)reai<  in  tlie  contiimit y  of  the  vessel  seen  at  tlie  base  of  the 
cup  and  on  the  surface  of  the  retina,  it  often  reaiipeariiifi-at  a  slifjhtiy 
ditlerent  position  on  tlie  latter  from  what  it  disappeareil  at  on  the 
former.  If  vicwe(l  in  a  foreshortened  maimer,  the  blood  in  the  vessel 
appears  very  dark. 

riie  margin  of  a  cuppe(l  disk  in  jilaueoma  often  throws  a  shadow 
on  its  surface.  ,so  that  it  appears  lijilitest  in  tlie  centre;  th<'  markinjis 
of  the  lamina  crihrosa  on  its  surface  are  usually  well  defined,  and 
its  color  is  sometimes  altered  to  a  Jin     /ish  or  lihiish  hue. 

Conditions  which  Predispose  to  Primary  Glaucoma  or  Excite 
Acute  Attacks. 

Age.  There  aic  cases  of  i;laucoma  that  date  from  birth,  or  even 
before  birth,  which  are  not  the  result  of  some  obvious  prece(l(>nt 
disea.se,  anil  which  mijiht  be  classed  as  oases  of  primary  };laucoma. 
They  .are.  probably,  the  result  of  some  con<reriital  defect  in  de- 
velo|tmenl,  and  evidently  have  a  different  c;iusation  to  that  of 
other  cases  of  primary  <;l;uicoma.  They  \\iM  therefore,  be  dealt 
with  separ.ately  under  the  headinfr  of  conjcenital  jrlaucoma  or  primary 
buphthalmos.  i;\cl;idin<;  these  ca.ses,  it  may  bi'  stated  that  the 
li.abiliiy  to  primary  ^huicoma  increases  with  advance  of  life.  PriestlcN' 
Smith'  h;is  shown,  from  a  careful  analysis  of  KMM)  cases,  that  at  the 
a^e  of  sixty-five  years  the  chance  of  an  attack  of  <ilaiicoma  is  at 
least  one  huiidrecl  times  {jreater  than  at  Hfteen  years,  and  more  than 
twice  as  ji;reat  ;is  at  forty-live  years  of  aj;e.  Primary  glaue()ma  under 
tiiirty  years  is  very  rare;  in  practice  it  is  met  with  most  commonly 
in  the  decade  between  sixty  and  seventy  ye.irs. 

Sex.  Women  .are  more  liable  to  primary  glaucoma  than  men. 
especially  to  acute  attacks. 

Heredity.  Several  strikinj;  instances  are  recorded  in  which  prini.nv 
jrlaucoma  has  occurred  in  members  of  the  same  lamily,  through  two 
or  three  p;eiieratioiis.  'I'he  number  of  c;ises  where  an  hereditary 
tendency  is  met  with  comjiared  with  the  number  of  cases  of  jjlauroma 
which  occur  .are.  howi'ver.  few. 

Race.  Certain  races  are  stateil  to  be  more  liable  to  primary  jjlau- 
coma  than  others,  viz.:  the  .lews,  the  I'.gyptians,  and  the  ne.srro(>s 
of  lirazil.  More  definite  statistical  evidence  is  re(|uired  on  these 
matters  before  it  I'aii  be  said  that  they  are  i)roved. 

Errors  of  Refraction.  Nearly  .">()  per  cent,  of  eyes  afTected  with 
jirimary  glaucoma  are  hyp<'rmetropic.  .and  it  is  generally  believed 
that  a  liy[)crmclropic  eye  is  pn-disposi'd  to  glaucoma.  It  should  br 
borne  in  mind,  however,  that  hypennetropia   is  the  commonest   re- 


'  Tmiisiictiipris  nf  Ult:  OphtlmlmoInjfUMl  Society  of  ttii'  CiulO'l  Killf^'lom.  18S0.  V'.l    vi.  p.  2*'-. 


(ir.ALC'iMA. 


541 


fnictivo  error,  and  that  tlic  pmijurtioii  of  casos  of  jilaiicoiiia  occiir- 
riiii;  ill  association  with  hyiicniictropia  is  not  very  much  iarftcr  than 
tiiat  of  cases  of  liyiuTnii-troiiia  to  tlic  popuhition  at  larfrc 

(ilauconia  in  cases  of  hi^li  myopia  is  very  uncommon. 

Accommodative  Effort,  'hiere  seems  f;oo«l  reason  to  Ix'lieve 
tliat  prolonjietl  near  work  teii.is  to  the  |)roiiuction  of  jjrimary  glau- 
coma.    Sch i'    lias    published   statistics    to    show    that    the   oirur- 

reiice  of  glaucoma  is  often  associated  with  nefjiect  of  the  use  of  proper 

Smallness  of  Cornea.  I'riesiley  Smith-  has  proved  conc!usiv(  ly 
tiiat  eves  with  small  cornea'  are  iireilisposed  to  primary  glaucoma. 
He  sa\~  Iliat  eyes  in  which  the  cornea  measures  only  ten  millimetres  in 
the  horizoiitar  diameter  seem  seldom  to  escape  the  disease.  He  iias 
larthi'r  shown  that  smallness   of   the  cornea  means  smallness  of  the 

evchall.  .  .      . 

Depressing  Emotions.  Among  the  more  direct  causes  of  primary 
iriaucoma.  first  and  foremost  is  emotional  excitement  of  a  dejjressiug 
Th.-iracter.  (irief  connected  with  the  death  of  a  friend  or  relative, 
niixiety  coniiecteil  with  business  matters,  or  worry  and  trouble  due 
lo  other  cause,  very  commonly  precedes  the  onset  of  glaucoma. 

Widows  seem  especially  liable  to  glaucoma.  Thus  out  of  1 17  cases 
7  J  were  females,  4;i  males.  Of  the  74  females,  .'iS  were  married,  27 
widows.  7  single,  2  unrecorded.  Of  the  U  males,  M  wer(>  married, 
S  widowers,  1  single,  ."i  unrecorded. 

Loss  of  Sleep.  .Associated  with  anxiety  or  trouble,  very  coiii- 
iiionly,  is  loss  of  sle<'p,  and  the  two  seem  to  act  together  in  tending 
to  bring  on  glaucoma.  A  by  no  means  uncommon  history  is  that 
t!ie  first  symptoms  c:inie  on  after  the  jiatient  had  sat  uj)  at  night 
tiMidiiig  some  dearlv  loved  sick  relative  or  friend. 

Operation  on  One  Eye.  .VII  that  may  be  comprised  under  the 
term  "shock,"  both  mental  iUid  physical,  which  follows  an  oiK-ratioii 
lor  glaucoma  on  one  eye,  is  very  liable  to  excite  an  acute  attack  in 
the  other.  The  second  eye  wotiid  no  doubt  be  predisposed  to  glau- 
c.iiia.  but  mav  not  previously  have  evinced  any  symptoms  of  the 
di-'ase. 

Mydriatics.  The  use  of  a  mydriatic  such  as  atropine,  to  an  eye 
pf.MJispo.sed  to  i)rimary  glaucoma  is  very  liable  to  caus(>  increase  of 
tnivioii.  and  its  ai>plicatioii  may  excite  acute  attacks.  II  -used  in 
cliroiiic  cases,  it  may  intensify  the  increased  tension  and  cause  acute 
<\  iiiptoms  to  set  in. 

Local  Injuries.  A  slight  injury  of  the  eye.  an  abrasion  or  ulcer 
ut  the  cornea,  sometimes  .seems  to  be  the  determining  cause  of  the 
i.iiset  o|'  inimarv  glaucoma. 

Constitutional  Conditions.  .\n  attack  of  facial  neuralgia  is  some- 
times the  iirecursor  of  glaucoma.     Other  jiossible  contributing  con- 


1  Ari'tilv  r.  Onhltintniiilielc,  11S7,  Baiiil  xxxvlii.,  i>l)   1.  S.  Hn 

-  Tm..8Hflioiis  of  the  0|>lilhalnu,l,«icKl  Safety  ol  tlio  Initcd  KinKJ..m.  \fM.  vol.  x.  p.  fis. 


542 


Tin:  i:ye. 


stitutiiiiial  ciuiscs  arc  colil,  fatijiiic,  constipation,  aiitl  vascular  or 
lun^  altcctioiis  wiiicli  produce  venous  congestion  of  tlic  head  and 
eyes. 

The  Clinical  Types  of  Primary  Glaucoma. 

I'rom  wliat  lias  l>een  said  (;f  tlie  elTects  of  increased  tension  on  the 
dil't'erent  sti-uctures  of  the  eye.  it  will  l)e  seen  that  the  syin|itonis  of 
primary  glaucoma  \arv  coasideralily  according  to  its  mode  of  onset. 
Different  clinical  types  of  tiie  disease  may  cons<'c|'iently  he  described' 
acute  congestive,  subacute,  and  chronic  or  non-congestive. 

It  must,  however,  be  borne  in  mind  that  no  hard-and-fast  line 
can  l)e  drawn  between  these  ditferent  types.  They  merge  iuio  one 
another.  .\n  eye  may  be  affected  with  one  typi'  of  the  disea.-;e  at 
one  time  and  a  <lilTerent  one  at  another;  or  the  same  individual  may 
have  one  type  in  one  eye  and  a  different  type  in  its  fellow. 

Acute  Congestive  Glaucoma.  .\n  acute  attack  of  glaucoma  may 
occur  in  a  person  who  has  not  previously  had  premonitory  syni))- 
toms  of  the  disease;  it  is  then  spoken  of  as  jidmiimlinii  (jUincoma. 
More  frequently  it  conies  on  in  those  who  have  experienced  one  or 
more  slight  subacute  attacks  or  in  a  patient  w.  .)  has  been  suffering 
from  the  ciironic  form  of  the  diseaM'. 

The  attack  is  ushered  in  by  sudden  aching  |)ain  in  the  eye  and 
forehead,  sometimes  also  of  iIm  whole  side  of  tlie  face.  This  pain  is 
accompanied  by  a  general  feeling  of  nialai.se,  repeated  attacks  of 
vomiting,  and  loss  of  appetit(>.  So  severe  sometimes  are  these  gen- 
eral symi)toms  that  they  ;ire  attributed  to  "a  bilious  attack,"  and 
their  connection  witii  the  affection  of  the  eye  is  often  overlooked, 
even  by  the  medical  attendant. 

The  vision  rapidly  fails,  going  on  in  tlie  course  of  a  few  hours  or 
ilays,  according  to  the  severity  of  the  attack,  to  b;u'e  ])erception  of 
light  or  complete  blindness.  The  eyelids  and  conjunctiva  become 
somewlial  swullen  from  ledema.  The  ves-^els  of  the  ocuhir  conjunc- 
tiva and  episcli'r.il  lissue,  especially  the  main  trunks,  become  much 
congeste(l  with  venous  blood.  The  cornea  loses  its  natural  brilliancy, 
|)resenting  a  dull,  hazy  api>earance,  and  after  a  short  while  it  is  less 
sen<itiv<'  to  the  touch  than  norni;it.  The  anterior  chamber  is  very 
>litll()w;  the  pupil  is  semidilatecl  and  immobile,  it  Mimonly  assumes 
a  somewhat  oval  shape,  and  may  be  'ccetitric.  .  he  iris  viewed 
lliidujrh  the  ilull  coine.i  will  be  less  briiihtly  colored  than  tha*  of 
thi'  fellow  eye.  Turbidity  of  the  media  usually  prevents  any  view 
of  the  details  of  ihe  fundus  being  obtained  ophthalmoscopically.  On 
palp;  tioii  of  the  glolM'  through  the  iids,  the  tension  will  be  found 
considerably  raised,  usu.ally  as  much  .as  -}-'_' or  +;{.  If  the  case  is 
left  to  itself  without  trealmi'iit.  the  symptoms  of  congestion  will  last 
some  weeks,  and  then,  as  the  iritr.a-ocul.ar  vascular  circulation  adapts 
itself  to  the  altered  conditions,  subside.  The  tension  of  the  eye,  how- 
ever, remains  increased.  The  subsidence  of  the  congestion  is  accom- 
panied by  relii'f  of  pain  ;ind  some  iinproveinent  of  sight.    The  cornea 


GLACCOM.l. 


543 


)<  ■collies 
■'>;il 


loss  Iwzv  ;iiul  ;i  view  o 


if  the  fundus  can  he  obtained  oph- 


>;illlioSC()l)ll'allv 


vlu'ii,  if  tlie  ease 


lias  been  of  sutfieient  duration 


the  1 


•.laiaeterist'ie  eupiiiiiR  of  the  optie  disk  will  be  deteeted.     The 

liar^ed  and  tiie  pupil  dilated,  acting 


iiterior  ciliarv  vessels  reiiiain  en 


Is  n 


verv  slijilitly  to  light.     Fresh  subticuto  attacks  may  follow,  after  each 

is  recovered,  absolute  pennanent  bliiid- 


)f  which  li'ss  and  less  vision 
uitiniately  resulting 


wil 


Sonietinies  after  tlie  hrst  acute  attack  the  glaucomatous  condition 
become  chronic,  and  the   held  of  vision  gradually  and  steadily 


coiitiacls  .vithout  fresh  onsets  of  congestion  and  pain. 

ite  bhnd  and  the 


(liti 


:)f  abf<o- 


heii  the  eye  has  become  quite  l)iin(l  and  ttie  condition  o 
lute  glaucoma"  is  established,  the  iris  will  be  much  shrunken  and 
discobred,  the  pupil  dilated  and  immobile;  at  its  margin  on  the 
surface  of  the  iris  there  will  bo  a  dark  ring,  often  extending  farther 
ill  ,,ue  direction  than  elsewhere— octroi  mm  of  the  pigment  epithelium. 
'I'iie  cornea  will  bo  dull,  and  vesicles  may  form  on  its  surface.  It 
will  be  verv  liable  to  Iwconie  ulcerated,  a:id  the  ulcer  will  Ix'  difficult 
to  heal,  often  going  on  to  perforation,  with  escape  of  .some  of  the 
contents  of  the  globe. 

The  anterior  chamber  will  continue  very  shallow,  and  a  (.uU  grayish- 
^iveii  reflex  often  be  seen  from  th<>  pupil,  or  the  lens  may  become 
cataractous.  The  anterior  perforating  ves.sels  remain  enlarged,  and 
;it  any  weak  spots  in  the  walls  of  the  globe  the  sclerotic  will  give, 
iH'coming  stai)hvlomatous  aiul  discolored. 

Subacute  Glaucoma.  Subacute  attacks  of  glaucoma,  as  has  been 
Miid.  may  precede  or  succeed  an  acute  attack.  Tiiey  may  also 
occur  iiideiiendcntlv.  . 

In  a  subacute  attack  the  svmptoms  are  of  a  character  similar  to 
ih.ise  in  an  acute  attack,  but  "of  less  severity.  The  pahi  is  confined 
In  the  eve  and  is  of  the  nature  of  a  ciliary  neuralgia.  The  jiatient 
.•niiiplains  that  during  the  attack  there  is  an  appearance  as  of  a  fog 
ur  mist  in  front  of  the  sight,  and  that  around  lamps  at  night-timo 
he  sees  rings  of  colors  like  those  of  a  rainbow.  The  held  of  vision 
shows  contraction,  usually  on  the  nasal  side. 

The  injection  of  the  eve  is  not  very  intense:  it  has  a  dusky  hue, 
.iiicl  iisuallv  is  conhnod'to  the  anterior  perforating  and  episcleral 
vr.scls.  There  is  a  s-light  .steaminess  of  the  cornea,  especially  about 
its  (Tiitre,  resembling  ghiss  which  has  boon  breathed  ujion.  The 
ptiinl  is  semidil.-ited  an<l  sluggish  in  action:  the  anterior  chamber  is 
>li,illow.  On  oplitlialnu)scopic  examination  the  optic  disk  will  bo 
found  cni.ped.  In  an  early  case  the  cui)i>ing  may  be  very  slight, 
amounting  to  only  a  slight  aljru])!  bending  of  the  vessels  at  one 
margin. 

The  tension  will  generally  be  found  about  +1  or  +2.  A  sub- 
.iciile  iittack  may  varv  in  duration  from  a  few  hours  to  a  few  days. 

In  Mime  pali.Mils  I'iie  .-vniptoms  come  on  in  the  evr-nings.  subsiding 
lifter  a  night's  rest.  In" the  intervals,  at  hrst.  jierh-ct  visiim  r.- 
<tored,  or  a  slight  contraction  of  the  field  may  bo  the  only  da  ..ago 


044 


Tin:  i:yk. 


that  lias  Ihvii  (.ffcctcl.  As  tlic  attacks  1ht(iiii('  rrpcatc.l.  riioro  and 
more  iicrmaiiciit  ilaiiiafr<-  ciisiics,  tlic  aiiioiint  dcpciuliiifr  lai-'clv  (.ri 
tlicir  severity  and  ddralidii.  "   ' 

Some    eases    alter   one    ,.r   two    suhanite   attaeks   s.'ttle    into    a 
chronie  state  with  a  persistent  stiiall  amount  of  inerease  of  tension 
witlioiit  Imtlier  exaeerl.atioii  of  symptoms,  except   steady  contrac- 
tion ot  the  tieid  of  vision. 

Chronic  Non-congestive  Glaucoma.  A  case  of  friaiicoma  inav  run 
a  chronic  cmi-e  fn.in  first  to  last.  A  cast"  eommencin-  as  chronic 
,!;laiiconia  may  become  complicated  witli  an  acut-  or  subacute  attack 
A  ca.se  hejriimmjr  with  an  ;>cute  or  subacute  attack  niav  afterward 
pa.ss  into  a  chroiiic  condition.  In  chionic  glaucoma  there  is  no  pain 
and  the  patient  is  unable  to  state  dehnilelv.  in  a  ca.se  commencing 
as  such,  when  the  affection  bcfian.  Th,.  <Iisea.se  iiiav  pro-rress  to 
almost  complete  blindness  in  one  eye  in  unobservant  patieiUs  witli- 
oiit their  kiiowinji  that  anythiiif!;  is  the  matter. 

An  early  .symptom  often  is  the  api)areiit  rapid  advance  of  pres- 
l'yo|)ia,  the  patients  liavinj;  „)  keep  on  chan^rinjj  and  increasin"- 
tlie  streiifith  of  their  jilasses  for  readin-r. 

There  is  MO  injection  of  the  eye,  or  at  most  a  sli-;ht  iiicrea.se  in  the 
size  of  the  anterior  perforatin-;  veins.  To  outward  api)earances 
tio  alteration  m  tlu"  eye  is  to  be  observed.  Th."  cornea  remains 
bri-iht,  and  ,he  pupil  of  normal  size  .ind  reacting;  to  light  The 
anterior  chamber  is  usually  shallower  than  normal. 

The  only  Mibjective  syniptoni  is  the  lo.ss  of  si-ht,  which  coniiiioncos 
at  the  periphery  of  the  field  and  extends  inward.  The  failure  in 
vision  may  be  exceedingly  slow,  exteiidiiif;  over  maiiv  vears  Often 
periect  central  visi<,n  is  ivtained  when  tlu-  fi,.|d  has'  ix^come  con- 
tracted clos,.  up  to  the  central  area  in  all  directions.  The  degree  of 
tension  varies  in  amount  and  in  dilTerent  cases. 

TlKM-e  -ire  ca.ses  in  which  the  tension  is  hardly  evr  found  to  be 
appreciably  increased  by  tlie  finger-test,  but  in  which  th.-  cupping 
ol  the  optic  .hsk  an.l  l,,ss  of  vi.si,,n  .Misue  in  tli.>  same  way  as  in  cas.-s 
of  chr.MUc  glaucoma,  wh.'iv  th<>  inciv;is,-  .,f  t.'iision  is  un.l.mbt.'d  It 
I-  possible  that  111  .<.,m.-  ..f  thes..  .^s.-s  th.'  ti'iisi..!!  b.Tomes  rais,>d 
only  m  tiie  .■veinrigs,  at  which  tim.'s  th.-y  a.v  not  imd.'r  .)b,>.ervation 
ot  the  .<urg.M)n:  or  it  m;iy  b.'  tluit  th.-re  is  abnormal  elasticity  of 
the  lamma  cnbm.si,  which  all.)ws  it  to  be  .lepresse.l  back  witli  an 
cxcv.hngly  slight  incre.'ise  of  th.'  normal  amount  of  int'ra-ocul'ar 
pressure. 

In  .)tlier  c;iv,.s  ,,f  chronic  glaucoma  th.'  t.'iision  vari.'s  in  d.'gree  from 
tim.'  to  time;  "t  may  b.'  as  much  as   J  •_'. 

•<||hthalmosc..pically.cliaract<'risti,.  cupping  .if  th.'  optic. lisk.  with 
a  w.'ll-m;irk.'.i  scl.'fal  ring  .surr.Min.ling  th.'  .li.sk,  is  s.'.'ii.  I'ulsati.ni 
ol  th.'  r.'tui;,!  ..irt.'ries  in  the  vicinity  ..f  th.'  disk  will  be  pivsent  ..r 
r.'adiiv  ..bt.'.m.'.l  by  sli-ht  pr-'.-siire  of  \h-  finger  on  the  glob,'  The 
ch.)r.)i.l  will  pr.'S('iit  a  t.'ss.'llate.l  appearance. 


sr-watai 


ai.ArroMA. 


545 


Diagnosis  of  Primary  Glaucoma. 

In  cases  (if  acute  frliiuoina  the  j;eiieral  (listtirl)ance  is  often  so 
frrcai  lliat  the  fact  tliat  it  is  ail  secondary  to  increased  tension  of 
llic  eye  is  ii;'.l)le  to  h(  overlooked.  Cases  of  acute  glaucoma  not 
uiuMiiiinioiiiy  are  treated  for  sick  head  die,  neuralgia,  erysijieias, 
inlliieiiza,  or  toothache,  and  much  valuable  time  is  thereby  lost. 
'Ihe  I  ipid  failure  of  vision  sliould  serve  at  once  to  distiiifiuish 
jriaucoma  from  such  alTections.  Fhe  siiallow  anterior  chamber,  dull 
coriK.i,  semidiluied  pupil,  and  hicroase  of  tension  should  determino 
tlie  diajrnosis. 

A  dlliiculty  sometimes  arises  in  distinjiuishinji  cases  of  subacute 
primary  fxl.aucoma  from  iritis.  The  difficulty  is  mi  increased  when. 
as  occasionally  happens,  the  iritis  is  a.ssociated  with  increase  of 
Icnsiiiii.  In  both  conditions  the  iris  may  be  altered  in  brightness 
(ir  coliii  The  presence  of  posterior  s\T.('chia'  should  point  at  once 
lu  irili-,  bet  it  maj'  be  difficult  to  ilecide  Wmther  ir  not  any  are 
lirescni  without  dilating  tlie  pujul;  and  if  the  case  is  one  of  [irimary 
jliaucoma.  it  is  very  desirable  not  to  use  a  mydriatic.  In  glaucoma 
there  will  not  Ix'  so  much  ciliary  injection  and  photophobia  as  in 
iritis.  The  anterior  chamber  will  be  shallow,  while  in  'ritis  it 
will  be  of  normal  depth,  or  possibly  deeper  than  normal,  whh 
(l)ile(l  opacities  on  the  back  of  tlie  cornea  (kcmtilif:  punctata). 
The  history  of  the  ca.se  may  assist  in  the  diagnosis.  In  ])rimary 
glaucoma  a  history  of  previous  attacks  of  diimiess  of  sight  with 
an  appe.'raiice  of  rainbow  colors  around  lights  ina\'  be  elicited; 
while  in  iritis  there  may  have  been  a  recent  attack  of  sy])hilis  or 
gnimriiKeal  arthritis,  or  previous  attacks  -^f  .similr.r  inflaiinnation 
in  the  eye  itself  or  the  fellow  eye.  Differentiation  between  these  two 
;iffections  is  of  imi)ortanc(>  in  deciding  whether  to  presc.-ibc  a 
myotic  or  a  mydriatic. 

Confusion  sometimes  occms  in  distinguishing  between  cupping 
of  tlie  o|,tie  disk  due  to  glaucoma,  cupjiing  due  to  atrophy,  and 
iii|)|iing  the  result  of  a  |i!\vsi(ilogical  ])eculii>rity. 

As  already  state<l,  the  glaucomatous  cup  is  due  to  atrophy  of  the 
nerve  librcs  down  to  the  I,  nina  cribros.-i  and  depression  backward 
I'!  tile  lamina  cribrosa.  In  an  atrophic  cup  there  is  no  dejin'ssion 
ba<'k\vanl  of  the  lamina  cril)rosa,  only  atrojjhy  of  the  nerve  Hbres 
i|ii\Mi  to  it. 

Hdtli  the  glaiK'om.atous  cup.  and  the  atrophic  cup  apy  the 
'\li.i|r  area  of  the  optic  disk.  Th(>  latter,  however,  h.  j;radually 
-iiilving  edges,  while  the  former  has  steep  si(l(>s  or  overhanging  edges, 
.iKiuiiii   wiiich   the  retinal  vessels  disapjiear  for  ;i  jiortion  of  their 

lAtrlit. 

The  physiologic,,]  i'U|i  is  produced  by  divergence  of  the  nerve  fibres 
:!-  ilicy  eiiti'r  the  eye  after  piercing  the  'aniina  crii)rosa.    This  diver- 


'jrnce  occurs  ,><ooneroris  more  marke(I  in 
then  a  cup  or  depression  is  found  in  the 


some  eyes  thai)  in  others: 
head  of  the  nerve.     It  is 


sp-s^sa/r^s^:. 


^^^SS^S^S 


54G  riiK  i:ye. 

(listiKgiiislicd  from  tlio  other  two  forms  of  cui.pinjr  l.y  never  orciipv- 
in«  the  whole  area  of  the  optie  disk.  I.ik."  a  {ilaiicomaloiis  eup.'it 
sometimes  has  an  overhaiif;iii>;  eiljje,  aroimd  whieh  tiie  n'tinal  vessels 
are  seen  to  emi;  tliis  may  at  times  lead  iiiexperieiieed  observers  into 
making  an  erroneous  diagnosis.  whi<  ii  cap  l.e  avoided  hv  ohservinji 
that  only  a  portion  of  the  disk  is  invoiveo. 

The  diatriiosis  iM-tweeii  eases  of  ehroiiie  >;laiU'oma,  where  the  tension 
IS  not  increased  at  the  tirne  the  patient  is  s.>en,  and  cases  of  primary 
optic  atrophy,  is  not  always  easy,  liesjdes  the  diderences  in  tlie 
character  of  the  cnppini:  of  the  nerve  just  mentioned,  pulsation  of 
the  retmal  arteries  in  the  vicinity  of  the  disk  should  he  looked  for. 
Its  presence  should  [loint  at  once  to  friaucoma.  l!  d.sent.  a  slijiht 
amount  of  pressure  should  he  made  on  the  <;lol)e  with  the  hnfier,  to  see 
if  it  can  easily  he  evoked. 

The  character  of  the  field  of  vision  mav  he  of  considerahle 
a.ssistance  in  distinjtuishmj,'  hetween  these  two  nfTections.  A  con- 
traction of  the  imier  part  of  the  (iel.l  is  a  characteristic  .svmptom 
ot  filaucoina.  The  field  in  holh  conditions  mav  Ik-  conceiitrically 
eoi.'tracted  or  present  .sector-shai)ed  defects.  Iii  atrophv  the  fields 
tor  color  will  he  nmtracted  out  of  proportion  to  that  for  white,  or 
there  may  he  complete  color  hlindness;  while  in  jjlaucoma  the 
contniction  of  the  fields  for  color  is  always  concentric  with  that  for 
white,  and  color  hlindne.s.^  is  met  with  <!nlv  in  the  latest  sla-'cs  of 
the  disea.se.  "  '^ 


Varieties  of  Secondary  Glaucoma. 

As  the  result  of  various  different  diseased  conditions  of  the  eye  a 
deran-remen;  of  the  circulation  ,,f  the  intra-ocular  fluid  is  liable  to 
occur,  result 'iiji  in  increased  tension. 

The  different  dise;i.ses  in  connection  with  which  secondary  glau- 
coma occurs  are  dealt  with  in  detail  in  other  portions  of  tlii.i  work: 
it  is  necessary  here  only  to  emimenite  them,  and  to  point  out  the 
maimer  m  which  each  iiiteneres  with  the  circulation  .so  as  to  produce 
the<r|aucoinatouscoiidiii(in. 

Posterior  Synechiae  of  Iris.  As  the  result  of  iritis,  the  pnpillarv 
mar-:iii  of  the  iris  may  l.econie  adherent  to  the  lens  capsule  in  its 
entire  circumference,  a  condition  spoken  of  as  annular  posterior 
synechi.-t.  The  aqueous  humor  then  is  ohstructed  in  its  pa.ssafje  for- 
wanl  throufrh  the  pujiil  into  the  anterior  cliamher.  It  accumulates 
hetween  the  iris  and  lens,  l.owinj;  the  former  forward  and  producin<' 
the  condition  teniKMJ  iris  homhe.  At  first  this  accumulation  of  lluid 
hehmd  tlie  ins  is  compeii.sated  for  hy  escape  of  lluid  from  the  anterior 
chamber,  lllimately  the  root  uf  the  iris  comes  into  cont.act  with 
the  back  of  the  cornea,  so  that  not  oiilv  is  pa.ss;i<;e  of  fhiid  throufiii 
th-  puijd  (ibstnicted,  but  also  any  esc-ipe  tlmiuKli  the  .space,-  of  Fon- 
tana.  The  tension  then  hecoines  increa.sed. 
This  is  ;i  form  of  secondary  frlaucoma  which  is  readilv  relieved 


GIAL'VOMA. 


o47 


l>v  iriilcctoiiiy.  When  ;i  i>(irti(iii  nf  tlic  iris  is  ri'iiiovcd,  lluid  can  a^aiii 
piiss  I'uruani  into  lln'  anterior  ciiainiicr  and  tiic  normal  circulation 
will  he  re-<'sial)lislied. 

Sometimes  as  tiie  result  of  iritis,  not  only  the  pupillary  marfjin,  l)ut 
a'<o  the  whole  of  the  posterior  surface  of  the  iris  becomes  utiited  to  the 
lens  cajjsule,  a  condition  known  as  tutnl  intslcnDr  sunccliia.  Where 
this  is  present,  the  secretion  of  the  ciliary  body  is  unable  to  tind  its 
way  forward  between  the  iris  and  lens.  It  accuimilates  in  the  vitieous 
ciiamber,  increasinfi  the  pressure  there,  and  forcinj;  forw.ard  the  lens 
and  iris.  When  the  root  of  the  latter  conies  into  apposition  with  the 
periiihery  of  the  cornea,  farther  escape  of  fluid  from  the  anterior 
chainber  throufih  the  filtration  area  is  blocked,  and  fjlaucoma  becomes 
established. 

The  relief  of  tension  in  this  condition  by  iridectomy  is  not  an  easy 
matter.     It  is  very  diilicult  to  remove  a  piece  of  ivh  wliich  will  allow 


iliuiiiimii  M'l'oiiilBry  to  iritis  and  tlie  formution  of  aiimiliir  ixieterior  ^yiicohia.    Flui'l  fti-cumulating 
ill  il.f  |««tirior  iliamlicr  lias  bowed  the  iris  lorwanl  into  loiitact  with  the  back  of  the  cornea. 


lit  the. satisfactory  passage  of  fluiils  forward,  so  firmly  is  it  bound 
down  and  so  frail  (h.'s  its  (issue  become. 

Anterior  S3mechi8e  of  Irk  liie  formation  of  an  extensive  adhe- 
sicin  of  the  iris  to  the  scar  tissue  left  after  a  perforatiiif;  ulcer  of  tlie 
iiiriiea  may  prevent  jias.sajre  of  fluid  throuflh  the  i-upil,  so  that  the 
whole  anttuior  chamber  becomes  obliterated.  The  at|UO()Us  hmnor 
iiccumulates  between  the  back  of  the  iris  and  lens:  none  can  piin 
exit  from  the  eye  tiiroufih  the  spaces  of  Fontaiia  or  throiifili  the  lymph 
spai'cs  on  the  anterior  surfare  of  the  iris.  The  tciision  then  is  iii- 
ereased.  as  the  result  of  which  tlie  recently  iiiHamed  and  softened 
corneal  tissue  jtives  and  iiecomes  staphylomatous. 

.\  less  extensive  adh(>sion  of  the  iris  to  the  cornea,  which  does  not 
involve  tiie  entire  circumference  of  the  pupil,  may  cause  it  to  bo 
-o  lirawn  i'orwanl  as  to  iiiinj;  its  idot  into  coiilacl  with  the  l);ick  of  tlie 
lornea.  \\\  an  obstruction  to  the  passage  of  fiui  I  throuph  its  nnin 
exit  at  the  angle  of    '.     'Ulterior  chamber,  glaucoma  is  established. 


/.Ji-i'Jl 


54» 


77//:'  rvi:. 


Siicli  an  ()l).-itriicti(Pii  is  especially  liai)le  to  occur  when  a  cornea  hccotnes 
stapiiyloinalous,  as  an  increase  in  the  jiroininence  of  it  tcmls  to  draw 
the  iris  still  t'artlier  I'nrwanl. 

Anterior  Synechiae  of  Lens  Capsule  or  Hyaloid  Membrane  of 
Vitreous.  Alter  the  operations  of  extraction  of  cataract,  or  discission, 
or  after  woiimls  of  the  eye,  adhesions  of  liie  capsule  or  portions  of 
tile  vitreous  huinor  to  the  cornea  .are  lialile  to  form.  These  struc- 
tures, norin:dly  situated  behind  the  level  of  the  iris,  when  advanced 
in  position  in  this  w;iy.  may  so  draw  it  forward  as  to  hriiif;  its  root 
into  contact  with  the  hack  of  the  corne;i.  lilockinji  the  filtnition  area.' 
(ilaucoma  may  tlius  he  produced,  even  when  iridectomy  has  heen 
performed,  the  liltration  area  opposite  the  colohoma  heiiiji  lilocked 
by  a  small  piece  of  the  root  of  the  iris,  which  has  heen  left,  or  hy 
the  most  anterior  of  the  ciliary  processes,     (jlaucoina  hu.s  occurn  . 


Ki(i.  Hi 


'■'"'"■""'"  ^' '"O'  I"  til.;  fornmlimi  of  an  anlerinr  sjiiwhhi  of  ihe  liMis  caiwiili-  afler  I'xlniction 

cif  cHiarart.  .Vii  irlilfii..my  iia.l  Iveii  inTlormcl.  Imt  111  thu  ririipii  of  ilie  culuU.nm  Ihc  liltration 
ar™  i.«  iiloik.'.i  Ijy  the  anterior  of  the  i-iliary  (.riK'esses,  ilravvli  forwar.l  by  the  M.lherent  eapsuie. 
Oh  the  opi.ijiie  Mile  Ihe  angle  of  the  anterior  ehainher  is  bioeke.l  hy  a  broad  aiiliesion  of  the  root 
of  thi'  iris. 

when  tlie  whole  of  the  iris  has  escaped  through  a  wound  (traumatic 
aniridia-),  the  liltration  area  heiiijr  hlockeil  in  its  entire  circum- 
ference hy  the  anterior  of  the  ciliary  jiroces.ses,  dniwn  forward  hy 
re.i-ioii  of  adhesion  of  tiie  lens  capsule  to  the  cornea. 

Wounds  of  the  Lens.  Increase  nf  tension  sonietimes  results  from 
swelliiijr  of  the  lens  sulistaiice  in  its  capsule,  after  some  of  the  .•i(|ueous 
humor  has  heen  ;iilinitted  to  it  throujrh  a  wound.  In  such  ca.ses 
the  swollen  lens  seems  directly  to  pnw  forward  the  iris  and  close  the 
filtration  .irea.  The  tension  c-iii  usually  he  relieved  hv  making  a 
freer  o|ieninf;  in  the  caiisule  ;iiid  allowiiij:  .some  of  the  lens  matter  to 
escape  from  the  eye  or  into  the  .anterior  chamher. 


1  Transaction-  of  the  (i|,lithMhn.iloi:ii'aI  Sieiely  of  the  L'liiteil  Kinplom,  I.swi.  vol.  s.  p.  li)8. 
-'  0|ihlhillniic  Review,  lv.)|.  vol.  x.  p.  Iu."i. 


ULMCDMA. 


540 


Iiicrciisc  (if  tonsion  iimy  also  ncctir  after  wimiids  of  llic  lens,  wlicii 
tliirr  lias  twcii  ;i  free  oii(>iiiiiK  madi'  in  its  cmiisuIc  and  sonic  of  tlic 
lens  matter  has  conif  forward  and  dissolved  in  the  aqueous  humor. 


Kio.  3X. 


r.lHucoma  KCf oiiclsrv  to  dlslocBtion  of  the  leiw  Into  (he  luitcrior  chamber.  The  lei.s  wax  In  contact 
witli  the  Cornell.  "O'l  tlie  iris  closely  i.rcn-cl  foriviinl  inUi  c.nit»(  t  with  the  inTivhery  of  the  cornea 
hikI  hiuli  of  the  lens     In  the  iircpurution  ol  the  s|iecinicn  the  •trnctnrcs  h;ive  fMllen  ^liuhtly  aiart. 

1 ihrnpl  iK'M.l  In  the  iris,  wlivre  it  ceawl  to  be  in  contact  with  the  cornea  and  |Misse<l  into  conuct 

«i,h  ihc  lens,  i»  «ell  shown. 

.\fter  the  operation  of  discission  for  lamellar  rataraet  iiiereased 
tension  is  of  not  uncommon  occurrence.  The  aijueous  humor  liecomes 
loaded  with  the  colloid  substance  fjloliulin,  of  which  the  lens  is  mainly 


Fi.i.  K 


^J^ 

^^ 

^ 

^ 

1 

p 

^ 

^ 

w    ^ 

1 

nirtiicoma  secoiKliiry  to  traiunatic  dislocation  of  the  lens.  The  displaced  lens  has  presseil  forward 
the  iris  into  conuiet  with  the  back  of  the  cornea.  The  iris  and  ciliary  body  where  they  were  in 
iil.|>.sitinii  with  the  lens  are  much  atrophied.  In  the  preparation  of  the  specimen  an  oljvious 
sliclit  alteration  in  the  poKition  of  the  lens  has  taken  place. 


com[)o.sed:  it  is  then  much  le.ss  easy  for  it  to  hlter  out  of  the  eye 
than  in  its  normal  condition.  It  is  possible  also  that  bits  of  undis- 
y<-]\-<;\  liTis  substance  may  Ix'oome  entntfwled  in  the  mesh  of  the 
li^amentum  jiectinatum  and  fill  up  the  sjiaces  contained  in  it.  In- 
creaseij  tension  broufiht  about  in  this  way  is  always  readily  relieved 
by  a  jiaracentesis  and  evacuation  of  the  lens  matter. 


650 


nit:  i:Yt:. 


Dislocation  of  the  Lens.  (Ilauconin  is  a  not  iiifrc<|iii'tit  jir-rom- 
paiiinicrit  nf  dislocatioii  of  tlic  lens.  Cases  arc  met  with  in  wjiich 
tiif  suspensory  lipmierit  is  ilclicient  in  a  portion  of  its  cireinnfereiice, 
atiii  the  remain. ier  so  attachecj  as  to  allow  the  lens  to  sway  haekward" 

anil  forwani  will venii'iits  of  the  head.     In  sotne  of  these,  wiien 

the  patient  hanjis  his  head  down  and  the  lens  falls  forvvard,  the  oeiilar 
tension  Imtoimcs  inereased.  returninji,  however,  to  normal  when  he 
raises  his  hea<l  and  the  lens  falls  hack. 

Siniilaii\ ,  permanent  displacement  forward  of  the  lens  into  the 
anterior  chamlHT.  either  completely  or  |>artially,  caii.ses  increa.so  of 
tension.     The  displaced  lens  tills  up  tlie  pupil  and  blocks  the  passage 

of  fluid  through  it.    The  acjueous 
Km.  s-.>H  humor  then  accuiimlates  in   the 

vitreous  chamlM'r.     (I'ifj.  :\2i\.) 

Wheti  the  lens  is  displaced 
backward  or  laterally  and  in- 
creased tension  results,  the  angle 
of  the  ant<'rior  chainlMT  is  always 
found  do.sed.  The  relative  altera- 
tion in  position  of  the  len.s  and 
vitreous  body  seems  to  force 
directlv  forward  the  root  of  the 
iris.     lV\fr.  ;j27.) 

Serous  Cyclitis.  Mhen  the 
ciliary  body  is  inflamed,  the  fluid 
secreted  by  it  is  in  excess  and 
altered  in  character;  it  is  more 
serous  than  normal,  an<l  is  mi.xed 
with  a  number  of  formed  ele- 
ments, leucocytes,  and  cells  which 
have  desiiuainated  from  the 
secreting  .surface.  The  increased 
amount  of  albumin  in  the  fluid 
makes  it  m.)re  dimcult  for  it  to  filt.r  out  of  the  eye.  The  formed 
elements  in  it.  .'is  they  pa.-^s  through  .'le  ligamentuiii  pectinatum,  pet 
caught  in  the  mesh,  and.  accunmlating  there,  cause  obstruction 
(Fig.  .'il'S.) 

There  are  then  these  three  factors  v.hich  combine  to  give  rise  to 
increased  tension  in  serous  cyclitis;  ( li  excess  of  secretion;  (2l  albu- 
minous characler  of  tiie  aijueous  humor;  (.'})  accumulation  of  inflam- 
matory cells  in  the  spaces  of  I'ontana. 

The  obstruction  to  the  circulation  of  the  fluid  being  primarily  at 
the  outlets  from  the  .anterior  chamber,  and  ;he  !ilbuminoiis  character 
of  the  fluid  making  it  diflicult  for  it  to  filter  through  the  anterior 
hyidoid  iiieiiil.ra!!.-  iiito  tlie  vitrcuus,  .-in  ;iccutiiulati(Hi  takes  place  in 
the  ;intenor  chamlier.  which  becomes  deepened,  the  lens  and  iris 
being  depressed  backward.  The  glaucoma  in  such  ca.ses  is  treated 
best  by  rejieated  jiaracentesis,  rather  than  iridectomy, 


Angle  iifthc  anterior  rhambcTlnttiiiyi'  which 
hjMl  Klanc.Mnii  Neeondary  In  semuH  iriiiiK'ytiitis, 
!t  flioHs  wi.le  !.e|iaraliiin  of  the  root  of  the  Iris 
from  the  \m\  of  the  cornea,  hut  an  aci'iiinn. 
laticjn  of  intlii'ninatorycellson  Die  Inner  !:nrlace 
of  Jiescenie*  'lenibruiie  and  in  the  niesh  of 
the  liKanicnt.      i>eclin»tiiin. 


OLA  VCOMA. 


6S1 


Intra-ocular  Tumors.  A  turnor  niuwinn  forward  Intm  the  ri'tiiia, 
,,r  iHii.a'li  iIk-  ri'iiiia  I'rntii  tin-  clu.rui.l,  inuls  to  increase  the  pressure 
in  tiie  vilreuus  eliaiiil«'r.  This  may  I'nr  a  time  l.e  eompeiisated  fur 
|,y  an  increase.l  eseape  of  Ihiiil  tn.iii  the  vitreous  into  liie  ai.  erior 
ciiamlier,  iiiwi  an  increased  es<'ape  from  the  eyi-.  Gradually  the 
vitreous  Ix'comessoeonipressed  that  fluid  is  less.uMl  less.'asily  j.resM'd 


out  of  it.    Tlie  tension 
tliati  in  IIk-  anterior, 


..  then  in  tlie  vitreous  elia      .er  Iweomes  greater 
tlie  lens  and  iris  are  pushi-d  forwMnl  until  the 


root  of  till'  latter  eon 


les  in  eontart  with  the  filtration  area  in  tin 


niriiea,  :<nil  a  permanent 
stahlished.      (KiH-  ."Sl'JI.) 


hloek  to  the  eseape  of  fluid  from  the  eye 


IS   ( 


In  a  eas( 
iiif-rease  o 
tana  contain  cells  similar  in  ( 


are,   n 


liarv  hoilv,  which  has  caused 


,-,  of  sarcoma  of  the  iris  or  ci      _  . 

f  tension,  it  will  nenerally  In-  found  that  the  spaces  of  Kon 


haracter  to  those  of  the  growth.     They 


iiturallv,  most   numerou? 


in  the  part  in  the  vicinity  of  the 


jrmwth,  hut  m.ay  alsi 


Ih-  met  with  in 


part." 
ani: 


c|Ult 


e    reino 


te    fr 


■om    it. 


Th. 


rui.  3.".), 


le  of  the  anterior  chamlHr  may 
also  he  found  closed,  hy  the  root  of 
the  iris  havinji  heeii  directly  pushed 


laaiicniim  sfiiiiiilary  to  melsncilic  nar- 
cdiim  of  the  cillHry  l»-ly.  The  loos  In 
>lio«ii  illrt'CIly  preswl  f(ir»«r.l  by  the 
pn.Mlh  The  kukU' of  ihc  anterior  eh«m- 
btr  l«  el  iseil  by  coiilael  of  the  root  of  the 
Iris  anil  cornea. 


fiirwaid  hy  the  growth,  or  hy  thick- 
(  ning  of  till-  root  of  the  iris  Sy  the 
jrrowth  itself. 

Epithelial  Cysts  in  the  Anterior 
Chamber.'  AVhen  an  oiM-ning  has 
been  made  into  the  anteri  'r  cham- 
ixr,  either  l>y  an  operation  or  acci- 
dentally, some  t)f  the  surface  epi- 
thelium may  he  imi)lanted  or  spread 
liliinj;  the  wound  into  Hie  anterior 
cliamher.  Tl"'  epithelium,  subse- 
.|uenllv  forming  a  cyst   which    fills 

the  wli.ile  anterior  chamber,  obstruct  *  the  passage  of  ai|iieous  humor 
into  it,  and  causes  increase  of  tensio". 

Detachment  of  the  Retina,  (ila  icoma  sometimes  comes  on  m 
eves  with  simple  detachment  of  the  retina.  When  this  is  the  case,  the 
|.Ve.-;ence  of  an  intra-ocular  growth  is  gem-rally  suspecteil.  and  often 
ii  is  not  imtil  the  removal  of  the  eye  that  it  is  ascertained  definitely 
tliat  the  condition  is  one  of  simple  detachment.  The  extent  of  thn 
(iit.ichment  is  usuallv  great,  ami  the  vitreous  much  .shrunken.  Some 
li'iiiorrhage  or  serous"  etTusion  into  the  subretinal  sjjace  forces  forward 
tlie  lens  and  iris,  blocking  the  angle  of  the  anterior  chamber,  much  in 
till'  same  wav  as  in  the  case  of  an  intra-ocular  growth. 

Thrombosis  of  the  Retinal  Veins.  The  coiulition  which  is  coin- 
:iHK:!v  >\<nlrn  of  as  "  hemorrh'tgic  retinitis"  is  probably  m  inost 
cases  due  to  thrombosis  of  the  central  retinal  vein;  it  may  sometimes 


1   rnnistifiinn'- 


of  iho  OphthBlmoU)«ical  Scicicty  of  the  Cnite*!  Kinirdom,  1«92,  vol.  xU.  p.  175. 


552 


Tilt:  Kit: 


!><•  the  |.ri'ciir.s.ir  nf  an  attack  nf  ulaiicmiia.  The  syiii|i|..iiis  of  tin- 
attack  ri'scinhic  th(.s<'  of  a  caw  of  primary  jilaiiconia.  from  which 
it  can  only  U-  (hsiiiiduishcd  hy  the  [.rcscniT  of  numerous  hcmor- 
rUaiiifi  scaltcrt'd  over  the  retina,  an.l  the  enlarKement  of  the  retinal 
Ni'ins. 

Thromliosis  of  the  ntinai  vein  is  mostly  met  with  in  elderly  jM-ople, 
and  may  exist  without  any  increas*'  of  ocular  tension. 

It  seems  proljaiile  that  it  is  only  in  those  i-yes  which  ar  struc- 
turally predisposed  that  glaucoma  is  set  u|),  increase  of  pressiri'  in 
the  vitreous  chamlier  lieini;  'I"'  excilin;;  cause.  The  venous  enfior^je- 
ment  and  serous  elTusiou  into  the  retina,  together  with  the  .serous 
effusion  into  the  vitreous  which  follows  throml)osis.  cause  this 
increas.'  of  pressure.  In  such  c;i.ses  the  iris  and  lens  an-  pressed 
forward  and  the  an>;le  of  the  :inferior  ehatnU'r  closed.  It  is  a  con- 
dition which  it  is  very  necessary  to  dinerentiate  from  primary  ulaii- 
eoma,  iM'c-iuse  operative  procedures  on  such  eyes  are  followed 
freijueiitly  l)y  extensive  and  ilisastrous  heiiiorrhaci'. 

When-  possible,  ojMTations  in  such  casi-s  should  he  avoided,  pref- 
erence heinn  niveu  to  treatment  with  myotics.  If  an  oin-ration 
Ix'comes  urgently  necessary,  a  paracentesis'or  sclerotomy  should  he 
IMTformed.  the  esca|M'  of  fluid  and  lowering  of  tension  iK'iuK  effected 
as  gradually  as  possible. 

Congenital  Aniridia  and  Coloboma  of  the  Iris,  lint  glaucoma 
can  sufxTvene  when  there  is  ap|)arently  entire  congenital  absence. 

Fill.  a.10. 


eoliK.Miital  aniridia  in  mIikIi  Klani-onia  Hilli  »i-.l  on  a  i^rl.TatiijK  ulr.r  nl  th.;  i.iriwa.  The  an^lt 
"I  thennuriori-liumUTisshmni  l.liH.-',t.i  bv  a  very  nHliriu-niury  irs,  wh::  ;i  was  «.,sniall  as  m.t  lo 
U-  visible  vlinii'ally.    It  nas  U«>nie  ai.:.erent  t()  llie  bai-li  iif  tlic  fonrca. 

or  ;icol(.h,,in;i  r.f  the  iris,  seem.-  at  first  wholly  (■  u  of  keepinji  with 
till'  fad  libit  an  iridectomy  is  the  most  ofTective  ,,eatm(>nt  for  the 
n  iief  of  tension.  Several  cases  of  fil.mconia,  both  primary  and 
seconil;iry,  in  association  with  the.se  defects  have  been  recorded.' 
•Fijj.  ;!;!().;■      i'atliolo^ica!  exainination  of  f■ye.■^  with  these  di-feets  lias 


'  OphthalL  io  Heview.  isin.  [..  101;  Transactions  of  the  Ophthalmological  Society  of  the  fnlted 
Kingdom,  iwftj.  vol.  xiii.  \>  12h. 


)1  LA  I  COMA. 


5d3 


slinwii  tl.jit  the  ciliary  Imdy  really  iuIh  in  a  fTiiall  nidiiiifntiirv  iri^<, 
wiiicli,  thiiiiuli  (Hit  (if  siitlii'ir-iit  li  until  ti.  rciKlcr  it  visible  heyond 
the  scleriicdriieal  margin,  is  of  siitlicietit  size  wlieti  pressed  fiirwaril 
tn  Idiiek  the  liltraliiiii  area.  In  two  case's  where  iiicreasfnl  tension 
was  |ireseiit  the  rudimentary  iris  was  actually  found  bl(M-kinff  the 
lilt  rat  ion  area. 

There  is  rea.son  to  iM-lieve  that  ('a-ses  with  congenital  d' :  ,  's  of  the 
iri>  may  Ih'  |iredis|iosed  to  glaucoma.  Strands  of  tissue  have  In-en 
liiinid  .sirelchiM^  from  the  anterior  surface  of  the  defective  iris  to 
the  li);amenlum  peciiiialnni,  showing  a  conjjenitally  imperfect  sepa- 
ration of  these  structures. 

Congenital  Glaucoma,  or  Primary  Buphthalmos. 

liiilarcement  of  the  cornea,  and  the  jiroduction  of  a  condition  rc- 


ilii 


semlimijT  a 


hullock's  eve,  tnav  occur  as  the  ri-sult  of  increased  int 


ra- 


ocular  tension  in  children,  in  whatever  way  that  increa.se  is  Wrougiit 
aliiiut. 

Then'  is  ;i  form  of  buphthalmos  that  is  not  the  result  of  any 
obvious  precedent  di.sease,  and  tiiat  may  In*  termed  prim.'iry.  In 
many  such  cases  a  definite  history  of  the  .-^yinptoms  dating  from 
birth  can  Ik-  obtained,  and  jirobably  so  in  all,  the  symptoms  in  stime 
at  first  Immiik  so  slight  jis  to  es"ai)e  observation. 

The  increase  of  tension  is  unaccompanied  by  injection  or  other 
,'ic\ile  sympt.iins.  The  enlargement  of  the  glolw  continues  steadily 
without  pain.  It  is  not  only  the  cornea  th;it  is  increased  in  size, 
iiul  the  whole  eyeball  in  all  its  meridians  as  well. 

The  measurements  of  the  '.'ve  of  a  boy,  aged  four  years,  which 
was  affected  in  this  way,  \ver»*:  antero-posteriorly  2N  mm.,  vertically 
'_'()..")  mm.,  while  the  diameter  (  '  the  cornea  was  14.5  mm.  Besides 
liaving  its  diameters  increased,  :.i'  cornea  becomes  more  <'onvex  and 
globular  in  sliai)e. 

The  stretching  of  the  cornea  and  sclerotic  occasions  thinning  in 
tlie  latter.  This  thinning  allows  of  the  pigment  of  the  uveal  tract 
being  seen  through,  .so  that  it  appears  of  a  bluish-gray  color. 

The  anterior  chamber  becomes  very  deep,  aid  the  iris  is  often 
Irciiiulou  ■  ;in  movements  of  the  eye,  from  weiikeniiiiiuf  the  susjiensory 
liiiatiient  or  fluidity  of  the  vitreous  behiml  it.  ()phthalmoscoi)ically, 
the  o|)lic  disk  is  fiumd  deeply  cup|)ed. 

In  some  ca.ses  the  increa.sed  tension  pei"sists,  and  failure  of  sight 
.-leadily  progresses  until  the  eye  becomes  quite  blind.  In  others,  a 
spontaneous  relief  of  tension  occurs,  and,  altliough  the  eve  rrmain.s 
l"Minanently  enlarged,  there  is  no  further  increa.se  in  size  or  deterio- 
rniiun  of  sight 

.\  congenital  malformation'  in  the  cliannels  of  e.\it  of  fluid  fr>  ui 


'  Triachor  Coll   ...  Kesearchi-s  Into  the      latomy  and  PatholngT  of  the  Eye,  p   104.    F.  R.  C- 
Trunsactlons  of  the  ophtbalmoluglcal  So....y  of  the  United  Kingdom,  vol.  xvl.  p.  ;i04. 


554 


THE  EYE. 


tlic  <>yp  is  the  |)r<)h:il)l('  cause  of  tin-  iiicrcMsc  of  tension  in  these  cases. 
Ill  some  a  conjieiiital  ailiiesion,  or.  ratlier.  failure  in  separation  of 
the  peripiierv  of  tile  iris  ami  l)aci<  of  tile  cornea,  lias  been  foiiiul.  in 
some,  strands  of  tissue  about  the  ariftle  of  tiie  anterior  chamber,  suji- 
pestive  of  ;iclliesi()iis  which  liad  become  stretched  and  broken  down 
by  the  collection  of  fluid  ill  the  anterior  chamber,  wliich  forced  hack- 
ward  the  iris  and  forward  the  corne;i.  Such  a  breakiiifi  down  of 
conjreiiital  adhesions  which  at  one  time  existed,  explains  the  cases 
ill  which  spontaneous  relief  of  tension  occurs.  In  other  cases  the 
canal  of  Schlemm  was  stated  to  be  c(iiij;eiiitally  absent. 

The  o|)orations  of  iridectomy  ami  .sclerotomy  in  tliese  cases  fre- 
(jucntiy  fail  to  relieve  tension  or  to  check  the  expansion  of  the  globe. 

Kl(i.  331. 


Tin- atiKle  of  the  anterior  clmmlier  iii  a  cat*  ol  euiiKenital  KltiticDinii  or  primary  bupbthalmo^. 
Showing  a  t'otigeiiital  adhfsinn  of  ihu  root  uf  the  irl:*  t-j  thr  hack  of  the  (!oriica.  The  rest  of  the  iris 
is  vvitlfly  K.'piirHle<l  from  tile  cornt-a,  the  anterior  chamber  having  been  very  <ieep. 


and  ait  attended  with  jireater  risk  than  in  cases  of  glaucoma  in  the 
adult. 

The  expansion  of  the  globe  causes  stretching  and  weakening  of 
the  suspensory  ligament  of  the  lens,  wiiicli  renders  it  very  liable  to 
rujiture  on  the  escape  of  atjueous  from  the  deepened  anterior  cliain- 
iier.  Dislocation  of  the  lens  or  loss  of  vitreous,  which  is  usually  of 
a  fluid  consist. 'iicy,  are  complications,  therefore,  likely  to  occur. 

Hepeated  paracentesis  and  the  u.se  of  myotics  have  Iweii  ('inployed 
as  altcriiatixc  measures,  and.  although  attended  with  less  danger, 
are  fre(|ueiitly  ('(pially  unsuccessful  in  checking  the  progress  of  the 
afl'ection. 

i  he  appe.ii.iiices  of  Mime  ol  (he  eycN,  wiiicli  liavf  been  removed  for 
this  condition,  suggest  that  the  adherent  tags  of  ti.ssue  about  t hi' root 


OLALXOMA. 


655 


of  the  iris  iiiiplit  bo  (lisonfraRo I  or  incised  l)y  tho  point  of  ii  knife 
]),(ssc(l  into  the  cxlrcnic  angle  of  tlie  ('liiinii)er.  Such  an  operation 
lias  JK'cn  practised  i)y  \'incenti'  for  jjlauconia  in  the  eyes  of  older 
people. 

Pathogenesis  of  Primary  Glaucoma. 

The  whole  scfuienoo  of  events  whidi  result  in  the  production  of 
increased  tension  in  primary  glaucoma  is  hy  no  means  so  obvious  as 
in  some  of  tlie  secondary  forms  of  the  afTectiim.  It  is  nee(lless  here 
lo  enter  into  the  'lumerous  theorii's  which  liave  been  suggested  as  to 
the  origin  of  this  disease,  many  of  which,  with  the  growth  of 
knowledge  respecting  the  intra-ocular  circulation,  have  beeti  shown 
til  be  unten.able. 

Any  increase  of  secretion  into  the  eye  is  compensated  for  by  an 
iiK  rease(l  outllow.  so  that  no  theory  of  the  pathogenesis  of  glauci  ina 
based  on  an  incn^ased  secretion  alone  cm  be  accepted.  We  must 
look  to  the  channels  of  exit  of  (iuid  from  the  eye  for  some  obstruc- 
tion to  account  for  the  increased  intra-ocular  ]iri'ssure. 

As  pointed  out  by  Max  Knies  and  Weber,  the  filtration  area  at 
the  angle  of  the  anterior  chamber  in  primary  glaucoma  is  found 
obstructed  by  ajiposition  or  adhesion  of  the  root  of  the  iris  to  the 
periplu'ry  of  the  cornea,  the  iris  apparently  Iwing  puslied  forward 
l)y  |iressure  of  the  ciliary  processes  against  its  root. 

If  a  l)lock  to  the  exit  of  fluids  from  the  eye  at  the  angle  of  the 
anterior  chaml)er  is  the  primary  cause  of  glaucoma,  we  should 
expect  to  meet  with  an  accumulation  of  acpieous  humor  and  a  deepen- 
ing of  the  anterior  chamber.  Instead  of  this,  we  find  the  anterior 
chamber  shallowed,  the  shallowness  often  |)receding  the  onset  of 
increased  tension. 

I'riestley  Smith  has  met  this  difficulty  by  suggesting  that  there  is 
:il  first  .-m  accumulation  of  fluid  in  the  vitreous  chamber,  due  to 
oi)sl ruction  at  the  circumlental  space,  which  causes  the  lens,  iris,  and 
ciliary  )irocesses  to  be  pressed  forward.  He  luis  shown  that  changes 
which  pre(lis|)ose  to  narrowing  of  the  circumlental  space  predisjiose 
to  glaucoma.  It  will  be  well  here  to  (piote  his  words  in  which  he 
sums  up  his  \iews  on  this  mafter;- 

''  I'rim.iry  glaucoma  a|)iiears  usu.ally  to  <l(>p(>n(l  on  some  vascular 
disturbance  which  congests  the  uve:d  tract,  or  upon  a  faulty  relation 
nf  the  lens  to  the  jiarts  around  it,  or  upon  both.  If  the  patient  l)e 
elderly,  we  know  that  the  lens  is  relatively  large.  If  the  cornea  be 
small,  we  may  infer  that  the  whole  eyeball  is  small,  and  that  the  rela- 
iiiin-i  of  the  lens  are  such  as  to  preilispose  to  compression  of  the 
liltration  angle,  es|H'cially  during  tlilatation  of  the  pupil.  An  obstruc- 
tion in  the  region  of  the  hyaloid  and  the  circundental  space,  which 
checks  the  escape  of  surplus  fluid  from  the  vitreous  and  leads  to  an 

'  Revuf  Ki'ih'Tiile  <VO[>h.,  November  30,  l*i'H. 

-  Norriaand  Oliver,  System  ol  Diseaaes  of  the  Kye,  vol.  111.  p.  6,'*. 


556 


Tin:  ICYE. 


advance  of  the  lens,  appoars  to  W  present  in  many  rases.  Slackness 
of  llie  zonular,  witli  eonsei|uenl  instability  of  the  lens,  is  prohalily  a 
rontiihutory  cause.  'rhrou;;li  one  or  other  of  these  causes,  or  several 
in  conihination.  tiie  ciliary  proce.s.ses  are  jiresseil  ajjainst  the  iris,  and 
the  tiltration  anjile  is  narrowed  or  closed." 

I'anas.  .lonnesco,  and  others  look  for  an  ex|)lanation  of  the  incr(>asetl 
tension  in  jrlauconia  to  .some  disturbance  in  the  controllinjr  action  of 
the  nervous  system  on  the  intra-ocular  prc-^sure.  .-\s  already  stated, 
oui'  knowledfre  of  this  controllinj;  action  is  at  present  incomplete. 

The  reduction  of  tension  in  ,<;laucoma  which  .lonnesco  has  been  able 
to  effect  by  resection  of  the  superior  ccrvicnl  sympathetic  panjilion 
lias  led  h^m  to  formulate  the  theory  that  glaucoma  is  due  to  iieriplieral 
or  central  irritation,  either  peinianent  or  intermittent,  of  the  ocular 
sympathetic  fil)res  which  pass  thniufih  it.  The  effects  on  the  eye  of 
such  irritation  have  been  mentioned.  The  dilatation  of  the  pupil, 
whi'ir  is  thereby  produced,  mifrlit  alone,  in  an  eye  with  ;i  slialli  : 
anterior  chamber  and  predisposed  to  filaucoma,  be  sullicient  to  bncp 
on  increase  of  tension,  just  as  atropine  mydriasis  sometimes  does. 

Th''  influence  which  emotional  disturbances  sometimes  have  in  the 
production  of  jjlaucoma  may  po.ssibly  in  this  way  find  an  expl.-i nation. 

Treatment  of  Primary  Glaucoma. 

Fifty  years  ajro  jrlaucoma  was  an  incurable  dis(>ase.  lentil  von 
(iraefe  introduced  the  treatment  of  it  by  iridectomy  in  l.S.JO,  no  means 
which  would  .afford  permanent  relief  was  known. 

In  1n7<)  the  next  most  valuable  method  for  the  reduction  ot  in- 
creased tension,  viz.:  the  use  of  myotics,  was  suggested  by  Lat|ueur,of 
Strasburg. 

These  two  chief  forms  of  treatment,  together  with  otlii-r  procedures 
for  the  reduction  of  tension,  will  now  be  individually  described,  and 
afterward  their  clinical  .application. 

Iridectomy  or  Iridectomydialysis.  The  way  in  which  an  iridectomy 
relieves  tension  in  jjrimary  glaucoma  has  been  the  source  of  nuich 
discussion.  The  pathological  examination  and  comparison  of  eyes  in 
which  it  has  proved  succe.-isful,  with  those  in  which  it  has  failed,  have 
thrown  nuicli  light  on  this  matter.' 

Several  eyes  have  been  examined  in  which  an  iridectomy  suc- 
cessfully relieved  the  tension  in  glaucoma  and  subseijuently  had  to 
l)e  removed  for  .some  intercurrent  malady.  In  these  eves  either  the 
obstructed  |)assage  for  the  exit  of  Huid  ;it  the  angle  oi"  the  .anterior 
chamber  was  found  o|)ened  up.  or  ;i  new  channel  of  exit  had  Iwen 
established  by  the  formation  of  what  is  termed  a  cvstoid  cicatrix. 
(Fig.  :«•_'.) 

The  opening  up  of  the  tiltration  .area  at  the  angle  of  the  anterior 
chami)er  h.id  in  sonn'  of  the  cases  been  etfecled  bv  removal  of  the 


'  Hoyal  Liinilon  0|>hUmlmli'  H(is|iitul  l!i'i«)rl»,  IWJl.  v(il.  xli'i.  p. 


(1  LA  i  COMA. 


557 


(ilistnirtiiip  iris  up  to  its  point  of  juiictioii  with  tlif  riliiiry  body,  in 
the  vicinity  of  tlu'  wouml.     In  otiicrs,  aitiioufili  a  |)ortion  of  the  root 


S4vii.>ii  ihrDiiKh  the  penlri'  cif  the  onlolH.ina  in  nn  pyo  which  Imrt  lia^l  an  iri.lcetoniy  pfrformtHl 
l.,r  flu'icnnm  of  two  mnnlhs'  stimciing.  The  tensidn  wiix  ruliuvi-ii  hy  tho  .>iK>ratioli.  The  eye  was 
,xfi«fcl  five  wvki  Inter  fur  ulceration  of  the  cornea.  The  iris  has  been  reinoveil  up  lo  tlic  ciliary 
l>i  ly  iiii'l  tile  Jinu'le  of  the  anterior  chamber  therel>y  opcneil  np. 


.-.  riioii  throiieh  a  cystoid  cicatrix,  wliich  lormcl  at  the  aimle  of  a  pololionia  In  an  eye  in  wliicli 
:ch  ■inm  cuinc  on  alter  extraction  of  cataract.  It  sliows  a  li'lilla  in  the  sclenK'omeal  tissue  liuc'l 
ly  a  lol'i  of  atropliieil  iris     Tlic  snlieonjunelival  tissue  anpund  tlie  listula  is  swollen. 


iii.l  Ih'ch  lifi.  ii    liccaiiic  disliiilp'il  fmiii   it^   faulty  ptisitit-n.     l!vi- 
liiitiy  in  such  cases  sulhcicnt  time  iiad  not  elapsed  for  it  to  hecoiiie 


o.jH 


Till-:  i:yi:. 


ailliciciit  to  tli<'  <'i)riica.  'I'lic  ilnifi  on  the  iris.  cscaiH-  of  a(|ii*'oiis.  and 
roiis('(Hiciit  rclicl'  of  iircsstirc  in  tin-  vitreous  cliainhcr.  tofrctiicr  witli 
tlic  local  escape  of  blood,  liad  sull'ced  to  restore  tlie  normal  channels 
for  the  circulation  of  fluid,     i  I'ij;.  .'{;>.'{.) 

When  a  cystoid  cicatrix  is  present,  .a  fistula  is  estalilished  in  the 
fihrous  tissue  at  the  sclerocorneal  Miarjrin,  thiowjih  which  fluid  inav 
pass  from  the  anterior  chamher  into  the  suliconjunclival  tissue  and  he 
alisorheil  there  liy  the  conimictival  vessels.  The  tissue  around  tiie 
fistul.i  is  found  usually  in  a  l>o<;i;y  condition. 

The  hstula  results  from  prola|)se  of  ;i  fold  of  iris,  which  prevents 
the  two  sides  of  the  wound  in  the  fibrous  tissue  of  the  sclera  and 
cornea  from  unitinjr,  but  over  which  the  conjunctiva  lieals.     At  first 


Flo.  sa. 


Sfctinn  tlir.'iiKh  ti  rystoiit  ricatrix  whioh  lurined  antTaii  iTiileotmnv  for  olimnic  Klancniim  Tin- 
tiMi'iiim  remaiiu'd  nr>rmal  lura  yrar:  thfi'Vf  «a>  llicMU'X(i«-il  mi  ncwuiil  "f  irilis  an>l  t«iii  A  li'liila 
ill  llio  sclfriKiininil  tissue  i«sh.nm,  lini'.l  iwrlly  liy  Ih.'  alrnpliit'il  rixit  of  llic  iris,  anil  (artly  liv  the 
ciliary  [)roce»M's.    The  sutK'onjiiiiriival  tissue  aroillld  the  tisttlla  is  swollen. 


the  iris  tissue  liiiin}r  such  tract  offers  an  iiiipeilimeiit  to  the  pa.ssajje 
of  fluid  out  of  the  eye:  but  beiiij;  a  weak  spot  in  the  jrlobe,  it  tends 
to  bul<;e.  and  the  iris  liniiiji  it  atrojihies.  until  ultimately  a  fistula  is 
e>t;iblislie(|.      I  I'if;.  ;{;i4.) 

.\  cystoiil  condition  of  a  cicatrix  after  iridectomy  appears  most 
often  at  the  an;rle  of  the  coloboma  /.  c.  the  position  where  the  |iro- 
lapse  of  a  fold  of  iris  is  most  likely  to  occur. 

.Mthoiijrh  the  production  of  such  a  condition  may  prove  beneficial 
in  relievinjr  tension,  it  is  one  which  is  attemleil  with  a  certain  aniotml 
of  risk.  What  is  pr.actically  an  .adhesion  between  the  coiiiunctiv.a 
and  iris  beiny;  formed.  ;inv  inflamm.atioii  of  the  former  readily  spreai's 
to  tli(   I;    ,er,  and  is  liable  to  start  a  iietieral  uveitis. 


OL.liVoMA. 


559 


An  iridtrtdtiiy  (nils  to  relieve  tension  in  primary  jilaucoina  win 


he  lloriHMl  |i; 


i<;es  for  tl'.e  exit  of  (liiid  from  tiie  eye  remain  unopened 


am 


I  no  new  eliannei  is  formed. 


Fth.  :»■■ 


SfoiKiii  thriiiiKli  the  centre  of  tlu-  railnbijinii  in  an  eye  with  alwolute  i;laucoina  wtiicii  had  had  an 
iii.liit'imy  inrt.irnied.  and  in  which  the  increased  tensiDn  snbseiinently  returned.  It  shows  the 
ciciitrix  In  lie  Fi  very  inripheral  one  and  fr  ■•  Irmn  any  entandeinent  nf  the  Iris.  The  anijle  of  tlie 
iinterior  chamber  remains  blockeil  by  a  ix.rilDn  of  the  root  of  the  iris,  intimately  adherent  to  the 
corncu. 


Fiii.  ;i:iii. 


Sec  tion  tlironnh  the  centre  of  the  colobi>inii  m  an  eye  « liicli  had  had  an  Iridectomy  performed  for 
-iil«i,ine  Kliiuconm.  and  in  which  tlic  increa.sed  tension  Inicl  snbsoqnently  returned.  It  shows  that 
»  liirRc  |«iriion  of  Ihc  (leripliery  of  tlie  iris  liad  t)eei.  leil  blocliint;  the  inUltration  area.  The  cut  end 
"t  iliciris  is  adhorcnl  to  tlie  corneal  cicatrix  II  l.».k^  a»  Ihongh  the  rcnitof  the  iris  miitht  have 
i»cn  i..rn  away  nnich  nearer  up  to  the  ciliary  Ivuly.  Probably  a  simple  iridectomy  wai  perfornie.1, 
n't  an  iridectomydialysis. 

■{'he  normal  passages  for  tlie  exit  of  fluid  at  the  angle  of  the  anterior 
'  liaiiiher  a'f  iino])eried  up: 


oGO 


THE  EYE. 


1    Uhcii  flu>  r..(.t  of  tlic  iris  has  Ixroriu'  s..  iiitiinatciv  adhoront  to 
tiK'  hack  ot  the  rornca  that  on  L.-inK  drauii  upon.  inst(-a<l  of  t<"annc 
at  Its  cxircnip  r<.ot.  it  tears  through  ;■.(  ih.-  point  whcr..  it  ceases  to 
l)e  adherent,   and  the  portion  vauAw^  ..bstnictioi    is  left  behind 
I  r  ij;.  X\U. ) 

•2  When  by  reason  of  the  way  in  whicii  the  iridecion.v  has  bo..n 
p."rfonne.  a  portion  of  its  root  is  left  behind,  which,  {iiouRh  not 
adherent  to  the  cornea,  has  failed  to  bec.ine  .lisiodjr,,!  »>,„;,  its  faulty 
position,     f  !•  ijr.  .'{.sr. ) 

.1  When  by  reason  of  delayed  ref.n  nionof  the  anterior  chaiMb.-r 
til."  lens  l.eco,n,.s  ,in,te,l  to  the  posterior  surface  of  the  wound  by 
phustic   exudation    thrown    out    from    the    latter.     Then    when    the 


S.       ,„  .hrongh  the  oenlre  of  ,hc  clnlnnna  m  an  ,  y.  which  had  hart  a„  iri.lectoray  r..rf.r.nert  for 
al«.„l»„.  J.  Hue,„nH     A„  nrthi^i,,,,  «,  ,he  Ion,  .apsule  to  the  pos,en.,r  «„rf«ce  nf  the  ^.meaTn  th 
r...   .,,,,, he  c„.utr,x  i«  .how,,.    The  len,  h,„  .«oo,ne  s,„„ewh«t  ,lis,.laee,l  .«,  k«  an   in  thrC™ 
,„  o,  the  .,,.,.„,,e„.     The  a„^.leor  the  ,  „erlor  elm,„.,.r  ,s  olo-seU  i.v  the  anterior  oltLXn- 
|.rooe.«-..  whid,  have  Ikvii  |.resa.l  f„rw,  A  hy  tl,e  a-lherenl  le„8.  '  " 

anterior  chan.ber  .l.,es  reform,  the  lens  becomes  .Iniwn  f.,rw;,r.l  its 
adherent  marfrm  [.ressinj:  the  anterior  of  the  ciliary  processes  into 
<''»'tMel  with  the  hitration  area  in  ll„.  n-ion  of  theVoloboma 

In  the  ,.,bs,.nce  of  prol..,pse  of  .■,  fol,|  of  iris,  no  fistula  and  no  new 
.•liMniie!  o|  exit  lor  fluid  ;ire  produced.     Fro 
viously  desirable  in  performini: 
to  reinoye  the 
„•,,,■       ...        -  -    ■■    1- •■!■■■  ■.•'■•',„•  I, ,>  „|,  lo  us  poiiii  otniiiction 

•the  chary  bo,  iy.  lort  un.Mtely  it  is  at  this  spot  that  the  iris  is 
thinnest,  .•md  it  ,s  l„,e  ih.at  it  is  most  lik.-ly  to  tear  through  when 
drawn  upi,!!.  unless  ;ibiiorm;illy  adherent. 

In  performinj:  an  iridectomv  for  d;iuco 
sciei-ocorne.al  margin  has  been  madt 


an 


rom  the  forefruirif;.  it  is  ob- 
iridectomy  for  glaucoma  to  trv 


oni;i,  (itfiT  an  incision  of  tlse 
,.   I       .         ,    ,  ,    ..  .  •  ''"'  "■'■'  ^'"""Id    be  drawn  out 

and  snipped  throu}rh  from  its  pupillary  to  its  ciliary  margin  at  one 


OLA  VCOMA. 


5«1 


Miifilc  1)1"  the  wound.  It  slidiild  then  lie  drawn  alimji  the  wliolf  Iciijjtli 
lit'  tlif  wound, so  as  to  tear  it  away, and,  finally,  cut  tlirougli  apain  at 
its  t'ln'tlif'!'  cxtri'inity.  This  nictiiod  of  pcrforniinf;  an  iridectomy  is 
very  (litTcri'Mt  from  that  adopted  prehminary  to  the  removal  of  a 
catanK'l  or  to  form  an  artificial  j)upil.  For  thi'se  purposes  a  piece 
of  iris  is  simply  drawn  out  of  the  wound  and  snipped  off. 

'i"o  distinguish  the  two  methods  of  performing  the  operation,  the 
one  from  the  other,  it  is  well  to  term  the  first  an  iridectomydialysis, 
and  the  latter  simi)le  iridectomy. 

Anterior  Sclerotomy.  Anterior  sclerotomy  of  de  WCcker  is  per- 
formed by  enterinji  a  (iraefe  knife  1  mm.  external  to  the  corneal 
marjiin,  carrying  it  across  the  anterior  chamber,  and  hringing  it  out 
ei|uidistart  on  the  op|)osite  side.  The  |)oiiits  of  entrance  and  exit 
are  planned  as  if  a  flap  2^  mm.  high  were  about  to  bo  cut.    After  the 


StTtion  throueb  the  angle  of  tlu'  antorior  chtinilH.'r  of  an  e.ve  with  al>w>lute  glaucomn.  upon  which 
:tii  cxjierimenlal  anterior  scltTDiinuy  was  jieri'ornied,  'i  mm  distant  l"rt»m  the  soterw<trneal  margin, 
immediately  aftor  i'nucleati<jn.  It  shows  that  the  periplicry  uf  the  iris  had  been  divided  in  two 
l>liiccs,  the  knife  having  pwsed  through  the  adherent  root  ul  iris  into  the  iMisterior  chamber. 

knife  is  inserted,  it  is  drawn  backward  and  forward  with  a  sawing 
motion,  but  is  taken  out  before  a  flap  has  been  c(.ni|iletely  cut.  A 
liridge  of  tissue  is  left  between  the  two  cuts,  composed  of  conjunctiva 
:md  part  of  the  .sclerotic.  Prolapse  of  iris  very  fretpiently  follows 
the  operation,  and  it  is  recommiMided  that  any  tendency  to  it  should 
1h'  counteracted  by  the  use  of  eserine  before  and  after  the  operation. 

The  operation  is  desigtied  to  form  a  cicatrix  at  the  scleroconieal 
margin,  without  the  removal  of  any  iris.  Its  value  in  producing  a 
|iennan«>nt  relief  of  tension  in  primary  glaucoma  has  proved  to  be 
lar  inferior  to  iridectomy,  and  the  results  obtained  by  it  are  very 
uncertain. 

Isxperinientallv  ami  piithologicnllv  it  ha.s  been  shown  th:it  a  mere 
liaiid  of  cicatricial  tissue  at  the  scleroconieal  margin  does  not  allow 
of  filtration  of  fluid  through  it. 

8(1 


m 


o«2 


rill-:  HYt:. 


When  |inilai>sc  df  :i  fuM  of  iris  IuIIdws  ,i  sclcrnlomy,  a  (istiila  and 
rystoiil  coiKliliim  of  llic  <'icalrix  may  Im'  fmiiicd,  as  after  iriilrctoiiiy. 
Ill  this  way  an  artilicial  clianncl  for  exit  of  fluid  will  l>c  forincd  and 
I  lie  iciisioii  r<'iic\('d. 

In  an  rye  wliicli  had  Im'cii  iMiuclcatcd  for  alisohitc  <tlaiiconia  tiu> 
o|>t'iation  was  iicrfornicd  iinnicdiatriy  afterward.  Sections  snlise- 
iiucntiy  inadi-  thioii>;li  tin  seat  of  o|M'ratioii  showed  that  at  the  points 
of  |iiiiietureand  coimter-ininctiire  the  root  of  the  iris  iiad  iieeii  divided 
in  two  places.  ( Kijj.  ;{;iS.)  The  knife  had  pas.sed  from  the  sclerotic 
through  the  iris  just  where  it  cea.sed  to  he  adherent  to  the  cornea  into 
the  jiosterior  chamher.  ,iiid  then  throufjli  the  iris  ajtaiii  into  the  ante- 
rior cl.ainher.  My  cutting  across  the  adherent  root  of  the  iris  in  this 
way  the  operation  may  pessihiy  open  up  a  passage  for  Huid  from 
the  Jiosterior  chainlM-r  into  the  spaces  of  Fontana. 

An  oiM'iation  termed  iridosclerotomy  or  .scleroiritoiny,  in  which 
the  adherent  root  of  the  iris  is  intentionally  cut  tlirouj;h,  has  Ih'cii 
I  -M-ti.sed  liy  Knies  and  Nicati. 

Scleral  Puncture  of  Posterior  Sclerotomy.  Posterior  sclerotomy 
is  not  an  operation  from  which  alone  permanent  relief  of  t(>nsion 


Via.  339. 


>i'Cliiili  .>f  nil  i\e  ii|-'M  »\  liicli  H  |H»(,.ri(ir  Mlfi,,l..iiiy  »,i«  |,Tl..riiif.l  liir  uliiiiocnilH.  iiii.l  whlrli  Mil.- 

^i-.|UL-litly  U-iMhif  Tiiiuh  i:ilhiiniil.     Tin-  i;:ip  in   Uu ,il-olthu  lyi-  l- >li.nni,  williii  ti.Kc.l  vilrcim- 

liiiniijr,  inui-li  iiiliitiuli.i.  wilh  r.nin.l  ivlls  |iniiiii.Kirii;  iIilhikIi  h.  Thi'  |iri.lii|i!*il  vilrc.,ii«  iviilcntly 
tiirnicil  lln'  truck  almiu  which  iiili  ctioii  kkiiicc!  ciilmMcc  In  the  eye. 

may  Ih-  expected.  It  may.  however,  in  certain  cases,  Iw  advanta- 
jieously  ein|iloyed  to  produce  a  temporary  effect,  or  as  a  iireliniinary 
procedure  to  iridectomy. 

The  puncture  is  in;ide  witli  a  (irai  ''e  knife,  which  is  ie.serfe.l  in 
such  a  way  as  to  make  an  openinir  meridiaiiiil  to  the  corneal  marjiin: 
for  in  such  a  wound  there  is  less  tendency  to  ftajie  than  in  one  made 


(ILMVitMA. 


.j(i;i 


|,ai:illcl  to  its  inarjiiii,  :iinl  tlic  cliuniidal  vcwi'ls  and  nerves,  whicli 
mil  l'((i-  the  iiiiisl  part  aiiliTD-iiosleiiorly,  are  less  likely  to  Im-  divided. 
A  s|M.I  is  chnseii  lof  llie  operation  on  the  sin'i'aee  of  llie  jjl"'"'. 
iM'liiiid  iIk'  ciliary  body  and  Ix'tween  the  r.'eti  iiiusele>,  iisiially  up 
Mild  out,  <>  mill,  or  more  |iosterior  to  the  eonu'al  marniii.  Het'ore 
iiisertinj?  the  knife  the  eonjunctiva  is  drawn  with  ti.xatioii  foreeps  a 
little  to  one  side,  so  that  on  conelusioii  of  the  operation  the  opening 
ill  it  and  in  the  walls  of  the  jjIoIm-  .shall  not  coincide  in  position.  In 
uiihdrawinn  the  knife  it  is  niveii  a  half-turn,  which  makes  the  wound 
L'.ipe  and  allows  of  escape  of  the  Huid. 

j'he  hemorrhage  which  results,  liotli  intra-ocular  and  extiinicular, 
i-;  usually  iiisif;nitii'ant  in  amount.  A  |i'olapsed  portion  of  the  vitreous 
liiimor  (Kig.  XW  in  the  wound  has  been  known  to  form  the  track 
uloiin  which  septic  infection  jjained  entrance  into  the  eye.  The 
escape  of  fluid  from  the  vitreous,  the  immediate  result  of  the  operation, 
allows  of  diminui  ii  of  pressure  in  the  vitreous  chamber  and  the 
recession  of  the  h'l  and  iris,  with  increa.se  in  the  depth  of  the  anterior 
chamber.  Kor  a  aort  while  after  the  operation  fhml  may  continue 
to  ooze  from  the  wound.  !^oon,  however,  it  coinniences  to  heal, 
liirtherdrainafie  is  arrested,  and  the  tension  ajrain  becomes  increa.sed. 

In  posterior  sclerotomies  performed  exiierimeiitally  on  rabbits, 
llie  wound  was  found  to  U'  closed  and  any  outflow  of  Huid  clu'cked 
on  the  eighth  day  iTobler'). 

Paracentesis.  Paracentesis  of  the  anterior  chamber  is  another 
upeiative  measure  which  affords  a  t<'mjiorary  relief  of  teii.sion,  and 
wiiicli  mav  sometimes  be  employed  in  ca.ses  of  enierjj;ency.  As  .soon 
:i>  sullicient  time  has  elapsed  for  a  fresh  secretion  of  the  intra-ocular 
thiid  to  accumulate,  the  tension  becomes  re-established.  The  amount 
111  relief  is  fireatest.  and  lasts  lonjjest,  when  the  anterior  chamber  is 
.|(c|.  and  a  larjje  amount  of  fluid  c;in  be  evacuated,  as  in  cases  ol 
•glaucoma  secondary  to  serous  iridocyclitis. 

Removal  of  the  Superior  Cervical  Ganglion  of  the  Sympathetic. 
liniioval  of  the  superior  cervical  fjaiiplion  of  the  sympathetic  has 
iiivii  shown  iiv  .loiiiiesco,  of  Hucharest.  to  be  an  operation  capable  of 
rnjuciiijt  the' tension  in  filaueoma.  The  results  of  the  operation 
ill  eii;ht  cases  he  summ.-irized  as  follows: 

I.   Immediate  and  lastinp;  reilnction  of  tension. 

_'.  Markeil  and  permanent  coiitraction  of  the  pupil,  oven  in  the 
raM's  ill  which  iridectomy  had  bei'U  previou.sly  performed. 

:!.   .\bseiice  of  frontal  headache. 

(.   Disappearance  of  the  att.acks  of  irritative  jrlaucoma. 

.').  ("onsiijirable  iierinanent  improvement  in  vision  in  all  cases  in 
uliich  ciiinplete  atrophy  of  the  nerve  had  not  set  in. 

Ill  other  surfieons'  "hands,  thouf^h  the  oiieration  has  sometimes 
l.icii  attended  with  success,  disastrous  results  liavi'  also  occurred. 
Swinr  palirtils  have  t!ii-d  as  the  result  of  the  operation.     Tn  others 


Archives  of  Ophthalmology,  March,  1901. 


.■)(t4 


tlicn 


THE  t:YK. 


luivc  Ihm-ii  luarkcl  tluslui.K  of  ll.c  si-lc  <.f  the  h.wl  aiul  fan-  hikI 


M'vcrc  pain  ai 


tier  ;ln'  ojii 


ratitiii.     Tlir  iiuT(';i.s( 


I  ifhsioii,  althouffli  liT 


tiiiif  niluiM.l,  lias  rrtunu-d  ni  soiiw  cii 

htlialiims  liavr  also  (li'vrl(»|HMl 


iftcH.    Syiiiptoiiis  of  tacliy- 


canlia  and  I'Vp 

Thf  nannliiMi  can  1m-  icaclu'" 


anlciioi'  or  tin-  posterior 

formiT  is  tlu"  simpler  aii.l  eaiises  less  injury 


1  (iilier  liy  an  ineisioii  iiiiulo  uloiift  tlie 

horder  of  tin-  steinomastoitl  muscle.     The 


.loiinesco  recoinmeiK 


1    sheatli    b 


(1,  till    vein  separated  from  the 


that    the  carotid   slieath   ix-   oiM-neii,  tlu       ,.      ,■      ,  ,     , 

art.TV.  and  the  Kanglion  found  i.-hin.l  't  KmRhanl  says  he  has 
,„„„d  i,  ,„„eh  simpler  to  exi.ose  tl-.e  oufr  edge  of  the  earotul  sheath, 
and  then,  with  a  i.hmt  hook,  to  pull  the  sheath  aiul  its  c.  iitents 
inward  toward  the  median  line,  when  the  ganglion  is  at  once  .•x,K)sed. 
It  is  then  <lrawn  forward  with  forceps  and  cut  out  with  sci.ssors. 

Myotics  Neither  invotics  nor  mydriatics  dropp<'<l  into  a  normal 
eve  produce  aiiv  alteration  in  the  teasion  which  is  appreciul.le  hy  tl." 
linger  test  At'ropine  dropped  into  an  eye  with  a  shallow  chamlMT 
:u.d  pre.lisp.w..,i  to  glauc.ma,  as  already  stated,  may  bring  on 
incr.'ased  tension.  ICserine  in  many  cases  of  i)ninary  glaucoma  will 
reduce  the  tension  to  normal. 

These  ilrugs  influence  tension  appreci.ibly  only  when  the  anterior 
•  hamber  is  shallow,  where  an  increa.sed  or  ilimiiiished  thickness  ol 
the  iris  is  capable  of  causing  ai)position,  or  withdrawal  of  apposition, 
of  its  root  with  the  back  of  the  cornea.  . 

In  acute  cases  of  glaucoma,  wher.'  the  sphincter  muscle  of  the  ins, 
from  pressure  on  the  ciliary  nerves,  is  paralyzed,  myotics  lail  to 
cause  contraction,  and.  conseciuently.  are  unable  to  relieve  ten- 
sion In  glaucoma  of  long  standing,  where  tl.c  Pot  of  the  ins  has 
become  absolutelv  adherent  to  the  back  of  the  coniea  and  diH's  not 
siiiinly  lie  in  apposition  with  it,  myotics  are  unable  to  separate  the 
adh<-sioii.  ,ind  in  these  cases  fail  also  to  reduce  the  abiKmnal  tension. 
l';seriMe.  besides  contracting  the  pujnl,  tends,  especially  in  some 
iM'ople.  ♦.  cause  a  certain  amount  of  hypera'inia  and  irritation  or  pain. 
It  .sh.  therefore,  not  1m'  used  stronger  or  more  often  than  is  abso- 

lutely I  |inred  to  produce  tlie  desired  (>ffect  on  the  pupil  and  tension. 
Solutions  of  (1.12")  per  cent,  or  (1.2.')  per  cent,  of  the  sulphate  are 
most  tn(|uentlv  emploved.  One  or  two  ai)plic,atioiu  of  a  1  i)i-r  cent, 
solution  will  sometimes.  howev<T.  reduce  tension  wh"n  the  weaker 
ones  havi'  failed. 

W'liiii  the  use  of  eserine  has  to  bo  persisted  in  for  some  time,  it 
is  well  to  combine  with  it  cocaine.  Cocaine  has  the  opposite  effect  to 
eserine;  it  dilates  the  i)Ui>il.  diminishes  the  sensibility  of  the  eye,  and 
eontnicts  the  bloodvessels.  If  a  solution  be  emj)loyed  containing 
0.2.')  i»r  rent,  of  .sulphate  of  eserine  and  1  per  cent,  of  hydrochloride 
orcocaine,  the  myotic  effect  of  the  eserine  will  predominate,  but  its 
irritatinir  :v.u\  Iivpeneniie  effects  will  be  reduced. 

Pilocari)ine  is  a  feebler  myotic  than  eserini'.  but  causes  less  irrit     on. 


1  H.rlisl.  These  .If  Pans.  190U. 


al.AVVOMA. 


Ut).> 


It  may  Im>  uscI  in  the  lorin  < 

iitT  CIMlt. 


il'  till'  nitrate  in  sululiittis  of  ()..">  or  0.7") 


itIC 


Morpliiiir  a(liiiiiiist.'r<-<l  hypoii.iiuically.  l)y  ivasoii  ol  tlu"  iiiyot 

(Itcct  it  |.ro.lu<-i-s  and  its   sfdalive  action,  uftt-n   prows  a  valuable 

KJilitioiial  ail!  to  otli.T  infasuivs  in  the  n'duction  of  increased  tt-n.-ion. 

OUnical  Application  of  Treatment  in  Glaucoma.  In  cases  ol  acute 
.'laii.oina  iridectoniv  siiould  he  iMTlornied  at  tin-  earliest  pos.sil>le 
m..inent:  a  few  liouis  .lelay  may  make  considerai)ie  dillen'tice  in  the 
.iiriount  of  sijiiit  which  will  U-  repiinod. 

Kxrine  should  he  dropped  into  the  eye  two  or  three  tunes  while 
the  patient  is  heiiifj  prepare.!  for  operation,  so  as  to  ohtain  as  much 
n.ntraetion  of  tlie  pupil  as  possihle.  It  preatly  hicilitates  thegraspwig 
,,l  the  iris  with  forceps  and  the  withdrawal  ot  a  iiortioii  Irom  the 

V,.      The  ( nestion  of  the  eve  and  the  increased  tension  prevent 

;,caine  producing  anv  marked  anaesthetic  efTcct,  .so  that  a  peneral 

uesthi-lic  has  to  1k'  administered.     Chloroform  is  much  to  H-  pn-- 


ive. 

f(iTed"a't  anv  rate  wliile  the  o|K'ration  is  U'lnp  jHTformod,  as  with 
il  thei'e  are  less  venous  congestion  ami  less  heaviii);  respiratory  move- 
ments than  with  ether. 


Ill  the  performance  of  any  intra-ocular  operation,  either  tor  acute 
,,r  chronic  glaucoma,  an  endeavor  should  he  made  to  lower  the  - 
iivased  tension  as  jrradually  as  pos.sih!f,  so  as  to  avoid  any 


in- 
sudden 
ni-h'.i  til.iod  into  the  intra-ocula"rl)loo< {vessels,  causing  their  ruptuie 
,11.1  h.'morrhage.  In  makhig  an  incision  into  the  anterior  chamher. 
tl„.  M.,.ieous  should  he  allowe.l  t..  drain  away,  ami  not  to  escape  with 
a  gush.  , 

\tler  an  iridectomv  a  compress  .should  he  api)liod  and  a  bandage 

tirmlv  a.ljwsted.     'IV  tiatieiK  shoul.l  he  ])Ut   to  bed  and  kept  there 

uiitirthe  ant(  vior  chamher  has  well  reh.rm.'d.     Care  should  be  taken 

t,,  prevent  the  patient  rubbing  or  touching  the  eye  when  half  asleep, 

l,v  tethering  the  hand  .m  the  si.le  ojxTate.l  on  to  the  foot    ot    the 

IhM    '^o    that    it   cannot   be  moved    Im-voiuI  a  certain   safe  di.«tance 

n„m  the  eye.     T..  pnn-ent    tl     sh..ck   of   th.' operation  exciting  an 

i.ut.'  attack  of  glaucoma  in  m.-  feUow  eye,  eserme  (Iroj)s  should  Ik- 

:i|,plie.l  t.)  the  latter  imme.liately  after  the  operation,  and  twice   a 

,>   ..ir  the  succeeding  week.  _ 

th.'  prognosis  in  acute  glaucoma,  if  the  operation  is  jMTtormed 

.ullici.-ntiv  earlv.  is  good.     If  it   h.as  iM^eii  .lelaye.l  fo.r  some  days, 

,li hough  "the  oiM>ratii-.n  mav  relieve  tension,  the  lost  vision  will  not 

!„•   r.-st..re.l      In  the  most    acute  ca.ses  vision  may  he  reduce.l  to  no 

l„.n.,.nti..n  of  liglit  for  a  few  Imiirs,  and  then  restored  to  almo.st  its 

n,.rm.Ml  acuitv.     If,  however,  there  has  \m-n  no  perception  of  light 

tnr  two  or  three  days,  tlie  chances  of  restoration  of  vision  aiv  very 

~iiiall. 

In  subacute  cases  of  glaucoma  a  greater  reduction  of  tension  can 
he  .■flVcte.l  bv  eserine  than  in  the  acute  cases- sometimes  a  compl.^tr 
nduction  though  bv  the  etTective  u.se  of  .vserine  in  such  cases  the 
immcliate  urgencv  for  iridectomv  is  not  so  great,  .still  there  can  he 


l;iv 


AiaA-fc.- 


.  •&i'mFims^mi^mfm:mswrm^ : 


d«6 


TIIF.  EYE. 


little  ijoiiht  that  tlir  MMiinT  it  is  iMTfiiriiird  tin-  iM'tti-r  cliaiici'  tlnTi' 
is  i)f  its  itriiviti);  siirci'ssliii. 

Ill  JHitii  ariitr  ami  siiliai'iiti'  cases  nf  );laiU'i>iiia.  slmiilil  tlii>  lens  ainl 
iris  1m'  iiiiicIi  iiii'»>ci|  lurwaiil  ami  lli^  aiili'iinr  cliaiiilMT  vitv  sliallnw, 
it  may  Im'  aihisalilc  In  |M'rl'nriii  a  pi'i'liiniiiary  sclrral  |iiiiicturi',  iind. 
by  cscaiM'  n|  lliiiil  I'rom  the  vitri'oiis  cIi'.iiiImt,  allow  uf  some  rcccMsiitii 
of  till'  It'iis.  A  knife  can  then  Im'  passeil  more  reailily  into  the  ante- 
rior chainlMT  and  the  risk  avoided  of  splittiiifj  the  layiTs  of  the 
cornea  instead. 

The  recession  of  the  lens  also  has  the  advantage  of  facilitatiiifj 
early  reformation  of  the  anterior  chamlKT,  and  so  preventing  adhe- 
.sion  U'twiH-n  the  lens  and  cornea,  which  adhesion  has  been  shown  to 
be  one  caus*'  why  iridectomy  may  fail  to  relieve  tension.  A  scleral 
puncture  pn'liniinary  to  iriilectomy  is  strongly  nTommended  by 
Priestley  Smith,  who  has  practised  it  extensively. 

In  chronic  ca.ses  of  <;lauconia  experience  has  shown  that  iridectomy 
is  not  nearly  such  a  reliable  measure  for  the  relief  of  ti'tision  Jis  in 
the  more  acute  caw'8.  It  produces  much  the  Iwst  results  in  the  cun; 
of  the  plaiicoinatous  condition,  if  |H'rforiiied  early  in  the  diseitse. 

Many  surgeons,  however,  hesitate  to  operate  on  jiatients  with  chronic 
plauconia  when  the  symptoms  are  very  slight,  when  the  central  vision 
is  normal,  and  when  there  is  only  slight  contractinii  of  the  tjeld  of 
vision.  Vet  it  is  in  just  such  cases  that  the  iridectomy  is  calculated 
Ix'st  to  arrest  the  disea.se.  .\  very  ilistinct  objivtion  to  |M'rformiiig 
iridectomy  in  these  c;i.ses  is  that  the  o|H'ration  nearly  always  jiroduces 
a  certain  amount  of  cornejil  astigmatism,  so  that  the  patient  finds 
that  thi'  immediate  effect  of  lif  opi-tni'iii  ':.^^  lieeii  to  reduce  his 
acuity  of  vision  uncoirected  by  gla.sses,  although  it  may  Im-  just  the 
.simo  as  Ix'fore  with  glas,ses. 

The  alternative  tn>atment  to  iridectomy  in  ca.'^es  of  chronic  glmi- 
coma  is  the  continued  use  of  myotics;  eitlier  eserine  or  pilocarpine. 

.Many  la.ses  of  chronic  glauconu'.  may  by  steady  |K'rseverancp  in 
this  treatment  be  kept  in  .;rrest  for  an  unlimited  time.  Some,  w, 
spite  of  if,  go  on  steailily  losing  sight.  ( )thers,  again,  notwithstanding 
the  myotic,  as  the  result  of  some  excejitional  exciting  or  emotional 
circumstance,  suffer  an  acute  exacerbation  of  symptoms,  when  the 
surgeon  is  forced  to  op'rate. 

The  choice  of  treatment  in  chronic  glaucoma,  in  any  individual  case, 
is  a  matter  calling  for  considerable  judgment  and  exiK'rience,  it  b'ing 
necessary  to  tak(>  into  consideration  the  patient's  circumstances,  age, 
expectancy  of  life,  general  health,  and  other  matters. 

Cases  of  .ihsoliife  glaucoma  are  met  with  in  which  operative  treat- 
ment of  some  form  becomes  necessary  for  the  relief  of  pain.  If  the 
patient  is  old  and  feeble,  or  if  the  eye  has  in  any  w;iy  become  unsightly 
from  st;ipltyloin;itoiis  or  other  changes,  it  had  best  be  excised.  I'nder 
other  circunisfances  the  effect  of  an  iiidectomy  may  first  \w  tried. 
In  such  eyes  iiidectomy  fre(|iieiilly  fails  to  ■  rodiice  periiuinent  relief 
of  tension  and  the  pain  recurs.     In  some  ot  iliein  severe  infra-ocular 


OLAircOMA. 


M7 


lii'im 

iH'tWf'Cll  I 

i  lens, 
I 


irrliiiK''  froi"  ♦'i'"  ^ 


hontitlul  vessels  ucciirs.     Tlie  I>1ihmI  (•oIlectiiiK 


Mill 


1„.  elM,r..i.l  aiul  sclerotic  luin-s  f..rwar.l  tl..'  tvtii.a,  vitrciis 

•iipiiiK  from  the  eye,  iiiul  eiiu- 

this  (lis)isir«)as  form  of 

liich  is  not  ubs«)hite. 


tu 


two  llllHT  St  met  ires  es« 


leatioti  lx'comiii(j 


inevitable.     In  rare  case; 


l„.inorrliane  follows  iriaectoiny  for  glaueoina  w 


If  all  iriilectoinv 
>lioiilil  Ih-  exaiiiiiie( 


has  failed  in  any  <msi 

I  carefully  to  see  if  the  lens  has  Im'coii 


to  relieve  tension,  the  eye 
tilted 


lorwa 


rd  throiijjh  adhesion  of 


it  toti 


le  wouiH 


1.   Where  such  an  adhesion 


isists,  the  li-ii; 


mil 


i\  Ik-  reiiiove( 


I.     In  making  a  fresh  incisi<i 


tlie 


fe   knife  should  In-  made  to  sweep  across 


the  |K»sterior  surfate 


1.1  the  old  one,  so  as 


to  dividi'  anythiiifi  adherent  to  it 


If  the  lens  luis  not  Ik-coiik 


tilted  forward,  th,  return  of  tension  is 


inesiiina 
liitratioii  area. 
ol  tli 


hlvdue  toa  jMtrtion  of  the  hk) 


t  of  the  iris  left  lilockinj;  up  the 


\  sclerotomy  should  then  he  jM-rformed  in  the  reRion 

'.lohorna.  which  will  cut  through  the  adherent  r. 


it  of 


ins,  aiu 


possibly  eslablish  a  pa.ssaRe 
ito  the  spaces  of  I'ontana 
tl 


Sometimes  in  the  pertormance  o 


for  Huid  from  th<-  ixwterior  chaiiilMT 
if  an  iridectomy  for  plaucoma  the 


leiitallv  wounded  and  be<-omes  ()|)a(|U( 


lens  is  accii 
to  occur  w 
-hallow,  the  anterior  sii 


This  is  most  likely 


the  pU| 


hen  a  keratome  is  employed  an.l  the  ant.-rior  chamlH-r  is 

rfuce  of  the  lens  iK-iiid  pressed  forward  throiipti 

ilso  to  occur  when  the  ojxTation  has 


lit.     It  has  been  known  a 


,„.,.„■  ,H.rformed\viih  a  (ira<-fe  knife,  from  the  iris  having  been  cut 
throiiirh  in  making  the  upward  cut. 

t  1  ne  cas,.  The  lens  beconi..  catanictous  after  ^^<^ /Wf^^' 
,,i,,,  living  lM.en  woim.l.'d.  In  these  it  is  generally  f.mn.  that 
:,;,,;.  I,!..'  prevLisly  l.-en  some  peripheral  stritr,  an.l  the  manipulation 
.,|-  the  ('■.:•  acts  as  a  maturation  oiH-ration. 

■•  .,  op..rntion  of  removal  of  the  superior  cervical  ganglion  of  the 
.V,  I mtl  etic  is  one  which  must  In-  regarded  as  .till,  to  a  certain  extent, 
..    tr  •  ivn  in  skilled  han.ls  it  may  \^  atte.ule.l  by  grave  risks, 

;:;;d  there  are  probably  few  who  would  care  to  -commond  it,  unless 
the  <.ther  and  simpler  measures  above  indicated  ha(    laiKd. 

P  i^ts  utTeriig  from  glaucoma  should  be  advised  to  adopt,  ^s 
,.,r ;  .racti.-able.  the  following  habit.s  in  lif<-:  all  worry.  '^^^^^^^' 
f  tiju  >  should  Iv  avoiiled.  They  should  Ik-  warmly  clad  and  guard 
..!,  sf  anything  like  a  chill.  Great  importance  shoul.l  Ik-  attache.. 
:',heir  ..-btaining  a  regular  and  a.le-.uate  a.noun  o  sleep  AM 
.training  .'fforts  lik.-lv  to  lea.l  to  c.ng.'stion  of  th.  hea.l  an.l  t,.c. 
s  ,  111  wluM,  p..ssible,  be  prey.>nted.  Where  th.-re  is  a  ten.lencv  to 
:  s  ;ui  ...  ap.-ri..nts  shouM  be  a.lminist..re.l.  V.nors  of  n-fra^mn 
sh!liilll  b.^  a.T!irately  corrected  an.l  no  very  prolonge.l  nenr  work 
I'lisiagi'd  ill- 


f# 


^'•'ikwk™' 


CIIAPTEK    XM. 

IHSmJIUNCKS  OK  VISION'  WITIIOIT  AITAUKXT 

LKSION. 

n\  i:i.mi;k  (!.  staui!,  m.d. 


TiiK  (•(iiiditioiis  ilcscrilicil  iiiulcr  tlic  licadiiit;  of  this  chapter  an' 
pi'dlM-rly  ciiihraciMl  hy  tlic  tiTiiis  (iiiHinnisis  il(iss(it'si};ht )  and  niiihliiu- 
lild  {dcti'<-tiv('  or  chill  sijilit  i,  Icriiis  whicli  arc  used  to  iiuhcatc  all  cases 
I  if  defective  \i>iiiii  whicli  d(i  not  result  from  visible  disease  of  the  eye 
-truciuii'.-.  and  whii'h  cannot  be  rcnicilied  by  the  correction  of  an 
exisiini;  error  in  refraction.  The  diajinosis  of  this  condition  is  often 
\cry  ditlicult.  a-  it  must  be  based  chietly  upon  the  evidence  of  suii- 
jective  symptoms. 

The  color  sense  may  be  lost  or  lessened,  the  lield  of  vision  limited, 
and  x'otomata  found.  In  this  class  of  diseases  may  be  included  the 
follow inji-named  conditions:  color  amblyopia,  amblyopia  exanopsia, 
conjrenital,  hysterical,  and  simulated,  ura'mic,  jjlycosuric,  malarial, 
from  liemorrha<re.  from  lif!;htnin}f  flash,  reflex,  scintillatiufi  scotoma, 
nyctalopia,  liemeralopia,  erythro|)sia,  snow  blindness,  micropsia, 
mejialopsia,  ami  metainorphopsia. 

It  is  |)robablc  that  future  increase  in  our  knowledj;e  will  rr'niove 
from  the  catej;ory  of  amblyopia  some  of  the  conditions  enumerated 
above  i)y  disclosing  their  real  nature. 

In  all  amblyopic  conditions  careful  Mplithalmosco|)ic  examination 
should  l>e  made,  as  many  cases  of  suppo.sed  .amblyopia  will,  by  careful 
;ind  lhoroui;h  examination,  be  found  to  depend  in  reality  U|)on  .some 
disease  of  the  retina  or  choroid  in  its  extreme  peripheral  rofji'^'is. 
parts  of  the  eye  which  are  ilillicult  to  see,  and  which  fre(|uently  esc.ipc 
scrutiny  in  the  routine  ophtlialmosco|iic  examination. 

,\nother  objective  point  in  the  examination  is  the  macular  legion. 
'I'his  should  be  closely  irispe<'ted  by  the  direct  method,  as  not  iiifre- 
i|ueiiily  in  low  dc;;rees  of  amblyopiji  slijiht  chanjies  are  found  in  the 
rejrion  of  the  macul;i,  >uch  as  a  jiraiuilar  or  stijipled  iippearance.  or 
the  pn-eiice  of  mimile  while,  f^ray,  or  yellowish  points  -conditions 
whii'h  in  some  cases  inidoiibtedly  have  their  orifjin  in  long  existing 
refractive  error  eyestrain!,  while  in  others  the  exciting  cause  seems 
to  be  .-I  I'enal  or  inteslinal  toxa-mia. 

Color  Blindness.  Perhaps  the  most  wonderful  of  all  our  senses 
i~  that  of  ;id.;ipt;!tion  or  refinement  of  thf  sens.,  nf  sigiit.  the  perception 
of  color.  I'ure  hues  of  red,  yellow,  and  blue  appear  to  the  eycso 
positively  unlike  ,ind  contrasted  that  it  is  remarkable  that  tlr'y  are 

."iti.H    I 


nisTUJlBA.WKS  OF  VISIOX  WITHOUT  Al'PMiEST  LESlOS.     -jfl'.t 


causcil  l)y  Wiivcs  (.1'  I'tlicr,  tliflViiiif;  only  in  Icnjitli  and  rate  of  vil>ia- 
lioii,  and  that  tliciv  is  a  graduated  scries  of  waves  froiii()iie  cuior 
lo  another,  linkinj;  theiii  together  and  iTiei-fjinK  the  colors  of  tiie  spec- 
iru;.     "'e  into  anotiier. 

,Mi.  ^  ri'.  -ense  of  siftht  was  first  deveioiMMl,  it  is  prohahie  tiiat 
n.-lhinft  niu.-e  \'.,,  i  lijiiit  and  dartiness  was  pereeived.  As  tiie  visual 
Mi;Z,'is  hecaine  ...ore  .leveloped.  more  delieate  ehanfjes  in  lifiht  and 
.'irdow  would  '«•  seen,  Imt  color,  except  in  so  far  as  it  modified  the 
..d.iui;;'  ■■  ■  'i'-t.t  reachinj;  the  eye,  wonid  not  he  visible.  A  hifih  state 
,,r  (leveloi)ment  of  the  eye  as  an  orf^an  of  vision  is  comp.atilile  with 
the  .'ihsence  of  all  color  sense,  and  may  have  existed  loii};  l)efore  the 
-ciise  of  color  hcfian  to  develoj).  The  time  at  which  tiie  color  sense 
appi'ared  is  imknown     liv  soiiu 


color 
it  is  helieveil  to  have  had  its  orifrin. 
■r'at  least  to  have  develo|>ed  within  historii'  times.  There  :ire  facts. 
liowe\er,  which  indicate  that  this  sense  existed  in  a  hif:hiy  developed 
,-ondition  in  prehistoric  man.  Mirds  ;ind  many  animals  undoubtedly 
distinguish  colors.  liven  in  so  low  ;m  order  of  animals  as  fishes  a 
M'nse'^if  color  seems  to  I'xist,  as  is  evidenced  by  their  protective 
coloring.  It  is  (|iiit<'  possible,  of  course,  tli.at  the  color  sense  of  the 
lower  animals  may  not  be  identical  with  that  in  man.  but  a  fact 
which  points  to  the  early  develoiiment  of  this  sen.se  is  that  babies 
have  a  well-develojM'd  sense  of  color,  whidi  would  hardly  be  the  c:ise 
were  this  a  recent  ac(piirement  of  the  human  race. 

Color  has  no  ob.iectiv(>  I'xistence.  but  is  an  internal  sensation,  and 
iiiav  be  caused  bv  pressure  on  the  eyeball  or  any  means  which  stuiiu- 
l.ites  or  excites  the  retina  of  the  eye.  In  the  jircsent  chapter  it  is 
loiisidered  as  duo  to  the  action  of  lifilit  waves. 

Objectively,  then,  color  corresponds  to  lifiht  waves  or  ether  undu- 
latioi'is  of  certain  length  and  rate  of  vibration,  at     least    this  will 
:,pply  to  such  colors  as  have  a  known  vibration  for  their  cause.     Tlu'fe 
;,iv  ('-olors.  however,  which  have  no  objective  definite  ether  waves  tor 
ilicir  production,  and  which  serve  to  illustrate  still  further  the  tact 
;liat  color  is  purely  a  physiolofjicai  sensation.     Such  colors  are  purple. 
which  does  not  occur  ill  "the  spectnmi,  ami  has  no  definite  wave  lenfith 
mr  it<  produ-'tion:  and  white,   if  this  may  be  called  a  color.     By 
ixperiment  it  has  been  determined  that  the  sensation  of  red  is  caused 
Kv  the  loiifiest  visible  wave  and  slowest  rate  of  vibration,  while  the 
-Imrtest   wave  and  the  most    rapid  vibration  give    the  sensation  ol 
\iolel.     l{ed,  then,  gives  us  one  en.l  of  the   visible  spectrum,  and 
\inlet    the  other  end.     Between   these  limits   there   is  a   graduated 
-cries  of  wave  lengths,  all  of  which  affect  our  visual  apparatu.s  and 
-ivc  us  the  various  colors  of  the  siiectrum.     The  s|)ectral  colors  jiass 
iroiii  one  into  .•mother  by  such  slight  gradations  that,  when  examined 
ill  a  long  spectrum,  no  sudden    change   from  one  color  to  another  is 
louiid   to  occur,  but  one  merges  so  gradually  into  another  that   it 
1-  dillicult  to  s;iv  iust  where  one  color  ends  and  another  U-gms.  so 
I  hat  the  spectrum  is  fouiui  to  be  nmde  up  of  an  infinite  number  of 
-radutions  of  colors.     If,  however,  the  s|M'ctrum  is  made  shorter,  so 


■•^s'arn.  'SSK' 


•SBTSWM:'  .-sKLa:-..  "•;►•: 


570 


Tin:  i:yi:. 


tlmt  till' colors  air  more  coiidciiscl.  as  it  were,  it  appears  as  if  ma.lr 
up  of  only  tiucc  or  four  colors-n-d,  firccu.  blue,  ami  viol.-t,  and  tiic 
transition  from  oiii' color  to  auoiiicr  is  more  al)rupt. 

There  are  several  theories  to  exi)lain  the  manner  in  which  the 
dirt'ereiit  colors  alTect  the  eve.  Without  enterinK  .  ito  a  discussion 
of  the  subject  Ihtc,  it  inav  1k>  stated  that  in  ^vwvA  ihese  theories 
sujipose  the  eve  to  hi'  provide.!  witli  sets  of  sensitive  elements  wliK  h 
are  affected  e'ither  directly  or  secondarily  l>y  some  three  ()r  more  of 
the  siM'ctral  colors.  For,  while  the  decomposition  of  white  hght  by 
in(>ans  of  a  prism  pives  seven  i)nsmatic  or  spectral  coh)rs,  it  is  touiiil 
that  all  thes<'  colors,  as  well  as  white,  may  be  obtained  by  combining 
three  colors,  such  as  red,  blue,  and  green. 

In  the  Voung-lielmholtz  theory  the  retina  is  sujjposed  to  Ik-  pro- 
vided with  three  sets  of  elements,  one  set  of  which  resjKmds  niost 
stronglv  to  red  ravs,  another  to  green,  and  a  third  is  most  aflected 
bv  blue  light.  All" the  elements  are,  however,  affected  to  some  e.vtent 
by  each  of  the  three  colors  mentioned.  Thus,  red  light  exerts  its 
greatest  action  upon  the  red-sensitive  elements,  although  it  affects 
the  given  also,  and  to  a  less(>r  degree  the  blue-percipient  (>lenieiits. 
Simirarly  with  green  and  blue,  all  the  elements  are  affected, 
but  in  "varying  degrees.  The  sinmlt.'ineous  action  of  red.  blue, 
and  gn'en  gives  the  I'olor  or  effect  of  white  light. 

Tb'  effect  of  color  waves  u|)on  the  percipient  elements  is  su])- 
posed  to  be  due,  not  to  the  action  of  light  waves  directly,  but 
t(v  the  ,. 'Composition  which  they  cause  of  a  i)hoto-cheniical 
sul)stance  with  which  the  .sen-itive  retinal  elements  are  sup- 
plie<l.  That  is,  the  red-sensitive  retinal  elements  are  affected 
by  the  ilecomiHisition  of  a  photo-chemical  substance  which  is 
ii'iost  sensitive  to  the  red  rays  of  the  spectrum.  Similarly  tli<> 
green-sensitive  and  blue-sensitive  elements  are  affected  by  green 
and   blue  light   waves. 

Inii)aired  color  sense,  or  color  l)linduess,  exists  m  :{  or  4  per  cent,  ol 
males  and  is  less  common  in  females.  Color  blindness  may  l)e  total 
or  partial.  Totallv  color-blind  individuals  see  the  spectrum  in  differ- 
<Mit  shades  of  grav",  and  all  objects  ajij^'ar  to  them  much  as  they  do 
to  normal  eves  iii  stereoscopic  ])hotographs.  To  the  partially  color 
blind  the  spi'ctrum  apiwars  in  two  colors  only,  with  a  gray  or  neutra 
band  in  it.  The  most  common  forms  of  color  blindness  are  red-  and 
"reen-blindness.  Ti/,'se  are  .sometimes  classed  under  one  head,  viz.; 
•"^red-green"  blindness,  from  the  fact  that  the  red-blind  do  not  see 
green  correctiv,  and  tin-  green-blind  do  not  .see  red  correctly— in  hict, 
an  blind  to  both  colors.  There  are  two  clas.ses  of  "  red-green  "  blind- 
ness and  tlK're  is  a  clinical  diffen'tice  between  them.  In  one  class  t he 
spi'ctnim  is  shortened  .at  one  end  (the  red),  while  in  the  other  the 
spectrum  is  not  shortened,  but  has  a  neutral  zone  in  it.  Those  having 
thw  delect  see  some  colors  corivctU,  olher  colors  iiuorrectly,  and  the 
rest ,  tho.se  to  which  tiK'V  are  ■•  blind."  not  as  colors  , 'It  all,  but  as  neutral 

gr.iys.     Hearing  this  in  mind,  the  following  .schedule  from  Le  ( onte 


i,i\Tri!i!\\ci:s  or  yistn\  wrniorr  Ai'i'Ani:\T  lkskis.    ,j71 

will  hv\\>  make  iiitcllifiil)!''  wIimI  the  color  l)liiiil  sec,  what  mistakes 
ijicy  aif  apt  to  make  in  iiiati'liiiiK  colors,  and  the  means  a.loplnl  ui 
iletectin^r  this  delect . 

I'uuE  Colors. 

I.    >V>  I'lurfCthf. 

n.  While  ami  blKck  ami  all  iiitermoliaiL-  shades,  or  Knys, 
h.  YiMow  ami  all  shades  of  the  sami'— i. ' .,  hrowii. 
.•.  Blue  and  all  shades  <if  the  same  or  slate  blues. 

II,     !><>  Hilt  Me  tit  all  as  cohrit. 

(I.  Kcda  are  seen  as  ditlerciil  shades  of  gray. 
(>.  I  Ireeiui  are  seen  as  ditTerent  shades  ul  gray. 

Mixed  Colors. 

HI.    Srr  ineorreftlu. 

n.  Scarlet,  whkh  is  a  miiture  of  red  an.i  yellow  light,  is  seen  as  (rray  and  yellow. 

whieh  eciuals  darli  brown. 
b.  Ornnite      re<l  •  yellow,  are  seen  as  gray  .  yellow -lighter  bniwii. 
c  Purple  -  red  f  blue,  are  seen  as  gray  <-■  blue  -  slate  blue, 
rf.  Yellowish  green    .yellow  +  green,  un-  seen  as  yel!.w  +  gray-bniwn. 
e.  Illuish  green      blue  .  green,  are  se.n  as  blue  .gray-  slate  blue. 

To  Ih'  clinicallv  accurate,  lliis  table  should  be  modified  in  some 
ways,  inasmucli  a.s  it  does  not  ihstiiiguish  two  chi.s.sos  of  red-green 
l,l'i,'„l',„.ss— one  with  and  one  without  shortened  spectrum.  The 
tai)le  serves  its  |>urpose.  however,  as  an  aid  in  eluciilatiiij:  the  subject. 
From  this  it  will  be  ob.served  that  the  red-j:ieen  l)lind  are  very  Uable 
to  contuse  or  mistake  all  mixed  colors,  as  well  as  reds  and  greens  with 
cither  browns  or  gray  blues. 

Blue  blindness  is  rare  and  of  little  i'lijwrtance  ciimcally.  Ihese 
I hiv.'  t  vjx's  comprise  practically  all  cast  color  blindness,  although 
there  are  manv  deviations  from  the  geiu.       yj)es. 

One  curious  result  of  color  blindness  i.^  that  persons  having  tins 
,i(.fect  are  able  to  discriminate  between  certain  hues  which  to  the 
normal  eve  ap])ear  identical:  c.  r/.,  two  complex  solutions  may  have 
the  .samtMM.lor  to  the  normal  eye,  but  to  the  color-blind  eye  some  one 
or  more  of  the  chromatic  constituents  of  the  solutions  may  not  be 
perceived,  ;iiid  ill  consetiueiice  the  two  solutions  appear  to  differ  in 

color.  .  , 

Color  blindness  is  usually  a  congenital  defect,  but  it  may  be  an 
.iciiiiri'd  coii.lition,  de])ending  on  some  disease  process  involving 
the  retina,  optic  nerve,  or  visual  centres,  such  as  atrophy  of  the  optic 
nerve,  tobacco  amblvopia,  and  cerebral  injuri(>s  or  disease.  In  the 
■niiuiicl  form  the  color  blindness  may  be  limited  to  a  part  of  the 
\  isual  field,  either  [M^ripheral  or  central,     .\notlier  difierence  betwwn 

tl, dijrenital  and  the  .'ictiuired  forms  of  this  defect  is  that  macfjuired 

,olor  blhidness  the  acuteiu'ss  of  vision  usually  is  hiwere.l,  while  in  the 
consienital  form  this  is  not  the  case. 

Tkst  koh  ("oi.oH  Hi.iNDNKSS.     Of  all  tests-aiid  there  are  more  than 
lid-ty  ditTercnt  onc^ -the  wool  test  of  Ilolmirren  is  jirobably  the  one 

s'l    fretiiieiitlv  used.     The  set  of  wools  consists  of  a  selection  of 

uoisted  varus  lived  with  various  colons.     The  skeins  of    test-colors 


•mm^''Fi^^  '«a&^fflit:5:-': 


"M 


P" 


ii^K?x^r  >?T;s5S^"fe^iS  5v 


i  : 


nirjilc.  and  ri'il.     <  M' 


._,  Tin:  EYh:. 

Oil 

;„v  tl.ir.-  ill  mnnlxT,  viz.    nn-.'ii,  rose  pink  .>r  pn  . 

.    vMuiuiu^  ~k-iu>.  so„u.  I.av.-  tl...  san,;.  n.l..;  a>  I  ■-  '-^;^  ;     , 

!J;„' r  of  tlu.  'olor  l.li.MlM.-ss.  and  is  not  to  lu-  us..!  n.  any  ua>  a>a  ..  M 
"'''Ct.-s.i<n.ad..in«uodli,l.t^dV  if  possihl. -and  ,1..  -v.- 

.       ,.       il  11u-',os,-sk,.in  of  ,n..M.  is  pla.^d  at  un.  s.d.    s.>,.an.  M 

Illation  IS  rc<|Ufstcil  t(i  scit  ( 1 


;  ,,  ,.  ,,ii„.l,.ss  is  to  1..'  .U'ti-nniiu'd,  .-xaniinations  w.U.  oti.c  n>- 
k  Js  1  .1  1...  mad...  Til.  s.ru,.d  ..xaniinatiu,,  witli  t  i.  l'un>l.' fs  ■ 
k.i     wil  sl,..w  that  ••r..d-l.lindn.ss-  .-xists  ,t  tl.c  colors  wind,  a  - 

:l:ic!;;.:V'o  Inatdi  -h..  pu,-pl.-  in.-hul..  sha.h.s  of  l,lu.  or. viol., :  wlnl. 


■  1  ,rrc(Mi  or  -rav  is  s.-l.'Ctrd  the  sul.jfct  is  -  jtre.-n-l.ln.d. 

?        V   li;; Thomson  Ints  d..vis...l  a  vory  .■onv-.m.-n,  '-"I;  ";;;';  ' 

..f    IH-  Holm,n.n  wools,  whirl,  .-msis.s  .,r  a  stick  will.  >;'''- ;;'^'^,^   ; 

•     Pl.t..  VIX        Vs  in   Hoinsiicns  method,  tho  tcst-skcm- 

as  shown  m  I  'j'"   -^  •);     "^r    ',  ,  '  .Li^^i,,,  ,,,  t.,  hr  matched  in  turn 

|r,:i,.!l!i  colors,  and  which  aiv  mmil.crcd  from  one  to  twenty. 
Tf. 11  tints  ari'  to  be  selected.  , 

Tl  ,.  id  m.ml-ers  heinfl  the  match  coh.rs  and  the  even  numle. 
„j  :  „.t  on  colors,  it  isevident  that  the  seleetion  ma<l.-  '>>■  tl-.  <;'   j- 

„.l  ,v,.  will  inchule  some  of  the  even  numbers,  wliih-  tli,.  eve  liu 


iniiii  tliis  defect  will  select  onlv  o.ld  liuinliers. 

Th  1      , 1  has  further  improved  his  test  by  discarding  the  c.  or- 

.tiek-u         creasing  the  number  of  the  coloi-skems  to    orty.  each  nt 

ieh       s      bangle  attached  bearing:  a  number.      Hy  'his  means      ^^ 

kei,         av  be  lu-aped  together  without  any  r..gulanty  ot  recui.iig 

..       s        .  1  .s  occuis  on  tlu.  color-stick,  thus  obviating  the  poss.bih  y 

iv'm^     L  hint    to  the  I.erson   u.ul.'r  ..xamination  by  the  ivgular 

:;l.,.?:;;;Se;;t  :"    y!.rns,as'miglit   occr  aft..r  repeated  ..xanunation. 


if  the  individual. 
The  Holnigivntest  is  very 


atisfactory  in  det(.cting  congenita!  color 


,,,i    i;;rimU..  a;;  uinM  conditio,.  so,..e  other  niethod  nn.. 
11       ,1    of    the  fict    t>"fore  mentioned,  that  the  bhndn.» 

;;a;^^;,i;;;;te;rn:l^n;d^;.r;a,.., ha,  the  color  ^ 

" orrectlv  seen,  and  the  defect  in  the  eolor  s.-nse  is  d.scm  e,    I '"  > 
Sng  a  sn.all  t..st-..bjeet,  such  as  a  distant  signal  light,  whose  ,etin..l 


;#«^ 


}'L/vrt:  XIX. 


^^^ 


\:Skf^ 


/./.s7rA'y;.i.vciw  of  vi.sioy  ninioirr  ajtmu-.w  Lt:>^i"y.   573 

■„„■,.',.  i.  sn  sumll  MS  I..  ImII  .-ntircly  will.iii  the  (•.,lni-l.lii..l  a.va.  It  is, 
,l„.n.f,,n.  •■via.'iit  tliat  sli.-ul-l  tl.c  wool-trst  iii.licaK'  no  .l<'t<ft  in  tlu- 
,,,|,,i  -I'lisc  wr  rami..!  l"'  sniv  witlioul  a  liiitlicr  (■xaiiiiiiatu.ii  that  a 
,Maoi- MM.i.inia-a  t..l.a(-<-..  s(M.t..iMa.  lur  ('xainpli-     .lurs  not  <"xist. 

Tl,..  existence  ..r  central  color  scotoma  may  !>»■  detectcl  l)y  tl>e  use 
,,,  ,|„.  ,„.jiineter.  employing'  small  s(iuares  of  colored  paper  of  tr(>m 
niir  In  tell  millimetres  size.  n    r  .     . 

\  innre  satisfactory  method  is  to  use  as  test-ohjects  small  distant 
,.,,i,,n,l  lights  the  (litTeri'iit  colors  of  which  should  he  distmpmshed; 
,„.  ,  ,|Mrir-l.hie  col.alt  filass  is  placed  over  each  eye  separately  and 
,l,e  vision  is  ihrected  to  a  small  distant  lijiht.  such  as  the  tame  of  a 
,..,„dle  \  normal  eve  sees  a  li^lit  of  one  color  surrounded  l)y  a  halo 
,;,  :,,iother  .'olor,  hut  a  color-blind  eye  sees  but  one  color,  blue,  or  a 
while  lisiht  surrounded  bv  a  blue  halo. 

Individuals  who  are  blin-l  to  red  are  also  blind  to  itscomplonientary 
,..,!,„■  Application  of  this  fact  as  a  t<-st  for  color  blmdne.s.s  may  be 
„,„!,'.  in  the  followin<t  way  .\  sheet  of  white  paper  is  illunnnated  by 
uvo  lisihls  placed  at  a  little  distance,  one  lipht  having  a  red  glass  m 
iV,,ni  of  it.  Hetwe<-n  tlu-  lights  and  tin-  pajier  a  small  ol).|ect,  such 
,-  -I  pencil  is  placed  so  situated  that  two  .shadows  of  it  tall  on  the 
white  I'lper  One  shadow,  that  formed  by  the  rays  from  the  wlute 
li.rlu  will  be  red  in  color,  while  th<'  other  shadow  will  be  its  coin- 
piiin'entarv  coloi,  or  green,  A  color-blind  person  will  .see  but  one 
'hidow  under  th.^s.-  conditions;  or  at  lea.st  will  disnnguish  no 
,litieivnc.'  in  their  colors,  but  mereiy  a  difference  m  the  density  ot 

~  Amblyopia  ex  Anopsia.  .b/fWyc/"'"  /'■'""  l^i"''-^''-  I'' '"  '"""'>'  ^''''^'" 
1„„„1  an  evi'  is  disused,  its  visual  power  is  diminished  from  im])erfect 
,,li\si,,io.riVal  development  of  the  central  visual  centre.  An  active 
l„:t,,i  ii?  causing  this  condition  is  probably  the  act  of  suppressing 
,h.  viMon  ill  the  .lisu.s.-d  eve.  Particularly  is  this  true  it,  as  usually 
,„-,ius  in  stiabisiiius.  the  vision  of  the  s(ivnntmg  eye  is  suppressed 
l„.r:iiwe  of  the  contusion  of  images  otherwise  seen. 

Tills  suppression  of  vi.sioii,  which  really  nu-ans  an  abeyance  of  the 
,,l,v~iolo.rical  processes  in  the  visual  centres,  together  with  the  youth 
,,l  ihe  patient,  is  undoubtedly  the  important  factor  m  the  production 
..!  aiiiblvopiaexaliopsia.  ,        ,     ,■  t 

\,.v  ;,iso  is  im|.ortant  in  det.'rmining  the  result  ot  disuse,  in 
■i.hih  life  after  the  visual  centres  become  phy.siologically  developed, 
:,M,l,lvopia  does  not  result  from  disus.-.  It  is  in  th."  first  years  ol  hie. 
tl„.  years  of  ,leyelopmental  activity,  that  disuse  of  this  funeti'm. 
led  with  efforts  to  suppress  it,  exhibits  its  effect.     Thus  it  will  be 


.Md.nt  that  in  all  ca.s.'s  of  sciuint  in  chil.lren  efTorts  should  be  made 
,,,  u,aiiitain  physiological  activ.iv  in  the  sipiinting  eye  by  exercising 
i--  functions  for  a  short  or  long  time  daily,  while  the  other  eye  is 
. ,,,.!, ,j,,.|  (•,.„,„  ,^.,,rk  bv  means  of  a  bandage,  patch, or  opaciue  g.ass. 
Ihe  amblyopia  accompanying  .squint  is,  howev(>r,  frequently,  it  not 
usually,  a'coiiiri'iiilal  condition,  and  in  no  way  the  n^svilt  of  disuse. 


■{ 


Tin:  i:yi:. 


liui  in  casi's  nt'  siiiiiiil,  even  in  iIidsc  liaviiis;  normal  visual  ac'iilfni'?.> 
in  cacii  cvf.  tlif  |ii)\\cr  nl  iiindciilar  tixatiim  Ix'coini's  M'iiiiii>ly  ini- 
pain'tl.  so  thai  true  liinucuiar  lixalion  is  lairly  at'aiiM'd  atlff 
ciiii-cctinji  a  stfaliisnuis. 

In  ca-cs  1)1'  liifjli  I'cliactivc  cii'nf.  nut  ii;lr<'i|urn!ly  a  i'iin~iilri;ilj|c 
(l('<;n'i'  (it  anihlyupia  fcriains  alter  (•(irrcclidii  ul'  ilic  retracticii  l)y 
siiitalili'  lenses.  In  a  certain  nunil)er  ot  these  cases  the  aciitene>--  nl' 
visiiin  ini|iriives  when  correct inj;-<;lasses  are  worn,  at  lirsi  ra|iclly. 
then  more  slowly,  mitil  vision  liecoines  normal,  or  the  concliti<in  m.iy 
liecome  stationary  hel'orc  normal  vision  is  altaiiieil. 

Congenital  Amblyopia.  This  is  prohahly  tiie  result  of  arrested 
or  imi)erlcct  (levelo|iincnt  of  the  central  visual  centre.  It  often 
escapes  oliservation  durinji  chililhood,  ainl.  indeeil,  not  iiifre<|uenily  is 
undiscovered  till*  '  adult  ajre  or  middle  lite,  when  hy  chance,  pi'ihaps, 
the  patient  discovers  that  one  eye  is  hlind. 

When  atTectinj;  one  eye,  it  is  as.sociated  fre(|uently  with  stiahismus. 
Nysta>:mus,  also,  sotiu'tinies  accompanies  hij;h  dejirees  of  amlilyopia. 
The  entire  field  of  vis, on  may  he  atl'ected.  or  scotoma  may  he  present. 
No  olijective  conditions  adei|uat('  to  ai'couiit  for  the  defective  vision 
are  found.     The  condition  is  not  amenahle  to  treatment. 

Hysterical  Amblyopia,  .\monfi  the  ocular  manifestations  of  hys- 
teria, aiiil>lyo])i:i  is  often  pnseiit.  It  is  .always  associatcil  with  con- 
centric contraction  of  tin-  tield  of  vision.  .\  peculiarity  of  this  form 
(if  contracted  tichl  is  that  it  may  he  moditied  in  size  liy  excit.ation  of 
the  skin.  \  puncture  of  the  skin  hy  a  pin,  for  instance,  will  incicase 
the  size  of  the  lield,  and  hy  successively  irrilatinjr  or  e.\citinj;  the 
skin,  the  lield  may  he  increased  to  its  normal  size. 

Color  sense  is  often  disturhed,  and  there  may  he  inversion  of  the 
normal  color  lield — i.e..  instead  of  the  lield  lorhhii'  heinj;  larp'st  and 
tli.it  for  Krccii  the  smallest,  the  tield  for  f;ieen  is  foinid  laifjest  and 
tli.it  for  hhie  smallest.  There  may  he  polyopia,  monocular  diplopi.i. 
micropsia,  mefjalopsia,  hemianopsia,  or  central  scotoma. 

The  aculeness  of  vision  is  often  improxcd  hy  plain  hliie  j;la,sses. 

When  hlin<lness  is  coiii]ilete.  it  is  usuallv  inonolateral.  and  the 
pupil  reacts  when  the  other  eye  is  covered  .and  uncovered. 

<  )ther  disorders  of  sensation,  particularly  of  the  mucous  menihranes 
and  skin,  anil  especially  of  the  |>liaryn\.  almost  always  accompany 
liysti'rical  amhlyopia. 

Simulated  Amblyopia.  Mlimlness.  complete  or  p.irtial.  afl'eciin^' 
one  ir  hoth  eyes,  is  sometimes  pretended  !iy  individuals  who  hope 
thereliy  to  escape  the  performance  of  some  duty  or  t<i  jrain  com|ien- 
salioii  in  the  way  of  a  pension,  or  damafies.  If  the  individual  is  intel- 
lifient  and  cle\-er,  or.  on  the  other  hand  is  deii.sely  stupid,  it  may  he 
very  dillicailt  to  co:i\ict  him  of  deceit,  and  much  care  must  he  <rivcii 
to  the  examination  of  his  condition. 

Coniplete  lilindness  of  hoth  eyes  is  not  often  simulateil.  except  in 
those  cases  where  a  colisiderahle  defrree  of  amhlyopia  ri'ally  exists. 
Ill  these  ca~e-  the  action  <if  the  pupil  is.  perhaps,  the  hcst  iiulox  uf  the 


nlsrrnHAM 


'i:s  or  yisii>.\  wiriinir  Ari'Mn.sr  i.esids.    :,-:, 


,.,,ii,|ili.  !i.     Ill   al>s(.liil.'    hliiidiicss    in     hdli    <'.vcs    tlir    iMij.ils    will 
imhIv  ivsponcl  In  iinlil.     Sliuul.i  llir  |>atii'iil   iiavc  iisnl  atrniniic  In 

Kiii.  ;i4o. 
Jiiijfit  Eye 


KfTprsHl  of  ficlit  ««  seen  in  iieuraslhenla. 


576 


77/ f;  A.J/-;. 


ma: 


•k  ll 


II'  ii'al 


ndidhioii  III  till'  pupils,  this  fact  may  Im-  siis|M'fti'(l  if 
ihi'iv  is  I'Xlii'ini'  ililalalioii,  as  lln'  my.lnasis  arci.mpaiiyiiiK  amaiiiusis 
is  usually  miMliTatc  It  is  tnir.  liuwi'ViT.  tliat  tiif  pupils  iiiay  cnu- 
tract  uiuliT  till'  stiiuulus  nf  linlit,  nr  thai  tlic  iippnsiti'  cuiulitidii,  llial 
of  \vi(|i'ililatatii>ii  "f  tin'  pupil,  may  I'itliiT  of  tlii-iu  accompany  liliiiil- 
ncss:  so  that  it  will  Im-  sicii  that  tlic  unmasking  of  maliiip'riiin  in 
ihi'sc  cases  mav  Im'  very  ilitlicult. 

A  dose  watcli  slioulil  I"'  kept  on  the  actions  of  the  iiuliviilual  when 
he  believes  himself  free  Ironi  ohservation. 

A  prism  of  (1°  or  s°  may  Im>  placed  with  its  base  out  before  one 
eye  anil  left  in  place  for  a" few  miimtes.  If  on  its  smlilen  removal 
tile  eye  is  seen  to  ileviale  outward,  it  may  Im-  sus|M'cted  that  the  eye 
sees.'  Should  re|M'ated  tests  show  that  withdrawal  of  the  prism 
is  accompanied  by  this  movement  of  the  eye,  the  fact  that  the  eye 
sees  is  establisiied. 

If  blindness  in  one  eye  is  claimed,  a  prism  placed  before  the  pre- 
tended blind  eve  will  cause  no  chanue  in  the  position  of  the  eye  if  it 
be  reallv  bliiiil.  If.  however,  the  eye  does  participate  in  vision,  a 
prism  oi'  tt°  or  S°  placed  with  its  base  out  before  the  eye  causes  the 
eye  to  move  inward,  and  if  the  prism  be  suddenly  removed  while  the 
vision  is  tixed  on  some  near  object,  the  eye  can  be  seen  to  move  out- 
ward. 

Prisms  stroiij;  eiioujrh  to  cause  double  vision  may  Im'  put  on  the 
patient,  and  he  be  rei|uested  to  walk  or  to  p'  up  and  down  u  few- 
steps  of  a  flight  of  stairs. 

The  diplopia  caused  by  a  5°  or  (1°  prism  w-ith  base  ui)  or  down, 
for  example,  is  most  coiifusiiif;.  In  makinji  these  tests,  it  is,  of  course, 
important  to  see  to  it  that  the  patient  does  not  close  the  "blind" 
eye.  With  a  (>°  or  7°  prism  with  base  down  in  front  of  one  eye, 
and  the  vision  directed  to  some  distant  object,  the  eyes  will  alter- 
nately move  up  and  down  if  they  be  alternately  covered  and  uncov- 
ered with  a  screen. 

.\  jjiism  may  be  held  with  its  thin  edf;e  op])osite  the  middle  of  the 
pujiil  of  the  seeiii}!  eye.  thus  causiiifi  double  vision  in  the  single  eye. 
When  the  i)atient's  attention  is  directed  to  the  fact  that  he  can  see 
double  with  one  eye.  the  prism  may  be  moved  so  as  to  cover  the  pupil, 
when  if  he  still  admits  that  double  vision  exists,  he  is  seeing  with 
both  eyes.  These  tests  show  the  existence  of  binocular  vision,  but 
do  not  indicate  the  acuteness  of  vision  in  the  blind  eye. 

.\moiig  the  quantitative  test.s  may  be  mentioned  the  following:  A 
strong  convex  lens— c.  </.,  U)  1).— is  placed  before  the  .seeing eye,  and  the 
test-type  is  held  at  such  a  distance  that  it  can  be  read  with  this  eye, 
which  with  an  emmetroiiic  eye  is  one-tenth  metre:  then  with  both  eyes 
o])en  the  tyi)e  is  moved  farther  away,  and  if  it  is  still  read,  it  is  being 
read  by  the  '"blind"  eyi 

The  stereoscoiM"  may  be  used  with  cards  bearing  various  designs 
which  differ  on  the  tw'o  sides,  and  which  are  combined  by  the  vision 
of  two  eves  to  form  a  definite  figure  or  letter. 


.'.'^•^fri.-ri^ 


msTUJiJlA.WHS  OF  VISIOS  WITHOUT  AVPARKST  LF   'OS.     577 


W'iuTv  the  scoinn  cv"  twn  struiij:  cyliinlcrs — e.  ij.,   I  ').  aiiil    i  4  1). 


— an-  so  airaiint'd  sis  In  neutralize  eai 


)i  other,  I.  <".,  with  axes  tojji-thei 


111  til 


I" 


lion  lliev  (Ii>  iitit  afl'eet  llie  vision.     Now.  wliile  the  patient 


is  re;iiliii>r  ihstant  ti'st-ty|H"  one  cvhnder  is  turned  ll)°  or  l.'»°,  thus 
entirely  <•!  ijlinn  tiie  relraetiun  ol  the  eonihinatioii  and  lessening 
the  visual  aeiiily  of  the  eye  hefore  wiiicli  it  is  placed.  This  elianp- 
-hould  U'  niade'whili'  the  patient  is  readinR  larfct-  ty|K',  as  in  reading 
-mall  tyiK'.  which  demands  of  the  patient  close  attention  to  detail, 
a  compaialively  small  change  in  the  lens  before  one  eye  is  noticed 
at  once,  even  though  liotli  eyes  have  normal  visual  acuteness  and 
are  Ihmiih  used  logether.  When  one  eye  has  suluiormal  vision,  then 
.-ny  chanp'  in  the  refraction  of  the  lens  in  front  of  the  ljett«*reye  ia, 
oiiviouslv,  more  (|Uicl;lv  detected. 

of  course,  the  '.■efpiction  of  the  eye  should  Ik-  det<'rmined,  at  Icasit 
appro.vimately,  hy  usiiifi  the  shadow  test  with  the  supposed  blind 
eye.  ami  etTorts  to  imjirove  vision  l)y  correcting  lenses  should  be  made. 
"  Snellen's  transparent  red  and  green  test-letters  of  ilitTerent  sizes 
may  enable  one  to  detect  simulation,  and  at  the  same  time  to  determine 
the"  amount  of  vision  in  each  eye.  The  patient  is  re(iuested  first  to 
read  the  letters  without  anything  before  his  eyes.  Then  a  sjH'ctacle 
frame,  holding  a  red  g!ass  iii  one  side  and  in  the  other  a  green  gla.s8, 
is  put  on  him.  and  he  is  asked  to  read  the  letters  again,  taking  care 
that  he  kee])s  both  eyes  o|)<'n.  The  green  glass  shuts  otT  from  one 
eye  all  the  light  coming  from  the  red  letters,  thus  making  them  invisi- 
ble to  the  eve.  Similarly  the  red  glass  makes  the  green  letters  in- 
vi>ible  to  the  otlier  eye.  "  By  noting  what  letters  are  read,  it  is  easy 
to  determine  wliet;ier  one  only  or  both  eyes  are  used,  and  what  acute- 
ne-s  of  vision  is  represented  by  the  size  of  ty|M' read. 

Ursemic  Amblyopia.  Amblyoiiia  from  ura-mic  poisoning  Ls  seen 
accompanying  the  albuminuria"  of  scarlet  fever,  variola,  measles,  and 
pregnancy,  it  is  a.ssociated  fre«iuently  with  symptoms  of  brain  irri- 
tation, such  as  vomiting,  convulsions,  coma,  and  hemiplegia.  Hoth 
eyes  are  affected,  and  blindness  may  lu'  complete  within  a  few  hours 
Iron,  its  onset.  A  peculiarity  of  th'is  condition  is  that  the  i)upillary 
reactions  are  not  lost.  The  jirognosis  so  far  as  vision  is  concerned 
i-  good,  blindness  usually  di.sapi)ei'ring  with  subsidence  of  the 
.ilbiiminuria. 

Glycosuric  Amblyopia.  Diabetes  sometimes  causes  amblyopm, 
:tiid  it  is  characterizeil  bv  a  central  color  scotoma.  Central  scotoma 
Inr  white  may  al.so  be  present.  The  visual  field  may  be  normal  or 
contracted,  or  may  be  hemianopic.  The  jirognosis  is  unfavorable, 
■lit hough  u.seful  vision  may  long  be  retained. 

Ma/arial  Amblyopia,  \lalaria  is  another  di.Mvise  which,  in  addi- 
tion to  those  cases  of  impaired  vision  due  to  aiinarent  lesion,  causes 
•  ilher  disUirhances  of  vision  in  which  the  ophthalmoscopic  findings 
.lie  negative.  The  affection  apjieai-s  as  a  tr:Uisient  lo==  of  virion, 
lasting  from  a  few  hours  to  several  (la\  s.  and  disappears  under  treat- 
ment with  (juinine.     The  amblyopia  begins  with  the  chill  and  ends 

:!7 


578 


/•///;  /.»;. 


Willi  tlir  ..iisct  ..I  111.-  sw.'Mtinii  -iM«i'.     Aliliniijih  l.liii.lii.ss  may  Im- 
ciilliplrlc.  the  pilliils  rflU't  llnlllially  In   li^lii. 

Amblyopia  from  Hemorrhage,  l.nss  ot  I.IimmI  U  inllnw.'il  ..crasi.iii- 
allv  by  imi.air.Ml  vMnii  or  l.v  hliii.liic^s.  Tli.-  .iHliirbaiic.-  in  visH.ri 
iiiav  ii'ol  iiiaiiil'.-si  ilsi'lf  until  smiir  tim<-  after  tlw  lii'iiinniiajjc  .'Vi-n 
•ill.T  iIm-  iK.niial  vulmiK-  ul"  I.K.nd  lias  Im'.mi  rt'-»'j-ial>lir.li<Ml  ami  llir 
I'tiuiiibrimii  uf  tlir  riiciilali.ni  ivslmrd.  InstaiicM-s  ni  tins  .■uii.liti..n 
havr  Ixi'ii  nl)s.TV.'.l  lnll..\viMi:  iii'iiioirliap's  wliicli  w.iv  ii..t  vrry 
seven'  i>l-  exliaiisliiin,  so  that  a  ciiiulilinn  uf  ana'ima  rnul.l  tiul  i)e 
sai.l  to  exist,  allliutiKli  il  ninre  ufteii  aer..iiii.aiiie>  „v  iuliuws  an  e\- 
sMiiciiiiiate.l  edii.iilioii.  It  is  seen  afi.T  nielh.iilia-;ia,  lia  luoptysis. 
pa^ric  lienii.rrliatie,  and  post-part uin  lieiiinrrliane.  The  anil.lvoi.ia 
sometimes  aeeompanvinn  ureal  anaemia  and  extrem.-  elilorosi-  may 
1m'  considered  llie  same  in  kind  as  lliat  iollowmy:  liemovrliajre.  A 
ease  of  this  naUire.  iindiT  the  nl.servalion  of  llie  writer,  oeemred  m 
a  frail,  anainie  woman,  lliirtv-six  years  old,  after  a  prolonged  periud 
of  laetati..n.  \  isioii  firadii.dlv  failed  for  several  days,  when  hlmd- 
i,c^«^  Ixrame  ahsolute.  The  lijilit  reaetion  of  the  pupils  was  not  lost, 
iMit  was  lessened,  and  the  pupils  wen-  hut  little  larger  than  normal 
in  size.  Tonic  tn-atiiient  was  ;it  once  instituted,  and  tlic  child 
wa-;  taken  fn.m  the  hn-ast.  The  condition  of  vision  leinanied 
michaniicd  for  llwee  weeks,  when  si>;ht  h-uaii  ton-turn,  and  soon 
normal  vision  was  n-ston-d. 

The  loss  of  vision  niav  ix-  trradual,  or  sud.len  an.l  complete,  or 
|.;ntial.  and  is  frcner.illy'biiateral.  'Iliere  may  l«-  central  scotoma. 
The  aflectioii  m;iv  n-m.ii.'  for  a  few  hnui>  nr  days,  or  ey«-n  for  a  tew 

weeks,  and   then'  ^niduallv  ,|i^appear  ipletely,  or  it    may   ieavi- 

hehind  il  p<'rnianeiil  defect>,  Tlie  iik.sI  unfavorable  cases  appear  to 
be  those  which  an-  late  -a  week  or  mo  ■• -in  followiiif;  the  liemor- 
rhap-.  and  thes(-  cases  usually  <liow,  at  a  later  .stajie,  aln)phy  ol  the 
opiic  nerves. 

it  should  b(-  n-m;irked  that  an  impairint-nt  of  vision  cominjr  on 
ihirin;:  an  exhausted  bodily  coiidilinii  may  be  dui-  to  a  w(-akeiim^' 
or  exhaustion  of  IIk-  |«iw(-r  of  accommodation,  and  the  state  ot  the 
n-fr:iction  and  accommodation  should  alw  ys  be  examined  in  such 
conditions. 

It  is,  of  coursi-.  important  to  have  some  piidt'  as  to  tlu-  pn>frno.sis 
in  these-  condition-.  The  negative  n-siilt  of  the  ophlhalnioscopie 
c\;uiiinalioii  is  no  index  in  makins;  a  projinosis,  for  we  meet  with 
cases  of  siiddi  •  blindness  occurriiiji  ilurin<i  tli<-  course  of  acute  dis- 
ease, in  which  no   clian};(-    in    the  ey(-  fuiulus    is  visible  for  w(-eks, 

d  y<-t  when-  biindiK-ss  is  permanent  and  in  which  atnjphy  of  the 

,,,tic   n.ive  eventually   appears.     Th(-   behavior  of  the  pupil   may 

Slivc  information  of  v.ilue,  as  when  pupillary  n-action  is  not  lost  m 

blindiK-ss  in  any  of  the  fon-fjoinjl  conditions  the  pnif!;iiosis  is  mon- 

lavoiable.  .  r  i  »    ■ 

Amblyopia  from  Lightning  Flash.  Loss  ot  vision  by  liKlitnin^' 
stn)k(-  has  been  n-iiorledin  many  instances,  and  may  beaccoinpiuucl 


insiriiiiAyt  IS  in-  yisii».\  wiriiorr  .i/vi «/■;>/•  lksih.s    :,- 


!» 


I,v  uIIht  Irsioiis,  such  as  Imrii  nf  the  skin  i.r  ci.iiica.  ptosis,  or  mjuiy 
u\  111.-  Ifiis.  niasiMKfalanKt.ur  iiittMimii.'Unrycoii.litiiiiisnf  the  .l<-<-|) 

MiMctuirs  ..f  tl vc.     The  -inlit  in  .-is.s  iinconii.licatc.l  l.y  intliiin- 

mat.iry  »r  ..iIht  visible  diallers  is  usually  fully  rt'st.ir.'d. 

Reflex  Amblyopia.  Iniiation  ..f  the  tifili  n.-rvf,  csptTially  that 
f..rni  arising  fr.mi  disrascl  tc«-th,  is  said  sonu-timcs  to  atT.rl  visi.m. 
\inl.lv..|)ia  in  <.nf  <'V.',  n-sultiiiK  fn.m  irritation  of  the  ciliary  tu'rv.-s 
in  Ih.'-  other  cvc,  has  Ix-en  report.- 1,  as  have  (-as.-s  of  anil)ly.i|.ia  froiii 
intestinal  irritation  .hi.-  t.)  the  pres.-nce  of  worms  in  the  intestinal 

'"scintillating  Scotoma.  Ihis  condition  (Fin.  a»2)  is  known  also 
MS  ••nn.aurosis  fupax."  an.l  as  "flicker  sc.toina."  The  c.n.htion  is 
chara.t.-riz.-.!  hv  th.-  apiM-araiic-  in  th<-  tiel.l  of  vision  ot  a  clou.  . 
ohscurinc  uioiv  or  less  c.inpl.-t.-ly  ohject.s  ui  one  imrt  ..t  the  fi.-i.l. 


SciiitlllatliiK  ncdtonm  in  migralue.    (Revtki 

this  clou.l  increas.-s  in  size  an.l  may  ..l.Iit.-rate  completely  on.'-half 
,,f  III.-  hel.l.  It  is  h..monvm..us-/.  f.,  affects  the  nasal  half  ..f  .me 
vHual  ti.-l.l.  an.l  the  l.-mp.".ral  half  ..f  the  ..th.-r.     A.-cmpanymji  this 

,.l lin.-ss  is  a  peculiar  wavy  or  flickering  visual  sensati.m.     Ott.n 

M>irk<  ..f  linht  api).-ar.  ..r  the  cl.m.l  may  he  bor.l.-re.l  by  a  biu'iit 
,.'|.r,.  The  acuteness  of  vision  is  .listurb.'.l.  bemji  generally  very 
,|.-ri.i.-.llv  .lecr(-as.-.l.  Th.-  scintillati.)ns  linally  cease,  the  clou.l  (lis- 
aupears/and  vision  is  again  normal.  A.-cmpanying  the  sensations 
iuit  m..ntion.-,l.  or  imm.-.liut.-ly  foll..wing  their  subsi.lence,  h.-a.lache 
usuallv  api)ears  an.l  is  Umite.l  to  one  si.le-migraine.  These  phenom- 
,.„•,  niav  result  from  irritation,  pn.bably  of  the  brain  cnex.  in.m 
tuxi.-  substanc.<s  absorbed  .luring  gastric  <.r  intestinal  m.hgesti..n. 
i;v.-s.rain  fn.m  .vfractivo  rrrnrs  is  surrly  a  no?  infre-pu-nt  .-ansi-. 
.ither  .liri-ctly  by  cau.sing  brain  irritati.m,  or  mdirectly  by  reHexly 
disturbing  the  functions  of  the  stomach. 


080 


THE  EYE. 


As  tomiiorary  ohscunitions  of  vision  occur  in  glaucoma,  tin-  tension 
of  the  eyes  slioiild  always  i)0  examined  in  this  condition,  in  order 
to  avoid  niistai<inn  tiie  character  of  the  affection. 

Nyctalopia.'     Niflht  hhrnhiess  is  a  functional  disease  characterized 
l.y  a  diminished  seiisiiulity  of  the  retina  to  lif;ht.     It  usually  occurs 
suddenly  in  spring  or  summer,  after  one  or  several  days  si)eiit   in 
l)ri;rlit  suiilijiht,  a  debilitated  condition  of  the  health  often  being  a 
contributing  cause.     In  the  beginning  the  centre  only  of  the  retina 
is  alTected,  and  a  more  or  less  sharjiiy  define  1  cloud  ai)i)ears  in  the 
ccnire  of  the  field,  whieh  compels  the  patieni  to  look  beyond  or  at 
the  sidi'  of  an  object  in  order  to  see  it  at  all  distinctly.     Krciuently 
all  of  the  field,  or  all  but  the  jjcriphery.  is  cloudy.     If  the  excitmg 
conditions  continue,  the  density  of  the  cloud  becomes  greater,  aiid 
the  blindness  comes  on  earlier  in  the  evening.     In  ea.ses  of  only 
moderate  severitv  the  full   light  of  a  bright  or  even  a  cloudy  ilay 
is  sufficient  to  pi'rmit  the  patient  to  read  or  distinguish  objects  near 
at  hand.     In  high  degrees  of  night  blindness,  however,  very  bright 
illumination  is  necessary  for  normal  vision.     An  unfavorable  position 
of  the  object   to  the  light,  a  cloudy  <lay,  shadows  falling  on  objects, 
all  materially  les.sen  the  visual  acuteness,  and  lessen  the  power  of 
distinguishing  colors.     Sudden  changes  in   illumination   alTcct    the 
visioirmuch  more  than  is  the  ca>f  with  tiie  normal  eye.     If  the  illu- 
mination is  reduce(l,  a  point  is  i  -ached  beyond  which  the  decrease 
ii    vision  is  very  rapid,  so  I'    '  ,h  very  sm.alj  decrea.se  in  illumination 
causes  a  profound  effect  ujitiii  \  ision,  often  rendering  objects  instantly 
unrecognizable:    evo      perce|jtion    of   light    may    disapjiear.      This 
particular  iioiiit  in  decreased  illumination  varies  with  different  indi- 
viduals.    Diiuinislietl  light   at   any  hour  of  the  day  has  the  same 
effect,  and  the  idea,  at  one  time  conmion.  thai  tin'  disease  was  confined 
to  certain  hours  of  the  day,  is  incorrect.    The  pupils  are  usually  some- 
what ililated,  but  react  "to  light,  and  the  iK-ld  is  often  irregularly 
contracted.     The  color  sense  is  fre<|uontly  distmV)ed,   and   coloreil 
virion  may  exist 

A  cure  usually  follows  removal  of  the  cause,  but  relapses  are 
fic(|ueiit.  rrotectioM  of  the  eyes  against  brigh'  light  and  the  use 
of  toiiii-  mdlii'ines  com|>rise  the  treatment  of  this  atTectioti. 

Hemeralopia.  Day  blindness  is  a  form  of  retinal  hypera'sthesia 
ill  wliicli  vi.-ion  is  diminished  during  ordinary  daylight,  but  is  good 
ill  ,1  dim  light.  It  may  be  caused  by  exposure  to  bright  light,  espe- 
ci;il!\  liv  light  ivllected  from  glistening  snow  or  ice.  \\\  important 
coiiiriliutiiig  'MUse  is  eyc'.^lraiii  from  refrai'tive  errors.  Inteiist-  photo- 
phuiii.i  i<  sometimes  present,  as  will  as  tla-  phenomena  called  phos- 
pheiies,  which  consist  of  subjective  symptoms  characterized  by  the 
appearance  of  highly  luminous  moving  clouds,  rings,  or  streaks, 
and  dazzling  sensations.     The  condition  may  exist  fis  one  of  other 

1  Thetcrm  iiycl*li)iiia  i.^(.niniis.'.l  toiii'liciitc'lay  hliiiiliii*.  nml  heim-ralopU  to  Indicate  night 
bllivlnts.s     The  tnie  mc«innK  "f  Hie  wopli'.  lioHever,  iieein-  to  !»■  a.«  atnite  unil. 


insruRiiAscEs  OF  visioy  wrmoLT  AVPAREyr  tEsioy.  5hi 

(.«,ii<T,.|iit:il  defects,   such   lus   iilliinism  or    colobonui  of    the    iris   or 

The  use  of  tinted  glasses,  hut  especially  the  careful  correction  of 
refraction,  will  eventually  cure  the  affection. 

Snow  Blindness.  This  niav  take  the  form  either  of  day  blindness 
or  ni"ht  blindness,  and  follows  exposure  to  the  sun's  rays  reHected 
from  snow  fields.  It  is  accompanied  often  by  mtlannnation  ol  the 
eonjunctiva  or  cornea,  intense  photophobia,  and  spasm  of  the  lids, 
altliough  it  mav  not  be  accomi)anied  by  intlamniatory  conditions 
It  bejrins  bv  a'ft^lual  or  rapid  darkening  of  the  visual  field,  and 
cmtinues  as  long  as  the  eves  are  exposed  to  glaring  light.  Pro- 
tection of  the  eyes  against  tlie  l>right  light  by  means  of  smokeil-glasses, 
ur  otherwise,  relieves  the  condition. 

\  condition  .somewhat  similar  to  the  foregoing  is  met  with  some- 
times in  iHTsons  who  are  employed  in  the  care  of  the  electric  arc 
light,  the  intense  light  of  which  has  an  injurious  effect  on  the  eye 
structures.  ,  . 

Micropsia,  Megalopsia,  Metamorphopsia.  In  iiiicroi)sia  the  con- 
dition of  vision  is  such  that  objects  look  too  small:  m  megalo|)sia 
thev  look  too  large:  and  in  metamorphopsia  they  appear  distorted. 

()ne  or  all  of  these  conditions  mav  be  present  when  the  retinal 
rods  aii.l  cones  are  displaced  by  exudate  or  other  cause.  If  the 
retinal  elements  are  pushed  asumler,  so  that  the  images  which  all 
,,11  the  retina  cover  fewer  elem.-nts,  the  objects  seen  will  appear  smaller 
tlein  thev  are;  if  the  retinal  elements  are  j.ressed  together,  the  opj.o- 
<ite  cond'ition  exi.sts,  and  it  is  evident  that  distortion  of  objects^may 
•nipcar  from  disturbance  of  the  order  of  the  rods  and  cones.  These 
c.n.litions  of  vision  are  made  out  best  by  causing  the  patient  to  look 
■It  1  -^et  of  parall(>l  lines  drawn  on  a  surface  and  held  near  at  hand, 
wlieii.  if  tlie  central  lines  aj.pear  bent  toward  .-acli  other  at  the  point 
,,t  fixation,  micropsia  with  metamorphopsia  appears,  while  it  the 
iiiie<  seem  bent  apart   at   this  point,  megalopsia  exists. 

l'are^i<  of.  or  weakened  accommodation,  whether  resulting  from 
,liM-a<e  or  p'roduc<-d  artificiallv  bv  drugs,  has  the  etTect  of  causing 
n,:ir  objects  to  apjx'ar  smaller  than  is  natural.  Tin-  psychic  etlect 
,,|  the  incre.-i.xed  effort  of  accommodation  re(|uired  to  see  the  object 
,li>tiiietly  is  to  give  the  hnpression  of  a  much  smaller  object.  In 
hv^teria'objects  sometimes  appear  too  large  or  too  small. 

■  M,'t,'imorphopsia  m:.y  be  .■ansed  by  irregularities  in  the  curvature 
or  ilmsitv  of  the  refracting  media  of  the  eye. 

Erythrbpsia.  This  is  a  coiulitioii  char;icteri/ed  by  saturation  (.1 
t|„.  |i,.!,l  ,,f  vi.<ion  with  a  certain  color,  and  may  be  due  to  coloring 
■  Hitler  in  the  dioptric  media  or  anterior  layers  of  the  retma.  It  is 
M.metinies  seen  during  the  occurrence  of  icterus,  and  is  then  probably 
.111,,  to  the  pre.-;enee  in  the  eve  structure  and  fluids  ol  bile  pigments. 
(',,l,,red  vi.Mon  is  often  noted"  after  cataract  extraction,  in  which  case 
■A.r  color  of  III,-  tiild  i-  comp-lemeniary  to  the  coh-r  of  the  light  wl  ich 
the  eve  saw  through  thi'  cataractous  lens.     That  is,  the  color  of  a 


I  '-/sat  Jiv.  w':3^tf^ 


5«2 


Till-:  EYE. 


(.■ataractous  li'iis  is  usually  yt'llowisli,  and  it  transmits  lifilit  of  lliis 
coliir.  s(i  that  after  the  yi'llnwish  It-iis  is  rciiiovcd  the  <'yc  sees  white 
liftht  ;is  l)luish  in  color.  This  condition  disai)|iears  in  thi'  course  of 
time  and  demands  no  treatment.  Red  vision  sometimes  follows 
exposure  of  the  eyes  to  stroiifi  lif^ht. 

(iazinfi  at  the  sun  through  a  telescope  having  a  colored  plass  behind 
the  eve-piec(>  is  followed  by  colored  vision  iM-rsistinp  for  days,  the 
color  seen  heiiig  complementary  to  the  color  of  the  kI'I"*'*  Ix'hind  the 
eye-piece.  The  injjestion  of  c(>rtain  druss.  svich  as  cannabis  indica. 
santonin,  amvl  nitrite,  picric  acid,  osmic  acid,  and  some  others  is 
often  followed  by  colored  vision.  Coffee  i.s  said  sometnues  to  cause 
red  vision. 


"n  f'EP»'" 


CHAPTER   XIII. 
rilE  EYE  IN  ITS  RELATION  TO  GENERAL  DISEASES.' 

By  C.  F.  CLARK,  M.D. 
CONSTITtJnONAL  DISEASES. 

Anemia  is  s.c...ubry  to  s.,  ...any  and  such   "livo--;;  l>;|;ho>;;^cal 

,.,ri,ions  that,  iu  ,-<...si.l.-ring  its  rotation  t-V'^^^'^ 'j;,  '' ffe  ,s  ,    the 

•w  .....■(.ss-irv  to  ol)s(-rvc  caution  to  avoul  confasing  the  ottctts  oi  iw 

;  n"    ia    n  P  T  witl.  tlu.se  of  tlu-  .lisoase  upon  which  it  acpcnds;  an. 

;    ;     S  wo   .xchidc  the  pmnary  ..r  essent  al  a.ja.nua.  (^'^l''^'^  « '^"^ 

,.,•    lie  or  i.rogressive  pernicious  ana'uua),  there  is,  probably,  no 

':  ,     it.  i  nal  conditil.n  wh..h  n.ore  fre.,u..ntly  luus  a  part  ...  pro- 

.•   ;  .rious  forn.sof  .sthcopia.  the  cons.clerat.o,.  of  wh.ch 

"S..S  so  .nv.ch  ..f  the  ti...e  of  tl..>  "if '"''""' .•'^V''":  ' '.  K,.tween 
N  ,  sul.urt  pertaining  to  the  con.plex  relation  wh.ch  ex.sts  b.  t  ^c 

,lH  .V  •  .ul  general  diseases  can  be  of  ftn-ater  ..npoi'tance  to  the 
.  i     .,;  t  Ln  that  V  hich  co.u.er..s  the  functional  n-tiex  <!.stu,.lunKH.s 

i '  -ofle'.  se..n  i..  patic.ts  who  hav.>  errors  of  refract.o..  a.ul  are  at  the 

''Z:;;::^'uZ'2ZZ':U.  .ni...l  of  the  wnter  that  the  ,;arly 
.,„a     '  h  i^.    use  of  those  n.ea..s,  hygienic.  dietef,c    a..d  nK..hc.nal. 
"el  to  overdue  a-.a-nia,  coul.l.  i..  a  large  number  ..  .ns^     e.> 
1     .V  for  ,na..v  vears  the  necessity  for  crn-ctinfi  the    .m  giades  ot 
;lv;:.^nl  ;!a  ai.l'as,ig.natisn.  which  are  so  i.nporta...  a  leatur..  .n  the 
„;,  Hie e  of  ophthal.nology  as  we  see  .t  .n  America. 
'    Tl ,.  ..'neral  asthenia  which  acco.npan.es  the  a.ue.n.c  state  nu  .- 
,.  J     ..vlf  as  as.la.nopia.  and  this  .nay  be  co.ijunct.val.  c.l.a.-y   mus- 
V         e  i.ial.     It  Lt  infre.,,.e..tly  happe.is  that  after  a  prolo.iged 
;  ;.  '    .     he  pa.-t  of  th.-  ophthahnic  surgeon  to  correct  proper  • 
V  .;.  ..i'   '.'  i Jnatis.n.  a..d  nn.scular  in.bala..ce  by  .neans  of  spher.- 
V   ninir     Hi  weak  pris.natic  Icses.  and  to  rel.eve  ol,scure 
;:  i;,;i;  n        .  s.  su<.h  as  headache,  etc.,  ap,.irently  due  to  eyestra 
,     ubii  .  ite  photophobia  a..d  co..junctival  irr.tat.on.  by  approp  .at 
■a      e        .    s  fou'nd  that  large  doses  of  a  ferrug..ions  tun.c  an.    a 
;,     rlv    .-g..lat...l  hf.-,  with  an  abu.ulan.-e  ..f  out-of-<l....r  exerc.M-, 
1      ;r    ..lir'inple...  reli..f  fo...  all   th.>  .listress.rj  r^::'i;;i;;ri.:;d 
,le,i,"f;  f:lass.'s  for  tlu-  ti.ne  bei.ig  uniuH-.-ssary.     On  the  ..th.  r  ha.ul. 

,  ■,,.,.  K„.h„r  wis,.«  .„  Kckn,.w....Ke  his  >n..em»h.»  to  i>.  J^  K.  l^gcr,  fur  '.^r-  ^.l.^M^  -.st- 
,„„...  ,.ttorl...l  hM>.  in  clleotlng  m..eri.l  for  the  f,.llo«in«  chapter.  ^  _^^^  ^ 


r-  •mms^.^v 


.J84 


THE  F.YE. 


it  frc(|U('ntly  liaiipoiis  that  all  of  the  host  diiwtod  plans  of  ponoral 
inatincnt  ("oniiilctcly  tail  when  they  aro  not  supplcinciitfil  hy  the 
most  jiaiiistakinfi  correction  of  all  such  errors  of  refraction  and  muscle 
inihalan 


UK) 


iiif. 
...  .leal  life  is  seldom  possible  to  our  patients,  ami  the  practical 
)l)lern  wliicli  faces  the  f;eneral  practitioner,  as  well  as  the  ophthalmic 


An  i 


surjieon,  m 


lealinji  with  such  ca,ses  is.  How  shall  we  afford  relief  to 
the^'symptoms  of  whicli  they  complain,  and  still  allow  them  to  con 
tinue 

to  tliem?       I'nder  these  circumstances  it    i 
correct  a 


live  the  life  ami  follow  the  pursuits  which  seem  necessary 

essential   not  only  to 


11  ftrorsof  refraction  antl  imbalance,  hut  also  to  treat  the 

anaemia  which  renders  tiiem  a  more  active  source  of  disturbance. 

In  simjile  aiuemia.  e\en  when  profound,  the  oplithalmoscopic  ap- 
pearaiK 
disk 
|)rodui 
orbit. 


,..,'es  are  often  iiefiative.     In  some  cases  we  find  i)allor  of  th 
and  under-tilled  bloodvessels.     When  sufficiently  ])rolonfied  to 
stinj;,  the  eveball  inav  become  somewhat  sunken  in  the 


■e  wa 


Congestion  of  the  coniunctiva  accomi'amed 


bv  d 


tmii'?  no 


rvness  is  some- 
crience  to  find 


case; 
tliere 


I) 


ted,  and  it  is  not  unconnnon  in  the  writer's  ex| 
if  what  would  be  classed  as  palpebral  conjunctivitis,  in  w 


sensation  of  t 


le  presei 


hich 
ice  of  dust  i>articles  in  the  eyes,  yicM 


)iilv  after  the  anaMuia  has  been  relieved  bv  treatment. 


lere 


r 

if  eve 


are  accidental  co 


symptoms  m   wi 


haracirr  as  to  .justify  the  term  |)erni( 


iiiditions  that  may  fiive  rise  to  a  number 
l-marked  cases,  even  when  not  of  such  a 

10 


us  aiuemia — ledema  of  tl 


lids,  eMr.ivasalioii  <if  bl 1  api)earin<;  suddenly,  generally  at  night, 

beneath  the  bulb.ir  conjunctiva,  and,  at   times,  oven  small  retinal 

hcniorrliatres. 


I 


1  s], 


(kinji  of  pernicious  anarnia.  Kmes.  (|Uotmg  l-raei 


ukel. 


men- 


tions p 
were   pale 


renehvMiatous  I'hanges  in  the  external  ocular  muscles.     They 


and  clav-c<iliire(| 


.,,,.    ,...,>    ...... lith  partial  absence  of  the  transverse 

striatioMs,  .and  the  tiiires  were  filleil  with  :i  yellow  or  brown  pigment, 
or  were  linely  granular,  sniue  tibres  being  ikimow  an<l  waxy. 

Occ.isionally  in  this  cMndition  we  may  ha\f  even  neuritis  or  retro- 
bnlb.ar  neuritis.  Idlloweil  by  atrophy  of  the  ojitic  nerves.  In  chlorosis 
eye  svniptoms  present  lliemselves  of  a  character  similr.r  to  tho.se  (>f 
anaiiiia:  l>ut.  unlike  ]iernicious  aiuemia,  chlorosis  is  not  accomi)anied 
bv  retinal  lieiiiDrrhage. 

Leukaemia.  In  this  f.ital  ilisease  eye  symptoms  may  or  may  not 
be  present.  Ill  the  acute  stage  hemorrhages  into  the  lids  or  con- 
junctiva iii.i\  ajipe.ar.  and  they  are  seen  also  ;it  limes  .as  n  late  maiii- 
fesialioii.  Neii|ilasnis  of  leuk.emic  origin  may  develop  in  the  orbit, 
though  llii-  i-  ;m  extremely  rare  occurrence,  and  involvement  of  the 
lacrym:d  glands  .nid  lids  has  been  reporteil.  Occasionally  the  iris 
and  choroid  are  involved:  in  the  former,  circumscribed  tumors  soiiie- 


tiiiies  ;ipin-;inilj:;  u 


vt--!V  tl 


lynij)li:itir  and  -plenic  enhirg  nients,  and 


I  It'iib^'lie  Arch.  f.  kliu  Mfl.,  xx. 


THE  EYE  IS  ITS  RELATION  TO  ilESERAL  DISEASES.       5«o 


certain  rases  prosont  tl.o  appoaranco  of  chronic  iritis  with  flocculcnt 
iipacitios  of  the  vitreous  (licrger). 

HcniorrliaRos  and  exudations  into  tho  choroid  and  o|)tic  nerve 
liave  also  been  ()bser\-ed.  althougli  the  most  freciuent  seat  of  sueli 
IcsioiLs  is  tlie  retina,  where  one  may  sonietinies  see  hriglit  areas 
,,f  defeneration.  I'oiicet  has  shown  how  vjiscular  degeneration 
malces  lieinorrhage  possiiile,  and  de  Schweinitz  describes  tlie  wliite 
^|)ots  with  red  iK)rders  which  m-dkc^  their  apjiearance  in  the  macuhir 
region  and  also  near  the  c<iuator.  TIh'sc  spots  are  said  to  consist 
of  leucocytes  surrounded  by  red  corpuscles.  "In  some  ca.ses  the 
,,range-reil  color  of  the  fundus  is  masked  by  a  fine,  striated,  grayish 
veil,  due  t<i  opacity  of  the  superficial  covering  of  the  retina  "  ( Berger). 
Although  albuiiiin  may  be  present  in  the  urine  in  leuka-mia,  the 
liiigiit  white  areas  of  infiltration  need  not  mislead  one  who  takes  into 
ae(M)unt  the  other  general  manifestations  of  the  disease,  especially  the 
iiiicroscoi)ic  appearance  of  the  blood. 

Ehachitis.  Whether  due  to  rhachitis  or  some  other  concomitant 
.Iv^crasia,  interstitial  keratitis  and  phlyctenular  conjunctivitis  and 
ki  latitis  are  observed  in  rhachitic  subjects.  Lamellar  or  zonular 
cataracts,  either  congenital  or  forming  in  early  childhood,  in  which 
■ve  liiid  alti'rnalt'  layers  of  opa(iue  and  transi)arent  lens  tissue,  deiK'iid 
lui-  their  development  ui)on  constitutional  disesuses  which  interfere 
iciporarily  or  periocUcallv  with  the  nutrition  of  the  lens,  and  their 
luiiuatioii  is  analogous  to  and  at  times  associated  with  correspoiuhng 
mierrui)tiens  in  the  formation  of  the  enamel  of  the  teeth. 

Hereditary  sviihilis,  scrofula,  and  rhachitis  have  all  been  assigned 
,<  causes  of  "this  interference  with  the  regular  process  of  development. 
hilt  it  is  to  the  i)rolonged  and  violent  convulsions  accompanying  the 
I M-t-named  disea.se,  and  occurring  during  the  period  of  active  develoi>- 
Miriil  of  th"  lens  cells,  that  the  majority  of  authorities  attribute  this 
I, ,1111  of  cataract.  \Vhil(>  (luite  generally  accepted,  considerable  doubt 
1-  tlin.wn  uiK.ii  this  theory,  so  far  as  the  convulsions  are  conciTiied. 
i.v  tlie  fact  that  prolonged  infantile  convulsions  so  fre(iuently  occur 
viih.Mit  the  development  of  cataract,  and  the  adchtional  fact  that 
111  Ml  large  a  proporti(m  of  cases  no  history  of  convulsions  can  be 

liicited.  1-  f 

Hsemophilia  This  condition,  so  little  understood,  cause-  disease  ot 
i„.  eve  far  h'ss  frequently  than  would  be  exi)ecte<l.  I'riesth'V  Smith 
!,!<  reported  one  case  of  orbital  hemorrhage  following  an  injury  m 
,  •bleeder,"  .and  Haab  states  that  retinal  hemorrhage  in  the  torm 
■  1  retinitis'  proliferaiis  has  been  olv~er\-ed.  Surgical  juocedures  m 
-ucii  cases  are  to  be  avoidi'd  when  it  is  possible,  and  especially  those 
iiivniviiig  the  use  of  the  knife. 

Tlie  wiiter  litis  removed  without  accident  a  i)apilloma  from  tlie 
mjimcti'.  >'  s.ac  bv  means  of  a  ligature  in  a  pronounced  ha'mo|)hiliac. 
Addison'i.  Disease,  .\side  from  the  asthenopia  which  natural.y  ac- 
li 


,|,„,.M.^  ..  ....^. ....    .'haracterized  by  marked  general  weakness,  the 

lids  may  share  in  the  general  bronzing  of  tiie  skin  of  the  face,  and 


Miiiiames  a  diseasi 


.J86 


Tl'E  EYr. 


tlicic  is  apt  tn  1)(>  jatiiidici'  of  thr  c  i-iFutiva,  while  Schroottor'  saw 
paiclics  on  lli(>  sclera.  . 

Myxoedema.  Tliis  disease  may  inaK-'  its  aiil>earaiice  lirst  111  tile  skin 
of  the  evelitls.  .\ini)lyoi.ia  has"  been  rei>oite(l.  an<l  Wadswortli  suw 
one  eas('  with  atrojihv  of  the  optic  nerve  iiivolviiij;  l)otli  eyes. 

With  jieiieral  alopecia  here  is  falliiij;  of  the  eyelashes,  and  this 
as  well  as  the  failure  of  acci-niniodation  and  concentric  limitation  ot 
tlie  visual  field,  which  may  occur  without  apparent  atrophy  of  the 
optic  nerve,  has  been  known  to  improve  or  disaiipear  under  treat- 
ment with  thvroid  extract. 

Diabetes.  '  I)i(i})et<:-<  Mcllihi-'.  Probably  no  other  constitutional 
disea.se  ])rodiices  a  greater  variety  of  ocular  inanifestatioiw  than 
(lialx'tes,  and  vet  in  its  milder  forms  it  may  be  |)resent  for  a  loiijj 
time  without  evidence  of  its  e\ist<-nce  l)einf;  api-arent  in  the  eyes. 
In  teiiip<irarv  toxic  and  traumatic  filycosuria.  nctwithstaiKling  the 
presence  of  large  (|uaiitities  of  sug.ar  in  the  urine,  the  eyes  are  not 
afiected  (Knies).  which  would  teiul  to  confirm  the  theory  that  the 
pn's<'iice  of  the  sugar  is  not  the  direct  cause  of  many  of  the  .symptoms. 
Among  those  who  sujiport  the  various  theories  <,f  the  etiology  ot 
this  interesting  disease  there  seems  to  1m>  a  general  agreement  on 
one  point,  and  that  is,  that  the  underlying  cause  is  some  profound 
disorderof  the  nervous  system. 

Tniloubtedly  many  of  the  ocular  manifestations  at  times  attributed 
to  diabetes  are  accidental  or  indirect  elTects;  but  when  it  is 
so  far  ;,<lvanced  that  assimilation  is  s<>nou.sly  interfered  with  aiiil 
evid(  nces  of  auto-intoxicatioii  present  themselves,  we  find,  as  in 
;ill)uminuiia,  the  most  profound  changes  in  almost  every  portion  ot 
tlie  eye.  and.  while  it  is  to  the  con.lition  of  the  cry.stalline  lens  and 
retina  that  attention  generally  is  directed,  the  external  ocular  muscles, 
the  cornea,  the  iris  and  ciliary  body,  the  lens,  the  vitreous  and  the 
choroid,  retina,  and  optic  nerve  may  all  be  alTected. 

In  advanced  cases  we  may  have  a  somewhat  intractable  form  of 
eczema  of  the  eilges  of  the  lids,  and  there  is  also  a  tendency  at  times 
to  the  formation  of  furuncles. 

Many  instanci's  have  been  recorded  of  diabetic  paralysis  ot  the 
external  ocular  muscles,  any  of  which  may  be  affected;  and  Leber  has 
jMiinteil  out  that  such  paralysis  may  l>e  due  directly  or  indirectly 
to  diabetes  or  may  result  from  the  cerebral  dista.se  on  which  it  depends. 
While  some  aulliorities  state  that  i)aralysis  more  commonly  affects 
the  branches  of  the  oculomotor,  Hirschberg  and  Lawford  agree  that 
in  their  experience  the  sixth  is  affecteil  more  fre(iuently.  Tnilateral 
ptosis,  from  paralysis  of  the  third,  and  lagoplithaliiios  from  uivolve- 
nient  of  the  facial,  are  .s<M'n  occasionally. 

The  paralysis  may  in  the  more  advanced  stages  be  permanent  ;iir 
it  may  be  slight  and  temporary  in  ciiaracter  in  those  casi>s  in  which 
the  constituMonal  malady  yield.s  to  treatment.     Nuclear  and  peiiph- 


1  Wien.  miMl.  BI»U  ,  18X6,  No.  21. 


lilt:  EYE  jy  rr^  helatios  to  uesehal  diseases.     5«7 

(■nil  liciiinrrlKijics  ami  toxic  ix^riphonil  n.uritis  liavc  Ih'cii  assijiiicil 
•1^  llic  causes  uf  paralysis  ..f  the  external  (iciilur  muscles,  and  to  the 
latter  cause  K.'ies  assi-ru-.  the  freciueiit  ueuraljlias  ami  iK-casioiia! 
iiuestiiesias  ami  seiisurv  disturbances  which  are  seen  in  diabetic 
patients.  He  calls  atten'tion  also  to  the  fact  that  a  peripheral  neuritis 
.,1  diabetic  origin  mav  cause  heriK's  zoster  ophthalmicus,  ami  that 
the  aiucsthesia  of  the  first  branch  of  the  trijjeniiiius  may  give  rise  to 
iiiiimparalvlic  keratitis. 

.V-  in  otiier  diseases  causing  marked  impairment  of  nutrition,  dia- 
lietes  in  its  terminal  stages  sometimes  cau.ses  destructive  keratitis. 

Diabetic  iritis  is  by  no  means  unconuuon,  as  was  established  by 
Leber,  in  1SS.J,  and  has  been  confirmed  by  many  writers  .since  that 
time.  Hutchinson  states  that  in  his  experience  it  generally  occurred 
ill  patients  who  were  also  the  subjects  of  gout.  .\s  a  complication  of 
operations,  such  as  cataract,  diabetic  iritis  is  not  only  very  intract- 
,l>le,  but  also  not  verv  uncommon.  Iritis  in  diabetes  is  generally  of 
ilie  plastic  tvjK-  but.  with  the  exception  of  ca.ses  following  operations, 
i~  not  usually  severe.  When  there  is  exudation  it  is  generally 
lil.riiious  in  character,  and  may  entirely  block  the  pupil,  in^  .some 
instances  being  as.sociated  with  hypopyon  and  hypluemla.  Cychtis 
1.  seen  occasionally,  an<l  is  followed  by  degenerative  changes  m  the 

\itreoUS.  .  1     I    I  II 

That  cat'sract  occurs  as  a  result  of  dial)etps  is  conceded  by  all 
iuihorities.  but  there  is  some  difference  of  opinion  as  to  how  it  is 
i,,u,|uced.  When  occurring  in  elderly  subjects  of  diabetes  the  pos- 
-i.  ijitv  of  its  being  a  mere  coincidence  should  be  borne  in  mind;  but 
nl.ileit  niav  occur  at  almost  any  age,  diabetic  cataract  is  ()ften  seen 
!i,  (iiiile  young  jx-ople,  several  instances  Iwing  recorded  in  patients 
1  iti"iii<'  in  age  from  eleven  to  fiftei-n  years. 

Hu'  proportion  of  individuals  with  diabetes  who  develop  cataract 
';,.  been  variously  estimated  at  from  t  to  25  per  cent.,  the  latter 
i»iii<r  t!ie  result  of  von  (Iraefe's  observations. 

It'is  (juestionable  whetiier  it  is  ever  possible  to  distingui.sh  by  a 
.  hv^ical  examination  between  a  cataract  due  to  diabetes  and  one 
!,.,.•  to  other  cau.ses.  although,  as  they  often  appear  in  relatively  young 

,,1,.  thi'v  are  apt  to  Im-  soft,  usually  developing  rapidly,  and  are  at 

-nnes  precnled  bv  almost   visible  swelling  of  the  lens.     They  may 

pnear  in  cases  in'  which  the  general  nutriticm  has  been  only  slightly 

'riled  as  well  as  in  those  in  whom  there  is  great  emaciation;  and 

re  is  great  diff.-rence  of  opinion  as  to  the  mode  of  develojHnent. 

'i.inaioriiy  of  the  elaborate  theories  advanced  to  account  forthepro- 

ictioii  of  cataract  in  dialK'tes  an>  easily  proved  to  1«>  imworthy  of  con- 

I.Tation    and  this  applies  especially  to  the  theory  that  the  opacity 

II  some  way  due  to  the  chemical  effect  of  the  .sugar  which  is  found 

Mie  substance  .)f  the  lens.     This  theory  proves  too  much,  for  sugar 

l«cn  found  in  the  lens  in  two-thirds  of  the  ca.ses  of  diabetes,  and 

1    nioir   freipientlv   in   the  aqueous   humor  ami   vitreon:-      It    is 

.bible  that  Knies'is  correct  when  he  states  that  diabetic  cata-ict 


V(i-jif 


!^:»m    .M:-:-^      r..      ^'l^M^^^T^ 


l^.itt^.r 


I 


HUH 


Tin:  i:yi:. 


il('\r|n|) 
result   '■ 


mi.lcr  til"  -iiiH-  cDUilitiiins  as  spoiitaiicnu-  rataract,  as  tin- 
Mist  iiihaiifts  III  tin  clKiniid.  and  pail'u'iilari.    m  the  cHiary 
l,ri)(rss(-    wliicli   furiiisli   tli.-   luiliitivo  supply   to  the   lens.     Toxic 
suhstaiuTs  ciirulatiiiK  ii.    li«'  1)1'"mI.  uii.l  iK.t  ••the  liarinlcss  supir. 
sot  up  tin-  iliscas.Ml  cDiKlitiDii  ot  the  uveal  tract,  wliicli  ni  turn  iin>- 

(luces  the  cataract.  ,  •  ,     ,     ,       •     , 

Several  wrKers  liavi-  cited  cases  of  dialx'tes  m  which  the  lenticular 
,,pa<'ities  have  disapp<'ared  when  the  neiieral  condition  improve.! 
under  trentnient,  jmiviiij;  that  such  opacities  were  not  the  result  ot 
coini)leteilefreiieration  of  the  lens  fihres. 

liei-m'  opi'i-atinj;  for  the  extraction  of  cataract  in  the  fas<«  of  a 
diahetic  patient,  it  is  well  that  some  dietetic  ami  constitutional  treat- 
ini'iit  Ih'  maufrurated  to  improve  his  general  condition.  After  ohserv- 
inji  this  precaution  and  i.rovidinn  the  condition  of  the  other  struc- 
tures of  the  eye  does  not  contraiiidicate  it,  the  oiM-rator  may  proceed 
with  reasonable  assunuice  of  success. 

Limitation  of  the  i)ower  of  accommodation  is  a  well-recogmzed 
svniptom  not  infre(iuently  met  with  in  even  mild  cases  of  diabetes, 
aeil  the  earlv  develo|)ment  of  presl)y()|)ia  should  always  lead  to 
examination  of  the  urine.  This,  ;is  well  as  the  occasional  mydriasis, 
is  attrilnited  hv  some  to  the  (icneral  mu.scular  weakness,  hy  others  to 
a  periphend  neuritis  or  to  lieinorrhages,  while  still  others  consider 
that  it  is  tlue  to  toxic  substances  circulating  in  the  blood. 

Diabetii-  myoiiia  has  been  reported  from  time  to  time,  and  while  in 
pome  instances  it  is  api)arently  due  to  other  cau.ses,  in  a  larpi-  i)ro- 
portion  of  cases  it  is  probably  due  to  swelliiiu  of  the  crystalline  lens 
ill  the  eaiiv  stafjes  of  a  iliabetic  cataract.  Myopia  deveh.piiifr  in 
]iatienls  p:i"<t  forty  or  fifty  years  of  afje  should  always  .suggest  an 
examiiial!     i  of  the  urine. 


if  aciiuired  hypermetropia  was  reiiorted  by  Horner' 


in  a 


iv-five  years  of  age  who  had  s<'vere  diabetes.     The  liyper- 

,i:i   .iiminis'hed   when  the  diabetic  condition  improve.!  under 

This  case  seems  to  be  unii|ue,  and  is  difiicult  to  account 


One  c; 
patient 
nii'tro 
ti-catment. 

for.  f    r   1  ■       (■ 

l{etinitis.  while  seldom  .seen  early  in  the  course  of  diabetes,  is  ol 
fre.iiieiit  occurrence  in  the  terminal  stages,  presenting  itself  in  an 
exudative  or  lieiiiorrhagic  form,  or  aitli  exudations  and  heniorrliages 
coniiiincd.  .\ppearing  at  a  period  in  tlie  course  of  t!i<'  disease  wlicii 
degenerative  ciianges  in  the  vessel  walls  are  present  in  other  |iarts 
of 'the  l>odv.  as  well  as  in  tli<"  eye.  it  is  not  strange  that  the  glycosuric 
form  is  sometimes  seen  in  association  with  albuminuric  retinitis,  lii 
the  exudati^■e  form  there  are  ;ipt  to  be  small,  light,  shining  |iatches 
with  minute  heniorrliages.  but  swelling  of  the  retina  and  involvement 
of  the  nerve  are  not  characteristic,  as  in  albuminuria.  Hemorrhages, 
e'liher  ill  the  small  punct.-ite  form  or  larger  and  of  sufhcient  extent 
to  lead  to  the  formation  of  vitreous  op.acities,  are  fre.iuenlly  seen. 

<  Kliiiische  M(>Imt^l)lillU•r  fur  Aiigtiiln'ilkiinile,  187.1.  8.  490. 


Tllh:  KIK  /.V  /r.S-  RELATIOS  TO  UESKliAL  DISKASES. 


5Hy 


^..v.Ttl  writ.-rs  iK.v.-  rcpurf.!  casos  ..f  h.Mi...rrlmnic  plauc..ina    aiul 

,  ,i„„.  t„  trrat.M.M.t,  .-xfiisiv..  irtinal  l,.-.n..rrhap-s  ..t  .Ual.rtu  ..npu. 
iiv  (.1  tlif  iiravci^t  iirognostic  sipiiticancc.  i    i.  ,  i   i;  .i- 

V„H..i  tl...  ran-r  n-sults  ..f  .lial..t.-s  w  s..n...t..n.-s  l.av-  du.knl  .l.>k, 
n,..iriti<  iiii<lii<'un.r.'tiiiitis,  witlisi'CDn.laryaln.phy. 

I    l.l'v    .a  a.ul  amaurosis,  wl.i.'h  an-  r.T,-m'.l  to  olscw  UTO.  an-  also 

,„.;';;il:;i:ii;  <;'^'  i..  ti...  .•uu.-s,.  ..f  .liabot...  whh  such  a.ui,iyop.u 

«(•  iii'iv  find  ci'Utral  scotoma  for  r<'<l. 

In'  lns.i,i,lus.  .Vs  a  r.-sult  of  or  assoc.atc.l  with  .Imbctcs 
in  "i  I  ,  .  a  n«.ul.c,  of  writers  have  rc,.ortc.l  hcnua.u-psm.  epi  c,,^.u 
,  ,ks  optic  n.-uritis.  ami  svinptonis  of  cerebral  •uiuor  but  it  is 
;  nhh.  s  Kuies  has  suKKeste.l.  that  in  tlu'se  cas..s  the  polyuria  was 
:;;:,;'";:,:i„;!i,leMtal  etT-ct  of  a  lesio..  in  the  floor  of  the  fourth  vontnele. 
ul.i.-l.  WIS  the  real  cause  of  the  sviiiptoiusrelerred  to. 
^^';;';„;::;,.hagicVeti.iitisis  said  -to  liave  b.-e..  fouiKl   in  diabetes   in- 

'oraies-  or  Basedow's  Disease  (Exophthalmic  Goitre).  I'alpi- 
,.„iro.  irregular  action  ..f  the  heart,  enlargement  of  the  thyrou 
i  Md,  and  pmtrusion  of  the  eyeballs  are  the  ^^^''^X^^^^^^ 
rr,M.Ms,.  although  in  the  early  stag.-s  one  or  mon-  o  these  s>"'Pt  ""^ 
,.  ;  1,.:  ibs..„t  In  well-mark..!  cas.-s  the  diagnosis  will  force  ,ts,-l 
;;;■:,;,;.:  „.ost  unobserving,  but  it  is  in  the  early  stages  and  atypical 
(■.,Ms  that  its  recogniti<m  is  of  the  greatest  vahie. 

c,  :1   p.,trus^m  <.f  the  eyballs  in  a.lvanced  cases  is  a  most 
„K,rl!"   svmptom:  but,  as  the  writer  has  had  occasion  to  veri  >•  l^ 
.   ,.  '    ueasurem.nt  in  a  mimln'r  of  instances  in  mild  cases    this  is 
'        r, ^parent.      Stellwag  lias  described  the  pei-sistent   shgh 
,  ,;     ..f'the  upper  lids,  and  von  (Iraefe  tl...  '^/f^^^-f.-f     T,"'?    , 

r„i  u„i,.hisoft..nI.bserv.Mi  in  i..oking  .l..wnwar.l.     Uns  latt.T  n. 
(    .\..f  's  svmpt..m.  wlm-h  mav  for  a  long  tim.-  be  th-  ..nly  symptom 
1      dis-J^e.  w;s  al.s..nt   .wily  tw.-lve  times  in  six  luiiulml  and 
,i     ...„  ..as...  inv..stigat.Ml  bv  Shark.-y.'     The  r.'tracti.m  of  tl..'  1  ds, 
XL  to  ..onstan.  an  ..tTeH  ..f  th.-  instillation  of  <-«-.u^  and    -; 
M,ic!Mv.ll.M- has  (.all.Ml  att.'nti...^  sugg.'sts  th.M-arlv  stag..s,.   (.rau 

^M...M.    and  appanmtlv  is  .In.-  also  to  a  .hr.rt   stimulation  ..f  the 
Mn.ilhetii  nerv.-s  suiiitlving  the  orliital  muscles. 
Th::^;;em..  pn.,n.ion  of    tl...  ..y..balls  seen  m  -lv.ince.1   cases 

,  ,n.il.ut...l  bv  son...  authoiiti.^s  to  spasm...li..  cm  raction  ..  th. 
,  ,  ...  musclar  fibr.'s  fo.m.i  in  th.-  orbit,  but  th.'  maj..nty  ot 
,  : !.  ,...f..r  i.  to  dilatation  of  th.-  ....bitai  ar,..n,.s  P-*-'"^,;- Ij;:  - 
v..|op,n..nt  of  tl...  fatty  an.l  conn.-ct.ve  tissu...  It  is  a  >  P  «•"" 
,.,  hMW,nvr.that  tl....-x..phthaln...s..tt..n  .Imm.ishesaft...  '1«'-'  ''■ 
11,..  n,..st  s,.ri..us  .■.ms...iuen....s  s..  far  as  th..  ..ye  is  conc..rn...l  >om  - 
■Z  ivsuit  tVo...  ..xp..sur..  ..f  the  (...m.-a  du.-  t..  this  pn.trusu  n  ot 
.:i,  .^..!■.a!l    whi.-h  ...av  imt  1...  clos.-.l  .'v..!!  .luring  sleep,  and  those 


>  Hritiih  Meilioal  Jmirnal.  October  25.  IS90. 


ill) 


THE  EYE. 


\va 


to  lie  t'li'  niniv  serious  llic  iiioic  nipiilly  llii'  cyi'  is  prc-scd  tor 
il  ui.cis.  rcsiiitiiif:  ill  ncLiila-  or  fioiiiu  on  to  sloii<;iiiiij; 
•Mr, , •mil  vii'iil  oiilv  wlini  ilicy  :irc  rcco<j;iiizi'(l  i-;iriy  aiK 


nl.     ( 


OlUC 


soiiictniii's  occi 


In 'a 


trd  witli  till-  uri'alt'st  cair  hy  llioroiij;lily  ^^iitiuiii«  tin-  liils.  and 
tliiis  alTiirdiiif;  |ifotrctioii. 

Uari'ly  diplopia  and  rvcii  niarixi'd  paralysis  of  one  or  niorc  of  iiu 


(■xtiTiial  ocular  imiscics 


as  iici'li  o 


liscrvcd,  and  soini'tinics  there  is 


severe  | 


•am 


in  tl 


le  eves.  \v 


Tlie    |i\l|iils    respond    \v 


ill)  profuse  scaliliii};  lacryination. 

ell   lo  direct   iliuiiiinatioii  ami  contract  on 


I'onverm'iice,  a 
times  observed. 


Itlioiijlli  moderate  dilatation  and  irrenularity  are  soiin 


.\i 
miirniu 


•ultati 


on  over  the  orl>it  sonu 


■limes  will  elicit  a  distinct  va.scular 


r.  similar  to  the  pi.icental  hrui 
ilxophthalmos,  while  j;enerally  sei 


'1 
Unenlly  unilatera 

Kni< 


■s   calls   a 


n  on  i)()th  sides.  i.=;  not  very  infre- 

iiid  often  varies  In  de};n'<'  in  the  two  eyes,  and 

tiention   to    Hack's'    interestinj;  ohservation   that   tiie 


lie  side  has  been    known  to  ilisai)pear  alter  tl 


exoplitlialmos  on  o  ■  ■         •      i         i 

mucous  membrane  of  the  nose  on  that  side  had  been  c:iuteri/.ed:  and 
IJolose-  has  obtained  tlie  same  result.  .\  few  other  similar  cases 
have  been  ivporteil,  iiut.as  Kiiies  remarks,  they  are  excejilional. 

Iritis  is  not  uncommon  in  severe  cases,  and  epi|iliori;i  ()tten  is 
marked.  Nvstajimus  and  tremor  of  the  eyelids  .ire  sometimes  ob- 
served, and  il  di'firee  of  corneal  insensibility  is  of  fre(|uent  occurrenci'. 
which,  as  Knies  has  remarked,  accoimis  for  the  infrequeiicy  of  the 
wiiikin;;  movements  in  many  cases  of  (Iraves'  disease. 

.\tidpliy  has  at  times  been  observed  ill  extreme  (■:■  >  s  as  a  result 
of  strelcliin;;  of  the  optic  nerves,  but  ophthalmoscopic  tindinps  are 
rare,  coiisistiu};  of  pulsation  of  the  retinal  veins  and  rarely  of  the 
arteries. 

.\s  severe  casi's  of  (ir;ives'  disease  are  aj)!  to  be  accompanied  by 
anaiiiia  and  netnasilienia,  il  is  natural  that  with  headache  and  vertifto 
we  should  often  hiid  all  of  the  dinrt  and  reflex  symptoms  which 
accompany  muscular  and  ciliary  asthi'iiopia  due  to  other  causes. 
esiH'ci.ally  if  there  is  a  coexisting!  error  of  refraction.  In  (iraves 
disea.se  the  visual  fields  are  at  times  concentrically  contracted,  whih- 
the  central  vision  and  color  sense  may  or  may  not  be  impaired. 

Goitre,  owinjr  t"  pressure  uiion  the  veins  of  tlie  neck,  at  times 
causes  disturbance  in  the  vascular  structures  of  tin-  eyes  by  venous 
stasis.  The  author  has  seen  one  case  in  which  he  was  convinced  ot  a 
caus-itive  relation  existiiifr  between  jjoitre  and  a  central  choroido- 
retinitis. 

General  glandular  enlargement,  or  jiolyadenitis.  has,  at  least  m 
one  instance  reported  by  KoiiifTstein.  been  accompanied  by  a  number 
of  small  tumetactioiis  alouj;  the  o|ttie  nerve  and  the  motor  oculi. 
with  extensive  neiiroietinitis  and  total  unilateral  o])hth;ilmoiile<ria 
externa. 


1  Doitsrlw  lllf'l.  VV.ich..  l'-S'>.  N".  J.'). 


:  \\\\\.  il-Uclli,.  l»9fi.  p.  ■-'6(1. 


rut:  EYE  IS  ITS  REI.ATWS  TO  (lESEliM  DISEASES.       o'.ll 


DISEASES  or  THE  DIGESTIVE  SYSTEM. 


Diseases  nf  tlu>  in 
iiilic(HU'iitly  llic  cause  i 
iheir  iiiiiMiitaiice  in  llii 


testiiiai  traet  and  llie  associated  nrnaiis  are  not 


liseaseH  of  the  eyes,  aitliouuli  und(iulitedi> 
•tioii  lias  at  times  Im-cii  exanKcrated. 


conne( 


This  is  esiH'ciaily 


true  of  tiie  disorders  aplwariiic  durinu  the  period  of 


Durinjt  tiie  |M'riod  ol  erui 
if  tiie  permanent,  teetii,  arn 
i.f  cari( 


•y  an-    'trii)Uted  so  frec|uently, 
I  of  eruption  1-    'lie  deciduous,  and  less  frec|uentiy 


lentition,  to  wiiicii  ail  tiie  ills  of  inlaiic 


id  later  as  a  result  of  the  various  forms 


uid  other  disejises  producinji  i 


rritati f  the  terminal  tila- 


liien 

of  the  ev! 


ts  of  the  fifth  nerve,  we  may  have  most  n:arked  reflex  symp  (.ni> 

l)Ut.  as  sunjjested  alM)ve,  in  their  zeal  for  luidmj:  a  plaus- 

itionOf  olvscure  phenomena,  hoth  physicians  and  parents 

liiere  is  such  a  tiling  as  coincidence  without 

1  etTect.     Nein-otic  manifestations,  such  a 


ilile  explan 

often  seem  to  forfjet  that  then 


tiie  relation  of  cause  ai 


IIM 


titation,  mvdnasis.  inyo 


iis,  relaxation,  and,  more  fre(|uently,  spasm 


4  accommoi 


latioii,  and  even  disturbances  o 


if  tlu!  external  ocular  mus 


sucii  as  insuiliciency 


iil)tedlv  n 


■lieved  at  times  hv  the  reiiu 


leading  in  some  cases  to  diplopia,  arc 


un- 


val  or  treatmiTit  of  a  carious 


too 

III' 


til.     Wliether  these  syinptonis  a 

the  result  of  a  htck  of  sulhcieiit  innervation  iliiriii 


i-e  (hie  to  a  true  fetlex  irritation. 


th 


I'Xistence  o 


lain  m 


the  tooth,  must  !«■  determiiK 


1  l)v  a  studv  of  each  case 


ria 


The  writer  was 
tioii  l)y  the  n 
ciieral  medicinal 


'troiinly  impressed  with  the  importance  of  this  assi 


ifter 


suit  ohtained  in  the  case  of  a  patient  who 
treatment  extending:  over  a  period  of  many  inontlis 


was  com 


pleteiy  relieved  of  the  most  .listressiiifi  sympt 


olll.- 


sia  accompanied    hy   gaseous  distention   and   insomnia 
uljustment  of  a  2°  prism  liase  in  (>ii  <;;'ch  ( 
iiiMilliciency  of  the  internal  recti.     Th 
!  vear.  when,  without  other  cause  w 


IS  n 


the 

ve,  fitr  the  correction  of 

•lief  continued    for  almost 


illeil 


to   reveal 


ull^(•lllar 


halaii 


lie 


patient  was  a   man 
(•lice,  who  s|)ent  hi 


hich  he  could  discover,  lie  found 

the  most  critical  examination 

■r  the  relr.ictioii.   presbyopia,  or 

it  s('enied  that  we  had  exhausted  our  resourres. 

)f  liftv  vearsof  aj;e,  an  attorney  in  active 


>ymptom<  all  returning.  aiK 


[I  change  in  eitlu 


iflice  work  and  hiseveniiifrs  in 


readint 


the  failure  to  ol)taiii  relief  was  ni.akiiif:  iiim  i 


st  unii; 


ippy 


when 


fiiclid 
.|(fe( 


Uffsre 


ted  to  him  that  it  would  be  well  to  give  atteiilion  to 


tive,  'ulcerated"  tooth  which  was  causi 


iir  liim 


so  little  :iimi'V- 


.at  inv  attention  had  not  lu'cn  ca 


to  it.     This  he  did.  and 


ti  the  reinovi 


)f  tl 


le  .source  o 


11-  at   once  and   iK'rmaiiently  (lisai)l)eare( 


ist  coin 
'ia  resu 


f  the  dental  irritation  the  gastric  symp- 

■d.     This  case  illustrate; 

id  astheii 


pleteiy  the  general  principle  that  dental  tlisease  ai 


itini:  from  muscular    inibalani 


two    absolutelv   ditTerent 


iditioiis.  but  in  both  of  which  the  terminal  tilamen 


its  of  the  lifth 


I  i\('  a 


re  involved,  may  produce  the 
in  a  remote-  orgsui 


.same 


group  of  rellex  nervous 


Iritis,  keratitis,  plilyctenuke,  and  even  glaucoma 


have  \wn\  at t rib- 


to  di.sease  of  the  teeth;  am 


I  it  is  undoiibtedlv  the  case  that  an 


.V.»2 


Tilt:  r.Yi:. 


■  Iv.  ..lar  i.Lsc  ss,  with  -r  witl...iil  iiivulv.-iiirht       lit-  iii.tmiii  ui  IIiRh- 

,.nr-    iPMV  CIV.,  risr  to  iiitVHmus  |.,on.s...s  ,,.  ll rl.u,  IlU,  an.l 

. wl.aM,  altli.-ujjli  su.li  a  rflatioii  is  of  /ar. •urnmv. 

■  S-i-.rs  iia.strir  an.l  p:i.stro-int«'stinal  .t-.i.*'  loa.  -  Mr,,urntl>  t.. 
.,„,,,,„  ,au.l  ..tlu.r>j.-iuT.I  .lisra..-.  wl.i.-l.,  m  turn,  <-uis<-  must  inarM-.l 

"u  ;;    vn.p, ^;  bu.  .iK-sc  will  I...  .Irait  with  ..l-w  ...r...    In  all  t-mw 

,..   K;.,!nMnf>t,.,al  .lisunL-rs  a( i-M'.-."i<-'l    .v  v.ol.nt  v-nntiup  th.. 

, ,  nh.i  -tiva   r.M  un,  o,  rliorni.!  .nay  I..-  thr  -•  i'  -f  h.M....rrl.a-(-.      riu- 

,.  .■■  .,    „-. f  ivai  aanp.r.  .^IKriall)         Mu..,    „„!.  .iHort.v,.  v.'s^' 

.^.,r  .„..•  .,p.Tations  invclviMK  s.Tl„Hi  ..f  tho  rv  i.all  :.M.l  sh..u..1 
h,    a'  ,    .„K  rras.m  f..r  tlic  avni.laiicf  ■  I  p-i.rai  .    M-ilM-sia,  wlu 

i.i'irti  mMc-    in    ucli  casfs.  ..    ,       ,        .        »».  . 

\r  rril  .l.lr  It.'  nf  !lH«  luUHUis  .•  .^hr  uc  nl  the  .iii;.vtiv"  tnu;t 
.SM  .,  .  ft<>n  m.  iJ.lr.-n  ni  ass..<-iati..n  vitli  phlyctnuilar.  mjiin  mtis 
.„,.l  k,.rui»i>  ai.l  th."  c.-rroction  ..l  .-rr  N„f  .1,  ..n.l  n-pulati.  t  the 
.,li,„,,,  ,.^  .■(•n.T.uns  arr  f..ll..wnl  ».y  such  i.^,  n.-.air  nMi.r..vrn.rnt 
"thai  MM.  n.aralK  -  i...-lin.Ml  to  Jx-li-'v..  that  th.MV  is  soin<-  assocat  ...ii 
lH.|w.-..n  th.  .lis..:ts.-  of  th.'  .-yr.  an.i  that  of  ilu-  al"«."'"tary  ''!«• 
,nor..  intiniat--  ^  .an  w..ul.l  »h«  in.'i.-at.Ml  by  th--  ;;ra.h.al  nnprovn,,,  t 
in  ihr  mitrii^       pmc^^-.  s  f.,ll.,«in«  -  .,  !,  ,„:,najrcni.'Mt  an.l  tn-atin.' 

Vascular  .   ,it..rp'tn..nt     !.i.     u.   co->li!.ati..n   and   the  c.)ns«..,n 
straininp  at  >ti)ol  may,  in  ili  •-< 


witii  wcak.ncl  v.-^s.i  wail-    l.'a.i 
lioroiihi!  hcniorriiaj:.  -:  ami,  :•  cordi 
Ills  v.fll  as      ir.mic      arrl:   ■'- have 
.'laucoina.     .  i.- .-lis.' calls  id      ''!<>" 


ha  I.  as  in  . 


lvsi-n(. 


(•..njunctival.  orhital,  retinal,  or  ^ 
to  H('r<''(r.  proloiijj(>.l   c.iiistii>a 
been  a— i);mi  ll  as  a  cau.sc  ol 
t..  the  tact  thai  nrolonp'.i  '^i.! 

,„,,rk.Ml  .•nfc.'l.l. nt  of  a.  .'..niiii  "btu.n.  an.l    Hi:,; 

.liarrli.ca  of  infaib  v  the  a.Mitioii  ..1  an  elenu'iit  y\ 
syst.ini.-  .lepletioi!  leu.ls  af      n.cs  I..  k.'rat..nialacia, 
'  In.liseaseo!   the  liver  ac.    nipani.'.l  \<}    iaun.hi'c, 
of  the  cMijun.tiva  is  ol'i.'n  n.>ie.l  lulore  'li.-  -^kin  is  ^ 
remain  after  "'i..  skin  has  lieare.l. 

HeiiK-raloi  ;.i,   ~  Ljective  yellow  vision 
tonin-i' 'i-^oning.      n-  v  "f    the  ret  ma.  ai    i 
result    iroiii    'lepallc    >!i-.'ase,   an.l     n    acul. 
Iieni.>rrh;!>:es.  .111.' t.)  sept i.-sul)staiin-  im  ilr 
I  Kiii.'si.     l,:iii.|o|t  li..lieves  that  we  may  ' 
relati.iii    .     .  \istin.i;  Letweon  cirrhosis  <■■ 
ivtim'i~,    IS  well  as  In  iii.'ral.ipia  without 
Sciiilillaliliir  sc.uoliia    ami   ocula'-  nii-'' 
-invh.'re,  ar.'  mii'ii  a— oei.al.  i  '.vith  ami  a| 


,  may  n- tii  ui 
in  the  chroni 
iifection  i'    'ii- 

Me  ilisc..   >ra    'in 
iii.'.l,  ami  mav 


■II    kel; 

11... 

.  H  »l  ! 

a 
■  hver  . 
i.'Utatioi: 
.   wliir-h  .  ■ 
ireiitl\'  .i.'p' 


f  SM' 


nrpiii  of  'lie  lou.T  l«) 
Th.  jii'iailiar  vell.iX' 
xaiithoin.-i  palpebral- 
iivpr:  ■■■'■•■■■\  r.^erster. 
n!  a<'Conim.>ilal  loii  ;i 
cause.  Intestinal  p: 
of  the  put>il^  '"111     ■" 


.    I,  an.l  oilier  ilisonle  i'  th.-  ilip'-ii 

-h  plates  in  the  skin  li''  .•y.'li'l-. 

;,  .'ire  ass.iciateil  ficiu.  !y  witii        i 

wMKaml  Mlawat-''hek  rep'.rt  c. 

.•.|Uat'    ial  leliti.'uhit  .i^  icit;        ! 

-ites,  a<  is  well  ^ii.   ■  ■  oft'   ■■ 
reti»>X  .     iilar  s 


ah 
'final 

iiii 


i,  rcii 

I  .poll 

-Iflll. 


■  sy 
known  a- 
•ase  .if  1h' 
.)f  failur. 
.  the  sain. 
(lilatatLM 


Ttii:  i-:>  ^:  '>■    >  ^  nEnriox  v 


<h:HAL  />lSt:ASh:s        ,-,!);{ 


DXSKitSIS  or  THE  MSPIRATOilY     RACT 

Diseases  ol  the  DOBe  and  pharynr  aro  r.-.i  •"i>'-l"'."">;  |'';'  ;;'"f;; 


,,t  .1'. 
iiii'i 

tiM 

n    V 

I    ,1111 


.f  thf  ••vcs,  :ti 


.1   linl 


-  f:it-i  is  lK>rn('  in  iimi'! 


iltrt     tlMIl     .11 


w 


lili^      I 


II   iiiau\ 


ill  pHMluc-o  rctli'X  syiiipt 


(1 


■,i-i(-  ii  «iunM'  dt'  iiiitidi.iii  111 
in   H'    fvc?'  wliicli    iiltlioiiKh 


)iiii)i' 

l'!l-i 

at' 
I>i  ltl< 


„,,v-..t-i...it..oi.:a.ii-di>.....r.   II ''''-' f''-;^'"';-';; 

..,1  orfraiiic  l('^*l<'l^^^  arc  pru.lur. d,  alttioiiftli 
,,(curr>  II  •!•  a  woiiUl  Ih'  iiitVrnMl  fioiii  the 
,,  til  ■  hu.  ••ol  111  this,  as  ill  many  .ith.-r 
'.  then-  is  a  nil  .s  .liscrcpaiicy  iM'tsvccii  th<- 
iiitiiii-iitnl  aii.l  1)V  Anicricaii  (il»s.iv.'rs.  Tin- 
.liscmlil  iiniiv  <-f  'I  "  n'portcil  ■  wrcs  of  cvf; 


lisl  iticcs  wcll-tlfti 
nci-    "t'  a-   Irt'qiu 

t 


iiti-ratun- 


[(■pal    111''"' 


r. 


.f    I! 
,       f'llHK 


sources  (• 


if  ..Hex  in     ition  by  niHratioii  aii<l 


ptuiii  so  (Iclti 
ijiiiiiiiij;  turhii 
iifcrinr  turtin 
■iiity  which  n. 
i(  iiihranc  iif  t 


111.  Mora 

iU-  I   till 

of 

„  ol    .  '•  ">■ 

r.sll  .1       iiC    111UC' 

plIlS    -11    the    (•> 

,ia,  iai    viiiati.iii,  jwrsist.  tit  or  nTiirriiii: 
|, ctioii,    l.icpharospasiii,   a-  c(.miiio.lativc 
uitioii  of  the  visual  lieKl.  ainhlyopia,  :■■ 
,1,  ,h.s«m1,  iiiav  even  excite  glaucoma.     Ohe; 
have  reiHine.1  cases  of  };laucoiiia  in  w».i' 
111     xcitiiiK  cause. 
The  intimate  associaiioii  existing  i 


s  to  have  it-  nnivex 

iMMJy,  hypeitiophy 

•  ,.  ImkIv.  or  ans  other 

y  Ik"  accompanied  by 

it>   nose,    liia>    proiluee 

'Oiese  niav  cause  |)ain    .ml   photi)- 

I'oiijunctival  and  ciliary 

r  muscular  astlienopii 

1  in  those  who  are  pn- 

111   uiii  Ix-nnox  Browji.' 

isa    irritation  serveil  as 


Mi- 
ls ■ 
til 
I1S< 

Ki 


nasopharpipal  cavi- 

inchidinfr  the  eye, 

'■owinRof  the  visual 

lown  to  follow  the 

the  nasal  cavities. 

n\>teria.  and  mentions 


in.l  the  various  structures  withu 

II  illustrated  by  the  temporary  con 

Ahich  in  a  nuiiilx-r  of  instances  lias 

,f  the  jralvaiioc.iiitery  in  treating  diM 

Kn    -  considers  this  as  a  form  of  traiinuit.    ,, 

he  I  ict  that  similar  symptoms  may  r.-snlt  iron,  otln  r  painful  p. 

I,  n  s  in  tt  neijjhlH.rhoo'd  of  the  eye-,  but  this  explanation  is  .■  .r.ely 
;.;    Xte";    with  tiie  results   reported    by  Hack    ami   "^J--;;';,    ^ 
„l,i..h  Craves'  disi^ase  was  cured  by  tlu   application  ..f  the  pab  ui" 
.MUterv  to  the  nas  .:  "iiicoiis  menibrane. 

lUiinitis  in  itsva-!  .as  forms,  especially  thos<  ;i.ssociated  with  umo 
,n,  ..  i    .  ,,roce.s.ses,  is  anio.m  the  most  fre.iueiit  can  .s  of  diseas.'  o 

;■:  :::,,;nctiva ...  eornea.u.d.  w.u^ :!'::.  r^^.s,^  :::::i 


'hall 
■  r 


means. 


iiel  of  communic 


atioii,  it  is  by  no  means  imjxiss 


their  products  to  be  conveye 


1  fn.in  the  nose  to  the  eyes  by  oiher 


That  it  is  i 


ossibli 


on 


the  other  h.md.  for  Ihiids  containiiifi 


I  lull.-  nialeriai  to  i)c  :;!mmu!\;< 

IwiiliH-hi'  i.ie.1.  Wwh  ,  1*-*V  N"  -'•• 


;|»f 


,1    «. 


!!!!  th.e  eye  to  the  nos(>  I? 

,l,lhr    r    .VUglMlhcllt.,  iwi.-..  I>.  *Vi 


iiifi'C- 
wel 


:« 


594 


THE  EYE. 


.•stal)lisli('(l.  And,  jilthotiKli,  Iwcausc  of  tumefaction  of  the  mvicous 
uuMiihranc  in  infectious  iliscascw  of  the  conjunctiva,  the  <iuct  is  often 
occlutled,  it  is  prol)al)le  that  such  material  not  infre(iuently  passes 
into  tlie  nasal  cavity  with  the  tears,  there  to  1m-  rendered  less  potent 
by  the  secretions  from  the  nasal  mucous  memlirane. 

"The  I'ase  with  which  fluids  may  reach  the  nose  and  nasopharynx 
should  alwavs  he  iiorne  in  mind  when  usinjj  my<lriatics  and  other 
substances  iii  the  conjunctival  sac;  and  it  should  also  be  remeniln'red 
that  solutions  of  atrojjine,  as  they  must  i're«|uently  be  used  in  the 
treatment  of  iritis,  contain  in  the  amount  instilled  far  inon;  than 
the  usual  iiharmaco|Meial  dose  of  that  remedy,  and  it  is  probalile 
that  a  larjier  proportion  is  absorbed  than  is  the  case  when  adminis- 
tered bv  the  month  in  therapeutic  doses. 

Transmission  of  disease  throufih  the  nasal  duct  from  tiie  coiijiinc- 
tival  sac  to  the  nose  is  certainly  extremely  rare,  but  Knii'.s  mentions 
lupus  and  epitiielioma  as  having  heen  so  transn»itted. 

In  acute  catarrhal  conjunctivitis  the  nasal  nnicous  membrane  sel- 
aoin  becomes  secondarily  involved;  but,  on  the  other  hand,  the  con- 
junctiva seldom  escapes  in  an  acute  coryza,  while  in  the  chronic 
forms  of  rhinitis  {\w  lacrymal  sac  or  conjunctiva  is  very  prone  to 
1m'  affected  at  some  perio<l,  es]>ecially  during  acute  exacerbatioiLS 
anil  in  the  atrophic  st:if:e,  when  crusts  form  near  the  nasal  orifice  of 
the  duct.  Syphilitic  coryza  is  seldom  transmitted  by  this  chamiei, 
but  I\nap|)  has  descrilxMl  a  case  of  lupus  of  the  na.sal  ('avity  which 
produced  tubercular  conjunctivitis.  In  many  of  the  infectious  dis- 
eases which  afl'ect  both  the  conjmictiva  and  the  nasal  mucous  mem- 
brane there  .seems  to  exi.st  no  evidence  that  there  has  been  trans- 
mission from  one  to  the  otinT.  liven  in  the  ca.se  of  diphtheria  and 
croup  ill  which  the  na.sal  and,  much  more  rarely,  the  conjunctival 
muci>us  membrane  are  involved,  there  seems  to  exist  no  proof  tiiat 
the  path  of  the  infection  has  been  throufih  the  nasal  duct. 

.\denoid  vegetations  in  the  vault  of  the  jjliarynx,  and  hypertrophy 
of  the  ph.tryii^eal  toiisiU,  are,  especially  in  children.  frei|ueiitly  found 
bearinj;  a  causative  rel.ition  to  diseases  of  the  eyes.  There  seems  to 
I'xist  a  somewh.at  intimate  relation  between  these  jcrowths  with  their 
a.-sociated  conditions,  and  plilyctemihir  conjunctivitis  and  keratitis. 
Disease  of  the  frontal,  ethmoidal,  and  sphenoidal  sinuses  dm'  to 
jnllamn,  iiioii  of  tiicir  liiiinji  membrane  or  occlusion  of  their  outlet, 
accompanied  bv  the  accumulation  of  serous,  mucous,  or  piinileiit 
tluitl,  or  llie  formation  of  ):ranulatioii  tissue  or  various  forms  of 
tuini'irs,  may  all  iiio>t  profoundly  a ITect  the  eyes,  and  for  loiij?  periods 
the  nature  of  tin-  trouble  may  escapi'  iletection. 

Supra-orbital  or,  more  r.irely,  infra-orbit.'il  neuralfjia,  pressure  symp- 
toms, and  rell<-x  i)henomeiia,ilisplaceiiient  of  the  eyeballs  witli  ptosis, 
and  disturbed  relations  of  the  extrinsic  ocular  muscles,  may  occur; 
and  in  the  e.irly  r-tap^s,  Ix-fon-  the  developie.i'iit  of  marked  protrusion, 
the  writer  has  in  two  instances  seen  on  oiihthalmoscopic  examination 
a  peculiar  parallel  striation  of  the  retina. 


THE  EYE  ly  ITfi  HELATIUS  TO  (lESERAL  DISEASES.       o'JS 

Wlicn  erosion  or  niiirk.'d  irifliiininatioii  of  the  bony  walls  of  the 
orbit  is  i)n's<-iit,  wr  iiuiv  luivc  an  orbital  (•clhilitis  or  abscess  accom- 
panied by  cheinosis  ami  inU-rference  with  corneal  nutrition,  and  con- 
HMiueiit  sloURhinR.  II'  tli(>  sphenoidal  sinus  is  involved  to  such  a  .lejjree 
•1^  to  cause  necrosis  of  its  walls,  we  are  apt  to  have  first  disturbance 
i,f  the  visual  field,  and  later  paralysis  "f  the  external  ocular  nniscles, 
and  blindness,  from  disease  of  the  optic  nerve,  chiasm,  or  tract. 

Diseases  of  the  ear,  which  may  i>roi)erly  Ix'  considered  in  connec- 
t  .  M  with  the  superior  respiratory  tract,  may  in  rare  instances  j)roduce 
.'ve  symptoms.  .\s  illustnitions  of  n>P.ex  nervous  phenomena  niay 
be  mentioned  bleiiharosiiasm,  which  sometimes  occurs  on  irritation 
of  the  external  auditory  meatus,  and  the  nystiigmus  which  Pfluger 
observed  on  compressing  a  i)olyi)Us. 

Mastoid  disease  or  operations  for  its  relief  may  cause  lagophthal- 
iiios  by  i)artial  or  complete  paralysis  of  the  facial  nerve,  although  the 
otM-rative  form  often  recovers.  When  meningitis  or  cerebral  abscess 
occurs,  we  inav  have  the  usual  results  in  i)aralysis  of  the  external 
ocular  musch-s',  optic  neuritis,  etc.:  and  Kipp'  and  Pomeroy'  have 
repo.K'd  thrw>  cases  of  metastatic  panophthalmitis  in  i)urulent  otitis 

Diseases  of  the  larynx,  trachea,  and  bronchial  tubes  are  not  often 
i^sociateil  with  disease  of  the  eves,  although  a  number  of  curious  reflex 
phenomena  ire  often  observed,  such  as  dilatation  of  the  left  pui)il 
•iccompanving  infiltration  of  the  apex  of  the  left  lung,  and  the  sneezing 
produced  "by  opening  <!i<'  <\es.  especially  in  cases  of  c<mjunctivitis 

.ind  keratitis.  .    ,  ,     ■  t  t\ 

Bronchitis  and  pneumonia  mav  !»•  accompamed  by  her)K's  ot  tne 
.ornea:  and  the  dvspna-a  of  emphysema  is,  as  Knies  has  pointed  out 
,.•(•< .mpanied  l.v  sta.sis  in  th«'  retinal  veins,  and  at  times  conjunctival 
■ui.l  retinal  hemorrhag.-s.  Schmall  has  often  seen  injection  of  the 
fundus  and  reports  five  ca.ses  of  visible  arterial  pulsation  m  phthisis 
NiMiroretinitis  has  been  reported  in  association  with  i.nemnonia:  and 
<;,,w.'rs  d.'scribes  a  ca.se  of  intense  febrile  bronchial  catarrh  with 
in-.ik.Ml  evanosis,  which  was  jiccompanied  by  lu'un.retmitis  with  enor- 
,n,mv  extiava.sitions,  manv  of  which  were  r.'gularly  arrange,  and 
Miualed  upon  the  smaller  vi-ins.  The  writer  has,  on  the  other  hand, 
-ivii  a  fatal  api.arenlly  metastatic  pneumonia  di'veloi)  in  the  course 
ni  panophthalmitis  following  gonorrlueal  ophthalmia. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Diseases   of   the    circulatory   system   manifest   themselves  m  the 
rye  by  hypera-mia,  aiuemia.  ledema,  hemorrhage,  and  the  results  of 
lumorrhage  in  the  conjunctiva,  uveal  tract,  nerve,  and  retina:  aiu 
ulicn  the  blood  is  modified  by  disease  or  is  the  bearer  of  effete  material 

1  Amcri™ii  .liiunial  of  tlii'  Mi'<llcal  .Sciences.  Aviil,  1W4. 
8  .Sew  Eii|{l»nil  Me<lli'«l  Moiilhly,  J«iiu»ry,  1W9. 


iti 


5'JtJ 


Tilt:  i:yi:. 


or  tdxiiis  frciicratctl  in  other  portions  of  tiic  body,  we  may  havo  also 
(•inl)olisiii,  throiiilHisis,  ami  various  forms  of  cxuiiatc  witliiii  tiic  ciio- 
roii 


1  and  retina.     Tiie  peenii 


itomital  arraiiftement  ot  the  eneu- 


lation  witliin  tiie  eve  sliouid  1)0  home  in  mind,     its  supply  of  hlood 


is  derivoii  from  both  the  internal  anc 


1  external  earotid  arterie.- 


Th 


tree  ana: 


itomosis  of  tiiese  two  systems  and  the  eommunieatioii  with 
theoi)i)ositesi(leof  tiie  brain  are  su<'h  as  to  jirovide  well  for  its  milri- 
lion.  even  when  serious  obstruetiou  exists  in  some  of  th<'  larjje  vessels, 
attention  should   be  directed   to  the   larf;e,   freely  anasto- 


i: 


;pecia 


mosing  arterial  and  venous  trunks  of  the  tuniea  vaseulosa  of  tl 
1,  overlaid  by  the  ehoriocapillaris,  which  alTo'-ds  niitritioii  t( 


chorou., 

the  layer  of  rods  and  cones,  or  epithelial  layer,  while  the  terminal 
.systein  made  up  of  the  central  retinal  artery  and  vein  with  their 
brandies  supplies  the  imier  or  "brain  layer"  of  the  retina. 

While  there  has  been  in  the  past  a  tendency  to  expect  too  much 
of  the  ophthalmoscopic  ajipearaiici'  of  the  va.scular  systein  of  the  eye 
in  interi)retins  the  iihenomena  of  the  general  va.scular  system,  and 
es|)ecially  the  conditions  exislinji  within  the  cranial  cavity,  and  while 
its  limitations  as  an  index  of  tli<>se  conditions  should  constantly  be 
borne  "i  n.ind,  the  !:ict  remains  that  when  jiroperly  iiiter|ireted  they 
are  of  the  utmost  value. 

In  estimating  the  va'ue  of  ocular  manifestations,  a  sharp  distinction 
should  be  drawn  between  those  conditions  observed  in  the  retina  v.hich 
are  a.ssociated  with  evidences  of  disease  of  the  blood  itself,  with 
the  accompanying  degeneration  of  the  vessel  walls,  and  those  due 
merely  to  ;ilterations  in  blood  vohmie  and  blood  i)re.ssure.  The  |)ecu- 
liar  conditio!  ~  of  the  circulation  within  the  eyeball,  in()difi<'d  as  they 
are  by  the  non-elastic  sclerotic  coat,  and  by  the  admirable  arrangement 
by  which  under  on linary  circumstances  the  large  trunks  of  lh<'  choroid 
serve  to  regulati'  the  pressure  Upon  the  visible  retinal  circulation,' 
renders  it  impracticable,  as  has  been  attempted,  to  use  the  retinal 
circulati(.n  as  a  means  of  gauging  the  blood  jjressure  in  the  vascular 
system  genendly,  or  "ven  in  that  of  the  brain. 

(!eneral  anaemia  may  be  accompanied  by  more  or  less  hyjienemia 
of  th<'  eyes,  and  it  is  mIv  in  extreme  cases  that  variations  of  blood 
pressure,  .so  easily  recognized  in  other  iiortions  of  tiie  vascular  system, 
can  be  properly  interpreted  by  means  of  the  ophthalmoscope. 

iiyperainia  of  the  conjunctiva  may  be  present  ;»s  a  Iik'.mI  manifes- 
tation where  there  is  a  corresponding  coiidiiion  of  the  general  circu- 
lation due  to  various  diseases,  but  it  is  not  a  very  consistent  sign, 
as  many  cases  of  most  obstinate  c.mjunctival  hypera'inia  accompany 
geiienil  aiuemia.  Hyperainia  ot  the  retina  and  optic  nerve  is  not 
apt  to  be  found  as  the  result  of  general  i>letliora,  but  is  more  fre- 
cjueiitlv  of  the  pa.ssive  form,  and  accomjianies  such  obstructive  con- 
ditions as  asthma  and  emidiy.senia,  and  such  heart  lesions  ius  induce 
venous  stasis, 

'  It  i«  pmhHiily  Id  »  i)i«tiirl«niTiif  Ihin  'li'lir  li'  Imlnncv  itmt  many  of  the  phenomena  of  glaucoma 


TJIi:  KYK  IS  ITS  liKLATIOS  TO  OESERAL  DlbEASES. 


597 


The  eve  i<  far  l>cttcr  iil)lc  to  i)r()toot  itself  iigainst  th(>  ill  effects 
of  a  su.hleii  increase  of  l)loo.l  pressure  tliaii  af,'aiiist  sudden  dinunu- 
ti„n  of  pressure,  iiltlioujil.  it  is  an  extremely  rare  (.eeurrenee  t..  have 
retinal  hemorrhage  or  other  permanent  retinal  disease  as  a  result  of 
either  unless  there  is  some  disease  of  the  walls  of  the  bloodvessels. 
The'  acute  anaemia  due  to  ext<-nsive  hemorrhage  is  only  in  rar(> 
instances  followed,  hv  .liseuse  of  the  eyes.  Fries'  \vu.s  able  to  hnd 
,l,e  recor.1  of  <.nlv  KKi  cases  that  have  occurred  durinj:  the  past  two 
h„ndre.l  and  thirtv-five  year^ :  and  of  th.s.>,  it  is  probable  that  many 
occurred  am..ns  those  having  some  iorm  of  (hsease  ol  the  bloodvessels. 
Sixtv  |)cr  cent,  were  from  gastric,  intestinal,  and  uterine  hemorrhage, 
•'.-,  per  cent,  from  artificial  abstracti<.n  of  bloo.l.  7  per  cent,  from 
epislaxis,  5  per  cent,  from  wounds,  and  only  1  per  cent,  from  pul- 
monic hemorrhage.  ,    .      ,  ^  ■     . 

That  serious  di.sease  of  the  eves  results  only  m  the  rares  instances 
from  extensive  hemorrhage  in  indivi.luals  with  healthy  bloodvessel.s 
i.  ini.arent  when  we  recall  the  enormous  number  of  instances  ot 
,,r,',fuse  h<>morrhage  occurring  as  the  n-sult  of  traumatism,  especially 
.luring  militarv  ••ngagements,  and  note  the  extreme  infre<iuency  of 
di^eaM'  of  the  eves  as  a  r.'sult .  Not  a  single  ca.se  is  .ecorded  as  having 
.,.:,„nv.l  during  the  Franco-Prussian  War  of  1S7()-71.  ^\ lu-n  amau- 
r,,Ms  and  amblvopia  do  occur  as  the  r.-sult  ol  extensive  loss  ot  blood, 
it  is  u<iiallv  after  several  davs  have  intervened,  and  it  seems  to  l)e 
,h.e  to  hemorrhage  into  the  optic  nerve,  resulting  from  fatty  degen- 
,,,„•,„„  of  the  vessel  walls  conse<iuent  upon  disturbance  of  nutrition 
Irom  insuilicient  supply  of  blood  (Knies). 

From  the  above  statistics  it  is  apparent  that  extensiv..  hemorrhage 
in.m  the  stomach.  Innvels,  an.l  uterus  is  •.  real  source  of  danger  to 
virion-  and.  having  in  mind  this  .langer  and  the  weakened  state  ot 
,1,..  bloo.lv<'ss<.ls.  the  phvsician  will  naturally  insist  upon  the  recuni- 
|„.nt  i-ostur.",  an.l  will  luactis..  intravenous  injections  or  a. loot  such 
other  m.'asures  as  may  tend  to  restore  the  e.|uihbrium  of  the  vascular 

'■  br'nortic  insiifhciencv  the  rhvthmical  redd,.niiig  and  bleaching 
sometimes  observed  in  the  tinger-nails  may  be  appaivnt  in  the  op'ic 
,M<  (.laeger),  and  i)ulsalion  of  the  arteri.-s  m  harmony  with  the 
ridi  il  liulse  is  also  generallv  seen  (Haab).  . 

'  (.,h,!r  cardiac  diseases  <;c<'asionally  affecting  the  eye  are  mitral 
in.ullici.-ncv,  dilatation  of  the  heart,  and  fattv  degeneration.  The 
Inter  disea'se  is  often  onlv  one  manifestation  of  a  general  i.rocess.  ot 
wliich  one  of  the  features  is  disease  of  the  ocular  vess(-ls. 

\mon.'  th"disea.ses  of  the  vascular  system  which  s.mietmies  although 
riivlv  affect  the  eves  mav  be  mentioned  aneurism  ot  the  aorta, 
uteriovnous  aneurism  of 'the  internal  caroti.l  an.l  the  cavernous 
.imis.  pnulucing  a  i.ulsating  exophthalnu.s,  and,  very  rarely,  aneurism 
i.f  the  ophthalmic  artery. 

1  Klin.  Mon»l«  f.  A.igeuheilli.,  l«76. 


Wm'^ifmK.^^it  ^f..'« 


5tlH 


THE  KYE. 


Til  iiiu'urisin  of  the  aorta  we  may  liavo  paralysis  of  the  sympathetic 
nerve,  wiiieii  leads  to  coiitraetioii  of  the  pupil  and  also  of  tiie  pal- 
pebral tissure  of  the  affected  side. 

A  local,  temporary  slowiiif;  of  the  l)h)()d  current,  due  to  traumatism 
or  other  cause,  producing  a  thrombus  from  which  small  masses  may 
break  away,  foreign  sui)staMces  in  the  bloodvessels,  and  endarteritis 
iti  its  various  forms,  eiuisinf;  fibrinous  de|)osits  on  the  vessel  walls 
or  the  valves  of  the  heart,  may  result  in  the  develo|)ment  of  embolism 
of  the  central  artery  of  the  retina  or  one  of  its  branches.  In  somt'  si.\- 
toen  cases  which  have  been  studied  anatomically  the  obstruction  was, 
in  most  instances,  found  in  the  region  of  the  lamina  cribrosa  (Haab). 

In  those  portions  of  the  general  vascular  system  in  which  there 
is  free  ana.stomosis,  such  emboli,  even  if  they  find  lodgement,  may 
cau.se  only  very  slight  and  temporary  disturbance,  and  this  is  in 
large  measure  true  of  tl-.e  ves.sels  of  the  choroid;  but  in  the  retina. 
a.s  ia  many  portiois  of  the  cerebral  cortex,  \\i'  have  one  of  the 
termiiril  systems  of  Cohnheim,  in  which  more  or  less  complete 
cutting;  otT  of  mitrition  occurs  in  the  area  sui)plied  by  the  obstructed 
vessel. 

Thrombosis  of  the  retinal  vessels  may  occur  as  a  complication  of 
intiammatory  and  especially  of  infectious  i)rocesses  in  the  orbit, 
whether  they  are  c,ause<l  by  erysipelas,  meningitis,  thrombosis  of  the 
cerebral  sinuses,  or  in  any  other  manner  (Ilaab).  They  may  involve 
both  the  arteries  and  veins,  and  are  apt  to  Im>  the  inunediate  effect 
of  stooping  or  straining  in  people  having  disease  of  the  bloodvessels. 

I'nless  the  p.atient  is  seen  soon  after  the  accident  has  occurred  ami 
the  case  is  st\idied  with  great  care,  it  is  in  many  instances  by  no 
means  easy  to  make  a  clear  distinction  betw(en  embolism,  throm- 
bosis, and  enilarteritis  obliterans.  Tlu*  presence  of  j)erivascular  infil- 
tration and  degeneration  accompanying  endarteritis,  and  visible  to 
the  ophthalmoscope,  is  indicative  of  thrombosis,  and  an  existing 
valvular  lesion  of  the  heart  is  characteristic  of  embolism. 

In  some  ca.ses,  however,  as  in  sever.il  which  have  bc-n  observed 
by  the  writer,  the  sudden  occurrence  of  the  .syini)toms  and  the  oph- 
thalmoscopic pictur(>  are  such  as  to  leave  no  room  for  doubt  as  to 
the  existence  of  an  embolism. 


DISEASES  or  THE  UBINART  ORGANS. 

Albuminuria,  .\mong  the  diseases  usually  grouped  umler  this  head, 
albutniruiria  (Hright's  disease)  in  its  various  forms  is  by  far  the  most 
imi>ortant,  and  the  one  in  which  eye  IcnIous  are  found  most  fre- 
quently. (K<lema  of  the  integument  of  the  eyelids  of  a  temporary 
character  may  occur  at  a  very  early  fwriod  in  nephritis;  but  |K'r- 
manent  (edema,  when  present,  usually  accompanies  (X'dema  in  the 
ankles  and  other  parts  of  the  body  as  ;i  late  manifestation. 

Chemosis  or  irdema  of  the  conjunctiva  is  rare. 


^ 


-rrx— ffS?^ 


rilK  EYE  Y.V  ITS  HKLATIOS  T"  (IESEHAL  DISEASES.       .j!)<» 

\iiunic  tl.c  iiitra-ocular  atTcctioiis  (lu<-  to  iiUniinimiria  \v«>  hav<' 
liviM-raniia  ..f  tli.-  papilla  an.l  ivtiiia.  retinitis  witl.  the  characteristi.- 
white  ^pots  arranjicd  in  ra.liatii.R  lin.'s  alxmt  tlu-  macula,  u<'»ntis, 
nriiiorctinitis,  and  cvi-n  choivcd  disk  with  henu.rrliaKcs,  especially,  n. 

tlif  iierve-fii)re  layer.  ,      .      i  i 

Detaclinient  of  the  reti-ia,  iritis,  and  honiorrhaRic  glaucoma  have 
1,,-eu  described  as  rare  conditions,  and  chorouhtis  as  of  not  mfre- 
ouent  occurrenc.-.  Chans.'s  du.-  to  tlie  latter  disease  have  often  U'on 
I'.u.ul  o„  aut<.psv:  hut  the  lesions,  which  seldom  are  rei.orted.  are 
,„ol.al)ly  ren.h'r..d  invisible  at  the  ophthalmoscopic  exammation  by 
the  pimnent  ei.ith.'limn  (Knies).  Whitish  patches,  generally  m  the 
macular  region,  but  not  infr(>(iuently  in  other  i>ortions  of  the  contra 
retina,  accompanied  bv  swelling  of  the  nerve-hbre  layer  and,  at 
times  bv  small,  often  Hame-shaiM-d  hemorrhages,  are  the  charac- 
teristic retinal  manifestations  of  albuminuria  on  ophthalmoscopic 

examination.  .  .  .  ,       .. 

Intensive  hemorrhage  into  the  vitreous  is  seen  sometimes,  but  it 

is  of  rare  occurrence.  ,  .•      •        :„ 

Complete  blindnes>  is  very  rare,  seklom  occurring,  excepting  in  coin- 
cident ura>mic  amaurosis  or  in  atrophy  of  the  optic  nerve  and  detach- 
leent  of  th(>  retina.  Retinitis  is  not  an  early  symptom,  but  it  is  not 
hlfreonentlv  the  first  svmptom  which  leads  to  a  correct  diagnosis. 
II  has  occiusionallv  been  Uie  exiH-rience  of  the  writer,  m  patients  having 
Mhnost  normal  vision  and  asing  their  eyes  (,uite  constantly,  to  hnd 
„„  mikhig  an  ophthalmosc()i)ic  examination  that  the  centra  fundus 
w.s  the  seat  of  extensive  retinal  infiltration.  In  these  cases  the  fovea 
hM<  ..scai.ed,  and  the  conducting  power  of  the  ax.is-cylmders  seemed 
to  1„.  tulimpaired.  The  <rdema  may  bo  marked  and  yet  the  rods 
:md  cones  mav  for  a  long  time  remain  umhsturlx-d. 

Tlu.  .lis(>ase  with  which  we  are  dealing  affects  the  b  o.kIvossoIs 
n.a.nlv  as  a  scl(Tosis;  and  Knies  has  pointed  out  that  all  the  other 
|,.<i„n"s  including  the  hemorrluiges.  <e(h-ma,  the  formation  of  folds, 
.,,,.1  .le'taclunent  of  the  retina,  and  fatty  degeneration  are  ^«-ondar>- 
,„  these  changes  in  the  l,loodvess..ls.  He  calls  attention  also  to  tlu 
l,,t  that  whil.-  disease  of  the  ch..n.idal  ves.sels  may  be  very  extensiv.- 
without  giving  -iso  to  such  nutritive  disturbances  as  are  seen  m  th.- 
,.,ina  it  is  because  in  the  choroi.l  we  have  a  collateral  supi.ly  while 
in  the  retina  the  arteri.s  are  cud  artories,  and  circulatory  disturbances 

;ire  not  compensatwl.  ,.,■.•  c  .k„  ^,,,.,11 

There  is  marke.l  thickening,  especially  of  the  intima,  of  the  .s  u  U 
arteri.-s  and  capillaries;  and  while  in  the  latter  we  often  hnd  dilatation, 
in  the  former  small  dissecting  aneurisms  are  not  ""''""^">""- ^„  •„„ 
W  eeks  r..ports  a  ctuse  of  hemorrluige  and  acu  e  glaucoma  occurnng 
with  albuminuric  retinitis,  ami  other  ciises  have  been  roconU-d  proving 
thMt  acute  glaucoma  is  one  of  the  occasional  comphcations  of  this 
,li-.' .>o  Hull  has  puinteil  out  that  dise:ise  of  the  walls  of  the  bU,od- 
vessels  is  probably  the  connecting  link  botwwn  these  two  c.nditions^ 
and  GowJrs  stated  that  in  some  cases  of  chrome  renal  disease  there 


wv^mF 


()(I0 


77/ A'  /;■  )•/■;. 


is  (liiiiiimtioii  in  size  of  tin-  retinal  artriics  iiKlciM-iidciilly  of  tin- 
t'Xistciici'  of  otlicr  f'vidciicc  of  special  renal  disease. 

Albuniinuric  disease  of  the  retina  is  to  Im-  found  in  all  forms  of 
nei)hritis:  but  it  is  rare  in  the  larjie  white  kidney  of  parencliynialous 
nephritis,  in  the  sta^e  of  fatty  de};eneratioii,  and  also  in  the  form 
characterized  as  waxy  kidney.  In  this  latter  form  liull  has  jjointed 
out  that  t  is  seen  only  when  the  waxy  dejreneratioii  occurs  in  a 
contracted  kidney.  Although  not  uncommon  in  the  albuminuria  of 
l)re<inancy,  and  sometimes  seen  in  th  ■  acute  forms  of  nephritis,  such 
as  ap)  ar  as  a  coiMi)iic;itioii  of  scarlatina,  all  observers  sei  lu  to  aj;ree 
tiiat  cnaufies  in  the  retina  ar(>  fomid  most  fre(|uently  in  the  late  stages 
of  tiiat  form  of  nephritis  wliich  is  accompanied  by  contracted  kidneys. 
Tln'V  make  their  appc  .ranee  when,  after  ;i  |)eriod  of  hifih  v.-iscuiar 
tension,  elimination  is  be^innin^;  to  fail,  but  are  by  no  means  always 
found  under  the.se  conditions. 

U'hile  jH'rhaps  somewhat  less  serious,  if  the  nephritis  is  of  the 
form  which  is  often  .seen  in  acute  exanthemalous  diseases  and  in 
prcfinancy,  the  |)rojinosis  is  always  j;rave.  or  at  least  doubtful,  the 
patients  often  dying  within  u  few  months  after  the  discovery  of  the 
retinitis. 

Knies,  in  s|)eaking  of  the  more  chronic  forms  of  nephritis,  states 
that  lifi'  is  rarely  prolonjjed  more  tliiin  one,  or  at  most  two  years 
after  the  discovery  of  retinal  infiltration:  but  when  seen  anioUR  those 
who  will  carefully  observe  the  hy<;ienic  and  other  rcfjulat ions  neces.sary 
under  such  circumstances,  it  has  not,  in  the  writer's  experience,  been 
uncommon  to  see  that  jieriod  jrreatly  extended.  In  the  albuminuria 
of  pregnancy,  threateneil  loss  of  sijihl  from  neuroretinitis  is  a  strong 
indication  for  the  induction  of  jiremature  labor. 

Though  generally  affecting  both  eyes,  unilatend  albumimiria  is 
observed  occasionally.     Hull  has  described  ten  cases. 

Lesions  of  the  retina  which  resemble  those  of  true  alhuminiu'ic 
retinitis,  undoubtedly  occur  as  .-i  result  of  profound  aiueiuia,  leu- 
ka'inia.  .'ind  diabetes,  and  in  some  forms  of  organic  disease  of  the 
br.iin.  as  well  as  in  a  certain  projiortion  of  cases  of  what  is  termed 
cyclical  albuminuria;  but  it  is  well  in  these  cases  to  make  freiiuent 
t<'sts  of  the  urine,  for,  as  is  well  ktmwn,  nephritis  may  coexist  with 
these  conditions,  and  albumin  be  absent  from  the  urine  for  a  con- 
sitlerable  period.  While  rare,  paralyses  of  the  external  ocular  mus- 
cles are  .seen  sometimes  in  this  dise;ise,  occurring  as  the  result  of  a 
hemorrhage  in  the  region  of  the  n<'r\-e  roots  or  miclei  (Knies"). 

\\"i\\\  ura'iriic  aniblyopi;i  or  .-unaurosis,  nmscular  paralysis  may  :it 
times  be  seen  ill  t lie  last  st.ages.  These  are  not  necessarily  accompanied 
by  changes  in  the  retina.  When  ura^mic  poisoning  occurs  in  acute 
nephritis,  as  in  that  of  pregnancy,  it  is  not  uncommon  to  find  that 
the  retina  h:!s  und.ergone  no  ciiani^e  whjitever^  astd,  in  fact  it  hfts 
been  pointed  out  that  the  combination  of  ura-mic  amblvopia  and 
reiin.i!  di.sea.se  is  comparatively  nire.  In  eclamjisia  the  pupils  are 
generally  dilated,  and  the  external  ocular  muscles  often  take  part  in 


TJIf:  KYE  IS  ITS  RELATloy  TO  GEM: HAL  DISEASE:^.       (,<': 

tlH'  c)nvulsi.)n.s.  ("atsinict  may  h<'  the  result  of  vascular  changes 
.li'iifiiilont  uiioii  lU'pliritis. 

ijxaluria,  uric  acid  diathesis,  and  phosphatuna  have  each  ui  rare 
instances  Ix'cn  assigned  as  the  cause  of  eye  lesu.ns.  hut  it  may  well 
1„.  doiihted  whether  the  changes  ohserved  in  the  eyes  wen-  properly 
to  he  attrihuled  to  these  conditions  or  to  some  other  unrecoginze.l 
•  lisease  on  which  thev  in  turn  were  dependent. 

Hansell'  recorded  a"  case  in  which  the  retinal  chai  , hough  not 

uuite  characteristic,  resembled  thus.'  of  alhummurK  t.s.      1  here 

was  failure  of  vision,  hut  there  were  no  subjective  >y  onis.  he 
Ml.norinallv  abundant  urine  contained  an  <'xc.'ss  ot  phosphates,  but 
lepeateil  examination  reveuled  no  albumin  or  sugar. 


DISEASES  OF  THE  SEXUAL  ORGANS. 

Much  has  been  written  on  the   etTects   of   sexual    excesses,  esi)e- 

<iallv  masturbation,  in  producing  diseas<-  of  the  eyes,  .iiid,  if  we  were 

u:   be    influenced  bv  the  extreme  views   of    many  otherwise    high 

-.uthorities,  we   would   conclude    that    there  exists  some  peculiarly 

iniimat.'  relation  between  the  eves  and  the  sexual  organs.    If  siK'h  a 

irlition  exists,  its  importance  has  certainly  been  vastly  overe.<tiniated. 

,S-xual  excesses  have  been  !i.><signed  as  a  cause  of  atrophy  ot  the 

,,,,iie  nerve,  but  it  is  doubtful  if  the  relation  of  cause  and  effect  has 

Lccn  established.  ...  .      , 

Conjunctival  livpera'mia,  catarrhal  inflammation,  impairment  of 

.„.,.un,modation,  nuiscular  a.sthenopia,  and   even    serious   disease  of 

the  optic  nerve,  have  all  been  attributed  to  habitual  masturbation, 

liiitli  in  male  and  female  patients.  ,      •       r. 

It  i-  undoubtedlv  the  case  that  a  degree  of  neurasthenia  often 
ivMilt-  from  the  direct  and  indirect  effects  of  this  morbid  habit, 
which  in  its  turn  serves  to  aggravate  asthenopic  con.litions  <hie  to 
other  ciuM's  In  common  with  other  conditions  leading  to  vascular 
.Mi-'cgement.  excessiv<>  m.Msturbation  :i,^  well  as  vonercjil  <>xces.ses 
Invr  been  known  in  numbers  of  instances  to  .serve  as  the  exciting 
raiise  of  various  forms  of  intra-ocular  and  subconjunctival  hemorrliages 
when  the  ves,sel  walls  have  been  weakened  by  disea.se. 

Coi.orrluea.  which  might  for  some  reascms  be  chissed  more  prol)or  y 
with  the  infectious  di.sea.ses.  is  treated  here  because  it  is  so  essentially 
,  ,li-ea-.'  of  the  g(>nital  mucous  membrane.  ( )phthalmia  neoiit.torum 
,nd  sronorrh.eal  ophthalmia  in  the  adult,  with  the  resulting  destruc- 
tive keratitis,  siro  the  well-known  eve  comi)lications  of  this  disea.se. 

Metastatic  disease  of  the  eve  is  also  sometimes  seen  ni  association 
with  .ronorrlxra.  especiallv  with  gonorrlueal  rheumatism  of  the  larger 
oiiits  aii.l  iritis  not  infre.iuentlv  acconijianies  the  rheumatism  duo 
I.,  this  dlsea.se      Well-tiuthenticiited  cases  of  ineta-static  gonorrhoeal 


I  FhlladelphlaPol.vcllule,  January  21,  1S97. 


!i 


G02 


riih:  h:YK. 


n.iijunctiviti>.  wiiti  iiitciisr  cliciuosis  and  scanty  non-puriilont  st-crc- 
tiiin,  Init   witlumt  (Ifstructivc  (•(Hiical  (•iiin|)lirations.  have  Imh-ii  rc- 

port*"*!. 

To  tlif  varicuis  fnrins  of  (listurhanoc  in  the  viuscular  ami  nt-rvoiis 
systems  whicli  arc  excited  by  al)iu)iinal  iiieiistniatiou  are  properly 
attrilnited  a  lar^e  ^jroiip  of  ocular  alTcctions.  and  in  a  still  larger 
nnniher  of  instances  diseases  of  the  eyes  due  to  other  causes  are 
anjrravated  i)y  such  disorders.  I'atients  who  are  ana-niic,  chlorotic, 
or  "scrofulous,  ■'  especially,  and  soinetinies  those  free  from  such  con- 
ditions, show  a  marked  tendency  to  disea.se  of  the  eyes  durinp  or 
immediately  jirior  to  menstruation.  This  may  Im'  insipiihcant.and 
manifest  itself  as  a  slight  (iMlema  of  the  lids,  or  by  the  up|M'arance 
of  dark  rings  under  the  eyes,  or  it  may  1h'  that  conjunctival  hyper- 
a'lnia  will  develop  or  well-d<>tined  a.sthenopic  syin{)t<)ms  prestMit  thein- 
.selves. 

(jiven  a  tendency  to  hor|)etic  eruptions  of  the  lids  or  cornea,  to 
marginal  blepharitis,  .styes,  phlyctenular  conjunctivitis  or  keratitis, 
oi  even  iritis,  the  approach  of  the  menstrual  period,  especially  if 
there  he  dysmenorrlKva,  is  apt  to  he  accompanied  by  an  outbreak. 

In  nervously  susce|)tible  patients  a  variety  of  .symptoms  of  an 
hysterical  character  may  i)re.sent  themselves  at  the  menstrual  period, 
su<'h  as  limitation  of  the  visual  fields  or  nuMlitication  of  the  color 
ti.'Ids. 

Leber'  calls  attention  to  the  |)o.ssibility  of  hemorrhages  into  the 
optic  ni'rve  during  menstruation  in  ca.ses  in  which  the  vesst'ls  are 
diseased,  and  Knies  mentions  cases  of  hemorrhages  into  the  con- 
jiniitiva,  vitreous,  and  anterior  chamber. 

.\ttacks  of  anterior  uveitis  and  dis.s<>minated  choroiditis  and  cho- 
roidori'tinitis  are  frecpiently  due  to  menstrual  disorders,  and  sudden 
snpitressioii  of  the  menses  is  said,  in  some  instances,  to  have  produced 
hemorrhages  into  the  o|)tic  nerve  and  Ms  .sheath. 

Hemorrhagic  glaucoma  is  sometimes  seen  at  the  time  of  the  meno- 
pause. .  . 

It  is  doubtful  whether  normal  pregnancy  and  normal  parturition 
in  ii  lealthy  woman  ever  are  accompanied  by  di.>-,eases  of  the  eyes:  but. 
as  in  menstruation,  '  pnwxisting  di.sea.se  of  the  eyes,  a  systemic  c<»n- 
dition,  such  as  ana-mia,  which  seriously  interferes  with  the  nornmi 
course  of  ])regnancy.  or  any  of  the  numerous  accidents  which  may 
befall  the  patient  during  this  critical  jx-riod,  •  >•  convert  what  should 
be  a  normal  physiological  process  into  a  i)r  i  e  source  of  disease  of 
the  eyes. 

In  a  nervously  susceptible  woman,  especially  if  she  is  anaemic  or 
is  the  .subject  of  any  form  of  disea.se  which  impairs  her  vitality,  mus- 
cular or  acconmiodative  asthenopia  may  iM'conie  a  source  of  great 

disc fort,  and  if,  u.-  We  frfqurntly  find,  thiTc  e.xist.s  a  latent  error  ni 

refraction  or  imbalance  of  the  external  ocular  nmscles,  the  symptoms 


I  Handb   v.  Gnefp-Sainilnrh,  Bd.  v.  p.  «19. 


THK  EYE  IS  ITS  RELATION  TO  OE^iERAL  DISEASES.       ^(r.i 

•lie  aKCnivat.'.!  an.l  are  soinrtiincs  most  (listr.'ssiiiK.  In  thcs.-  casos 
•,<  in  llmw  ..f  -M  hysterical  i.ature.  sucli  as  t(Mn|.(.rary  l.lin.ln.'ss 
unam)iMi.aiii.'.l  l)V  organic  lesion,  and  contraction  of  the  visual  helds. 
we  should  attribute  the  disturlmnce  to  the  ana-rnia  or  other  systemic 
condition  u|.on  which  it  really  de|K'n.ls,  and  look  upon  the  pregnant 
-tate  as  merely  an  exciting  cause. 

The  eves  »M'ar  their  part  in  the  altered  facial  expression  sometimes 
.een  during  pregnancy,  and  are  n..t  infn-ciuently  the  seat  ot  pigmen- 
tation.    l»hlyctenular  conjunctivitis  and  ev«'n  keratitis  sometimes  are 

rncountered.  ,     ,  ,       , 

The  occurrence  of  alhuminuria  during  the  lat«'r  months  of  pregnane) 
i^  apt  to  1h-  --companied  by  retinitis,  choroiditis,  optic  neuritis,  etc., 
which  are  considered  in  their  resi)Octive  chai.ters.  In  proj^Tly 
elected  cases  th<'  induction  of  jiremature  labor  may  check  the  progres.s 
,,r  the  di.s»'iise,  and,  while  not  infallible,  has  in  many  iiLstanccs  served 
t,,  ,,r.-vent  blindneas.  .\.s,  however,  the  .same  accident  is  apt  t(.  occur 
ill  future  pregnancies,  patients  should  be  warned  of  their  danger. 
Detachment  of  the  retina  and  retinal  hemorrhage  may  occur  even 
when  not  associated  with  albuminuria. 

U  is  natural  that  i)arturition,  especially  when  painful  or  prolonged 
should  in  cases  in  which  albuminuria  or  other  diseas*'  has  weakened 
,li,.  walls  of  the  vessels,  lead  to  h<Mnorrhage  into  th<>  retina  and  nerve. 
\maur()sis  niav  make  its  a[)iH'arance  during  parturition  as  a  result 
ol  the  ura'inia  of  eclampsia,  or  when  there  has  be<'n  profuse  uterine 
hemorrhage  it  may  r(>sult.  as  in  cases  of  great  loss  of  bloo<l  from  other 
..orlions  of  the  body. 

Hemorrhages  intJ)  the  retina  and  optic  nerve  occurring  during 
rhiMlx'd  without  api>arent  cause  are  attributed  by  Knies  to  emboli 
ni  the  c<Mitral  retinal  artery,  such  as  have  been  observed  after  phleg- 

MiMsia  alba  dolens.  .       ,         »•  i 

I'ueriHTal  septica-mia  mav  lead  to  nieta.stiises  in  the  retina  an. 

|,oroi<l  and  in  severe  ciuses  septic  embolism  may  readily  be  followed 
l.v  i)anoi.hthalmitis.  It  is  j-robable  that,  as  in  other  forms  of  se))- 
Mca'inia  an<l  i.vaMnia,  this  occurs  f.ir  more  fre<|uently  than  is  reported. 

,-  .ittention  is"  directed  to  other  symptoms  and  the  patients  so  seldom 

Vhortion  accompanied  bv  infection,  an.l  .sei)tic  processes  in  the 
A,, Mil)  ..ccurritvT  !>.<  the  result  of  disease,  .)r  f.)ll.)Wing  the  various 
urgical  proc-dures  involving  the  womb,  may,  in  a  similar  manner, 
ad  to  disease  ot  the  choroid,  retina,  and  optic  nerve. 
To  lactation  and  the  ana-mia  and  exhaustion  which  at  times  accom- 
nanv  it  an-  fre<iuently  due  phlvctenular  and  other  forms  of  keratitis, 
,!i.r  even  choroiditis  accompanied  by  vitreous  oj)acities  has  been 
uun.l  t.>  be  due  to  this  cause.  ,  .  •  ^u      tu,- 

TIk'  eves  .)f  infants  are  often  injured  at  the  time  of  birth.     1  tus 
Kiy  occur  in  a  variety  of  wava  in  prolonged  but  otherwise  norma 
ibors,  but  is  especially  apt  to  occur  in  cases  in  which  instrumental 
l.'livcry  becomes  necessary.    Here  almost  every  form  of  traumatism 


t)i)4 


Tin:  EYi: 


II 


■ 


\\n^  Ihm'ii  rt'C(<nli'il.  lici-liyiiuisis  iiitu  tin-  coiijuiicliva,  l»'iiii)rrli:iK<' 
within  tlic  eye  ur  nriiit.  mill  t'r:iclwri' nf  ilir  l'riiiit;ii  Imhk' or  at  tlicliasc 
(if  tlic skull,  wiili  icsiiitiiin  iifiiiitis,  I'lilldwcil  liy  |>aralysis  of  flic  optic 
nerve,  may  1h'  ciicdunicicd,  and  \\i'  may  have  pafalysi^  uf  any  ln'aiicli 
nf  till-  tliinl  nerve,  the  sixth,  or  the  facial.  Niimcnnis  c.ises  in  which 
paralyses  have  ncciirieij  have  been  |inl)lishei|  hy  Miulin.  Mloch,  Merger, 
and  iitheis.  Hut  when  we  cuiisider  the  nuinei'oiis  instances  in  which 
inslnnnelital  delivery  is  resorted  to.  serious  ;iccidents  to  the  eyes 
are  seen  to  he  of  relatixely  infre(|ucnt  ((ccurretice. 

( tphlhainioscopic  I'xaininaiioiis  of  the  newborn  have  in  many 
instances  revealed  i-etin;il  lieinorrhasies,  and  while  such  eyes  often 
recover  with  jjood  vision,  there  is  imich  rea.son  to  believe  that  many 
of  the  cases  of  amlilyojiia  so  frequently  seen  in  strabismus  are  due 
to  such  lesions,  the  j;ross  <'haii>;es,  such  .as  coiilil  be  seen  by  means 
of  the  ophlli.alnioscope,  having;  lonji  since  disappeared.  There  is 
room  for  further  investigation  of  this  subject. 

()phlhainiia  neonatorum,  almost  alw.ays  due  tn  the  irmiococcus  of 
Xeisser,  but  sometimes  tf.'tceable  to  other  sources  of  infection,  is  >ii 
conunon  as  to  rei|uire  little  cominem.  As  in  fionoriiui'a.  it  may  be 
associated  with  atfectioiis  of  the  joints. 


POISONS  AND  INFECTIOUS  DISEASES 


I 


Poisons.  The  direct  and  indirect  effects  of  the  introduction  into 
the  system  of  chemic.il  poisons  and  livinji  jji'rms  and  their  morbific 
products  are  so  varied  fh.at  it  is  extremely  ditiicult  to  arraii};*'  a 
sysf<'m  of  classification  which  will  be  thofoujihly  scientilic  ;ind  satisfy 
all  of  the  coiKlitions.  Indeed,  for  our  present  purpose  no  such 
classification  is  necessary,  as  our  object  will  be  attained  if.  byftroupiii^ 
similar  forms  of  jioisons  on  the  one  hand  and  the  infectious  processes 
on  the  other,  we  ;ire  able  to  [iresent  .a  coin|ir(>liensive  view  of  the 
manner  in  uiiich  thi-  eye  is  affected  directly  by  the  substances 
beloiiflinir  to  the  v.arious  groups,  or  indirectly  by  the  disea.sed  con- 
ditions which  they  excite  in  othei   parts  of  the  bod  v. 

.\  lai'tre  .and  most  important  jrroup  of  jioisonous  substances  afTecl 
the  eyes  by  producins;  some  form  of  retrobiilbar  neuritis,  at  times 
including;  .1  lesion  of  the  fj.injtiion  cells,  resiiltint:  in  what  is  fjenerally 
termed  toxic  amblyopia,  chiiracferizeil  by  form  and  color  scotoinata. 
To  this  {Tioup  belonji  alcohol,  tobacco,  lead,  .arsenic,  the  silver  salts, 
mercury,  phosphorus,  the  salts  of  potiissiuin,  iodoform,  ioduret  and 
tliiuret,  essence  of  .lamaica  jrinper  and  essence  of  pep])ermint.  bisul- 
phide of  carbon  and  chloride  of  sulphur,  nitrobenzol  ;ind  dinitro- 
l)enzol,  the  various  ciial-tar  products,  opium  and  its  alkaloids,  chloral, 
cannabis  indica,  te.a.  cotl'ee  and  chocolate,  ercot.  vanilla,  and  stramo- 
fuum.  carbon  dioxide,  osmic  acid,  i|uiniiie  and  the  various  pr()duct> 
of  cii!'lion.a  bark,  s.alicvlic  acid,  and  aspidium  or  filix  mas.  lOach  of 
these  substances,  it  luis  i)een  claimed,  lias  pro<luccd  true  toxic  am- 


nn: 


)>;  l\  lis  HEI.ATKiS  TO  liF.SEHM.  l>ISt:.\NES.       (j()5 


!,lyr;>i;i  "!>>  ;iii  action  nn  the  nannlmii  ( 
iicrv>.  "I   tln'ir  va; 
:;inri:il  clTcct   ii|hi|i   t 


cll- 


nrrv( 


til 


lit': 


am 


I  (iptic 


ocular  supply"  (tU-  S-liwrinitz).  and  wliilr  tlu-ir 
he  eves  will  !)(•  (•(ilisidiTcil  ilftv,  the  sviiiptollia- 


MjiN   and  I 


I  i.atlinluiiv  ut  rcir<.l>ulliar  iii-uiilis  will  lie  Inatcil  ..I  in  the 


liapiiTim  Diseases  of  the  Optic  Ncivi 


As  llic  trrni  poison  is  applicc 

ill. 
.■tti'cl  of  all  clHMMlca 


to  lliosr 


sulisiancfs  which,  if  intro- 


Ih'IWI 


•fd  into  tlic  svstcni,  prodiici-  disease,  we  here  consider  not   tl 

I  >iil>stances  n| the  eye,  lint  such  cITects  as  are 

I  ,1  jjiven  poison  is  introduceil  into  the 

ve,  and  we  should  make  a  distinction 

ite  attack  and  those  which 


iiiiduced  in  that   <»r;:an  when  ,i 
\-.|ein   or  direellv   into   the  c 


n  those  ellects  which  follow  an  acl 


hi;  Mv  make  their  appearance 


in  cases  of  chronic  poi>oninn.     In 


Fniih  arine  and  chronic  poisoninjr.  however,   the  more  proinnniced 
ften  the  indirect  etTect  of  till-  action  of  the  poi.son 


rvi'  symptoms  are  o 
upon  some  o 


Iher  part  of  the  hody,  Hich  as  the  vascular  system 


the 


ral  or  pi'ripheral  nervon-  system,  o 


r  the  ki<lnev: 


idirect   etTects  Ul>o 


ri  thi'  eve  of  acute  svsleinic  poisoniiiK  are 


i|it  to  mam 


fi'sl  themselves  in  the  action  of  the  iris  and  ciliary  hody, 


ydriasis,  myosis.  cycloph'fiia.  etc..  and  .soinetiiiH^s  in  the  ext 


I-  in 


iicular  muscles 


and 


I  in  chaiiijes  in  the  vessels  of  the  fundus.     Colnn-d 


\i-ion  and  illusions  are 
W  hile  intoxication  am 


(tip 
ilso  sometimes  noted. 


•iilistancr^  nami' 


hlvopia  is  the  most  noteworthy  etTect  of  the 

1  in  the  ahove  list,  a  numlierof  them  produce  other 


k-mptoms  of  which  we  must  not  lose  sijjht 


li'iiil-imisiiiiiiiii  produces  a  varii 


irijiheral  lesions,  re: 


1v  of    both    central   and 
hich 


iiltini:  in  disturhaiices  of   vision  which  are  geii- 


illv  traceable  to  .sclerosis  and  periarleri 


lis,  the  evidence  of  which 


iinetime^-  be  se( 


n  with  the  ophthalmoscopo.     Disturbances  of 


I  he  external  ocular  muscles  may 


follow  multiple  neuritis  due  to  this 


and  we  may  have  the  ciiaracteristic  picture  of  albumiiiuri( 
uria  may  result  from  lead-poisoning.     Th 


nioretinitis,  as  albumin 


[iplicalioii  of  lead  lotions  is   fre(|uently  folioweil  by 


itu 


lelibi 


le  dci'osils 


|e;i 


il  in    the 


l'l,i,sjilii>riis'^m 


is   sometimes  accom))ani<'tl  by  hemorrliap< 


ihe  retina,  and  later  by  fatty  depiieration.  -oinewhat  r 


ibling 


i.it   of  albni 


linuric  retiniib 


The  frei|uent   occurri' 


'('  of  hemor- 


iixes  in  th'     !>tic  nerve  and  brain  produces  characti'ristic  eye  symp- 

i/((V  seldom  produces  eye  symptoms,  although 

hemorrhages  and  tatty  degeneration,  as   in 

have    Imm'Ii    noted.      Tii.     eye   symptoms    in 


lc/(/i'  nitrriiri/-ii<>i--iii 
severe  cases  n  tinal 
i-phorus-poisoiiing 


liriiMic  c.'ises 


resemble  those  due  to  chronic  lead-poisoning. 


'II  ^(111  III 


r 


'iiniis 


(/  jrom  the  silver  salts,  aside  from  rare  cases  c 


Ihi 


manifests  itself  in  the  eye 
coniunctiva,  which  not  iiifre(|uen 


)f  retrobulbar 
onlv  in  the  (hirk  indelible  stain 


tlv  is  .seen 


as  the  result  of 


rii-ijril    iiiCa! 


::pi)!i 


ication:- 


liiilinc-i>oi.-(>,iln(i.  chieflv  when  it  is  administered  in   the  form  of 
lide  of  potassium,  induces  at  times  catarrhal  conjunctivitis,  but 


^1 


l« 


«jO<i 


THE  HYK 


nidii  Irr  |Ui'iitl.\-  pains  in  the  cvcm  anil  larrvniatiuM  in  aswwiation  with 
ilic  tvpii'al  cory/a.  Wv  sDinctitncs  mt  illustration.'^  of  ihc  cxiri'Mii' 
iiri!  iiion  |ifoilufcii  hy  the  ilcvt'lojinicnt  of  iiidjilf  of  iniTniry  when 
ii'\  ijiati'il  i"t''  '  '  is  liiislcd  into  tlic  t'M's  while  iodide  of  potas-inin 
is  Im  in^  ,1. ..;... II  "red  internally;  Imt,  although  these  drills  are  not 
inf!e(|iienily  used  at  tii;-  same  tune,  this  is  an  extremely  lari-  occiir- 
renee. 

limiiiiih  iij  juiUissiinii  in  exees.sivc  anioiiiits  has  Iwen  known  in 
SO!  '•  instances  lo  proiliiee  retrohulliar  neiiritis,  Imt  e\('ii  when  not 
in  MiliieiiMil  dose  to  eanse  the  eha'aeti'rislie  skin  eruption,  it  may  exeite 
eotijiUK'tivitis  with  phlyetenular  foci  of  intlamtuation  (Kniesi. 

Alfohiil,  which  prolialily  produces  more  cases  of  chronic  poi.sonin^ 
than  all  other  sulistances  topether,  causes  a  variety  of  eye  symptoms 
in  addition  to  retrohulliar  neuritis,  .\  liich  latter  disease  will  Im-  con- 
sidered elx'where. 

In  acute  alcoholism  we  have  at  times  as  an  early  manifestation, 
fai'tire  of  accoiMiriodation.  inco-4)rdination  of  the  ocular  muscles, 
causing  diplopia,  and  later,  ab.siMu'c  of  normal  pupillary  reaction. 
With  noniial  ophthalmos('o|)ic  appearances  wo  may,  in  delirium 
tremens,  havi  a  well-marked  concentric  limii.itioii  of  the  visual  field 
which  -ioinetinies  cniitimies  for  several  days.  What  is  known  as  retro- 
hulhar  I  axial  ojitic  neuritis  is  only  one  manifestation  of  the  inter- 
stitial aiil  parenchymatous  changes  and  Viuscul;ir  disease  due  t" 
chronic  alcoholism,  and  the  conse<|uent  lesions  which  develop  in  the 
111  lin.  spinal  cord,  kidneys,  etc.,  are  accompanied  l>y  such  changes 
in  the  'ves  as  are  found  in  a.s.-!ociatioii  with  t!>e  same  lesions  due  t^ 
other  <-,iuses. 

S'\erc  ilisease  of  the  centr.al  nervous  y>tem,  si.'li  as  ofti-n  su|K'r- 
venes  in  ca.-es  of  chronic  alcoholism,  i--  .iccompaiiied  liy  a  variety  of 
ey  lesions.  .'in>l  anionji  them,  in  rare  in--i:i!ices,  <>|ihthalmopl(  i;ia 
externa,  which  is  due  generally  to  hemorrlKinii-  intlaimnatiou  of  'he 
floor  of  liie  fourth  ventricle. 

Mrtlnil  nirii'itii  and  (DuijI  iiln>hiil  may  hoth  cause  sudden  lilmdiiess — 
iadei'd.  some  authors  have  claimed  that  to  tlicM'  suhstance.-^,  rathei 
than  to  pure  ethyl  hydrate,  is  due  the  retrohulh.ar  neuritis  which  often 
follows  the  use  of  the  more  conunon  forms  of  alcoholic  drinks. 

AfiiU  •tj)iin)i-j'iiisitnini;  causes  well-markeil  myosis  ,ind.  at  times, 
cloiidinf;  of  \i-^ion.  In  clunnic  cases  accomp.anied  by  marasmus  there 
is  also  apt  to  he  corneal  softeuinj;. 

Actilv  cliloriil-jtii'^iiiuHii  produces  myosis.  althouirh  .after  large  doses 
liave  lieen  .idMiinislered  f.ir  .1  Ioiil'  time  I'lydri.asis  s(,mctimes  is  noted 
The  cutaneous  eruption  ;uid  iirticari.".  of  the  li.ls.  whicli  are  .seen  after 
prolonged  use  of  thedrug.  are  apt  to  he  accompanied  by  conjunctivitis. 

S\i!ph(it'iil-jii  -luiiiiti  may  jiroduce  ptosis,  .•md  has  Ik'cu  known  to 
cau.se  anasthesia  <if  the  c<iniunctiva. 

('iirhi)ii  i!:<iru!i  -!:!!isi>>!!>!!;  !i;is  in  a   numher  s-.f  ca^es  iu'cf!  known    '■■■■■ 

produce  jianilxsis  of  the  ixternal  ocular  iTiuscles,  which  may  disapiwar 
after  a  few  weeks.     It  is  attributed  to  hemorrhagic  procosst^  in  the 


rut:  h:YH  is  its  rhi  irms  ro  ueskhm  diseases. 


mi 


lifii  iil)Mtru('tiuii 

iliiiii  (»f  r-arli(iii 

ii'trlia>ri'>. 

•11.  wliicli,  aci-'ird- 

■iiii-iia,  iM'diiis  li'ii 

Iruu,  uiiil  is  pri' 


iicrvc  iiucli'i  i>r  in  the  pfriplirrai  non-rs  (  Kimpp 
In  rcr<|iiraii(in  or  cirfulation  results  in  'In-  anaiti 
illiixidc  in  tlir  liliind,  rtc  arr  apt  to  liavi-  n'tiiial  ; 

Stiiiliiiiiii-iH>i.-oninii  is  cliarac'tcri/.tMl  liy  vfilnw  \  i> 
la^  to  Kiiics,  who  has  .  arcfully  investigated  its  phei 
i.r  tilleeii  iiiiimles  after  tiie  adiniiii-tration  ol   the 
ceiU'd  l)y  transient  vioh-t  vision.  'Ihe  pupillary  riiietion  »snorinni.  is  in 
the  appearanee  of  the  fuiiihis,  and  eetilral  vision  remains  undistiirlied 

Kri/ol  has  l>een  known  to  jirodiiee  i  irrowinK  of  the  retinal  hlood- 
\essel.s  and  tetnptinay  disturiiance  of  \ision.  with  sliii;;:ish  |uipiliary 
react!'  .  but  in  chronic  poisoinnn  the  prolonged  nutritive  distiirh- 
aiices  ut'i  urring  tis  the  rtMilt  of  spasm  of  the  \es.s<'ls  of  the  <'iliary 
iiody  are  ustiJilly  :u<sij;ned  as  the  cause  of  tin-  cataract  which  some- 
times follows  withiti  a  few  year-  of  such  an  attack. 

Fiutijits-jDiixiinitiij  varies  in  its  etTiM'l  upon  the  eye  aceordi'ijt  to  the 
uriiuie  of  the  alkaloid  jiroduced:  inuscarin-  <■ausin^r  spasm  of  accom- 
iiioiiation  and  inyosis,  whili'  other  varieties,  such  as  inorchella,  pro- 
duce mydriasis  i  Knies).  The  profound  systemic  disturiiance  prixluced 
liy  these  deadly  alkaloids  sometimes  results  in  fatty  de>:eneration 
.iiid  heiiiorrhap'  of  the  retina. 

Almpine  may  he  taken  :is  the  t>pe  of  tin-  mydriatics,  and  its  elTects 
upon  the  eye  when  Used  internally  in  a  poisonou-  dose  aie  well  imder- 
>tiHii|.  It  luiiy  cause  hypera'inia  of  the  fundus  as  well  as  cyclopleKia 
iiid  mydriasis,  and  in  those  who  an-  predispo.sed  may  excite  >:lau- 
i,Mn:t  \'ot  infre(|uently  we  find  in<lividuids  in  whom  the  smallest 
iiiiount  of  .itrn.ine  acts  as  a  local  poison  in  the  conjunctival  sac. 
(•roducinjr  a  n,  !,-i -r  form  of  conjunct ival  cat.irrh  aiul  a  so-called 
ec/eiii:i  of  the  '■  '  •  i  sometitues  stated  that  this  is  due  to  impure 
dilutions;  hut  v  lij,  'i  'i  rlli/.ation  and  the  oli-'t-ance  of  every 
I'Msonahle  prec.  ^  ;■)■■  tin  viriter  litis  convincetl  himseli  tl.at  thi-  is 
iMil  the  cas«'.  ■  •  ..:.r\  oi  iiie  or  duhoisine  will  usuali  l-<-  tolerated 
\'\  those  patieti-  .  wi   ■  :;i'e  susceptible  to  this  :.r'i.>t.  oi  atropine. 

II ilit^riinnnm'.  diihoisinr.  iliilurinc.  hin/ialr.ti    '■•-,     ■  ■■i,'>liimini\   etc., 

•  :ive  mydriatic  and  cycloplefiic  ett'ects  similai    .^«  l.'iose  of  atropine. 

lid  any  of  them  may,  umler  favorable  coiiilitioiis.  induce  ulam-oma. 

I'ulioisine  is  inore  prone  to  ctiuse  rleliri'.im.  and  also,  at  times,  pro- 

iires  ii.irrowiiifr  of  the  vi;t,al  field;  and  I'loley  i;is    inted  temportiry 

iiiblyopi.'i  !is  a  result  (•;'  lit"  iiistilliition  ol  -copolamiia'. 

('iiiiiini-imisitnitiij  if  'xnite.  may  cause  transient  amblyopia  witli 
•lUtr.ii-tion  of  the  retinal  arteries,  or  it  may  produce  syncope  with 
Mic  .itteiidaiit  temporary  blindness.  In  chronic  cocaine-poisotiiii}'  we 
'  ..ly  have  visual  hallucination  ehromatopsi;!,  hemia.iopsiji,  iniiTop- 
i.i.  diplopiii.  daiiciiiir  of  objec ,  and  ainblyo])i!i.  In  ti  numlwr  of 
■i-t.mces  iilaucomatous  symptoms  '  >e  develo|M'd  after  the  instilla- 
■  "ti  of  cocaine  into  the  coiijunctiv;  .  sac  or  after  its  use  on  the  nasal 

'\i-.:\;<  ineinl-rati'-. 

I'.orinc    instilled    into    the    conjurictiviil    .sjic    has,  in    a   few    in- 

tiices,    'iroduced    temporary    complete    blindness    and    a    dopree 


ti08 


riit:  EYE. 


i '. 


of  tiaiisiciit  aiiil)lyi)pi:i  soim'tiiiics  follows  tlio  injootinn  of  pilocarjjiiic. 
l)ut  it  is  a  curious  fact  tl- U  wlicu  adiuiiiistcrcd  internally  hoth  pliy- 
sostijiininc  and  pilocarpint  often  produce  mydriasis. 

i^andeshur;;  lias  r.'ported  live  cases  in  which  opacity  of  the  crys- 
tMlliiie  lens  followed  treatment  with  jalxirandi. 

I'lonininis  and  Inxdlhinnin.'-  found  in  certain  annuals,  or  as  the 
n'sult  of  the  action  of  microbes  u|>on  certain  articles  of  food,  such 
as  meat,  sausage,  oysters,  hsh,  ice-cream,  etc.,  |>roduce  a  varii'ty  of 
diseases  of  the  eyes."  Many  of  the  ptomaines  in  their  phy.sical  proper- 
ties resemble  certain  of  the  vejietahle  alkaloids,  which  accounts  for 
the  fact  that  i)ilateral  paralysis  or  paresis  of  accommochition  and 
mytlriasis  are  often  observed  after  poisoniiifi  from  decomposed  meats 
or  tish.  Muscarine  and  neurine  produce  spasm  of  acconunodation, 
while  lyrotoxicon  r-uises  paralysis.  Ptosis  and  paralysis  of  the  extrin- 
sic ocuiar  imisdes  have  also  Ixrn  observed.  nn(l  have  iH'cn  considered 
as  of  miclear  orifrin,  or  possibly  due  to  a  basilar  neuritis. 

Infectious  Diseases.  Infectious  diseases,  their  coiiii)lications  and 
seqnehe.  are  the  cause  of  numerous  eye  lesions.  Such  diseases  may 
1m'  due  to  siiifile  micro-orpuiixms  producing  wellnhlined  clinical 
manifestations,  such  as  are  seen  in  ftlanders,  tetaims,  and  splenic  fever, 
and  are  in  each  instance  peculiar  to  the  s|M'citic  ap<>ncy  which  pro- 
(hices  them,  or  they  may  result  from  the  more  complicated  pn)ees.ses 
by  which  ditT(>rent  !nicr()bes  may  In-  the  cau.>*e  of  the  .same  group  of 
clinical  svmi)toms,  as  is  the  case  in  ery.sijjelas  and  pya'inia.  In  either 
instance  the  resulting  eye  l(>sioii.s  may  be  a  direct  effect  of  the  primary 
infection,  or  an  indirect  result  of  the  mimeroas  complicating  condi- 
tions which  arise  in  tin-  course  of  the  disciise. 

The  involved  aiid  intricate  naliwe  of  the  subject  under  discussion 
will  1k"  appreciated  when  it  is  reniemlMTed  that  with  many  of  the 
infectious  proces.ses  which  are  supposed  to  have  a  specific  cause  we 
may  have  in  various  stages  of  the  disease  coinplicaticms  arising  from 
secondary  inleclioiis.  This  is  esix-cially  true  of  those  accompanied 
by  abscesses  and  pnruh'nt  proc(>sses,  the  mixed  infection  In-ieg  due 
to  the  addition  of  one  or  more  of  the  common  forms,  such  as  Staphy- 
lococcus pyogenes  aureus  and  albus,  Sfeptococcus  pyogenes,  Diplo- 
coccus  pneumonia',  etc.  Indeed,  the  clinical  picture  wliih  Is  made 
up  of  a  grouj)  of  signs  and  symptoms  to  which  we  give  a  s|)ecial 
name,  is  in  many  instances  de|M'ndent  for  its  existence  upon  the 
combined  action  of  two  or  more  of  these  inicre-organis>ns  and  their 
morbific  products.  It  is  often  to  these  secondary  infections,  which 
are  so  common  that  we  look  upon  them  as  a  necessary  part  of  the 
disease,  that  are  due  many  of  the  complications  which  make  their 
apjiearance  in  the  eyes. 

Knies  has  made  the  following  smninary  f)f  the  atTecti<ms  of  the 
eyes  which  may  occur  in  connection  with  infectious  discjuses: 

1.  Hemorrhages  in  all  parts  of  the  iH<ripheral  and  central  visual 
apparatus,  from  the  most  varied  causes  in  all  stagi-sof  the  disease,  and 
conse((uently  ev<'ry  jMLSsible  disorder  of  vi.sion,  motion,  and  seusation. 


Tilt:  Ali'  7.V  /7-.S'  RELATIOS  TO  UESERAL  DISEASES.       609 


2.  Foci  of  fiilty  dcRt'iicration  and  softoniiiR  in  tin*  central  divans 
and  the  eye,  visiltlc  in  the  retina  witli  the  ophtliainio.scope,  and  often 
associated  witii  iieniorrlianes. 

.{.  InHannnatory  dianpes  in  tiie  vessels  in  all  localities,  with  the 
aliove-nientioned  conse(iuences. 

4.  More  or  less  ditfusi'  inflammations  of  the  tissues  of  tin-  eye, 
es|K'ci:illy  of  the  uvea  and  retina,  iritis,  cyclitis,  choroiditis,  retinitis, 
ditTuse  interstitial  keratitis,  etc.  Meningitis  with  its  various  eye 
symptoms  also  devel(.i)s  in  the  s.ame  way. 

"  5.  C'han>;es  (chronic  and  acute  hemorrhaRic  forms)  in  the  ojitic 

nerve,  ciuasni,  tractus,  motor  and  sensory  ner\-es  (multi|)le  neuritis). 

().  Pure  atrophy  of   the  nerve  tissues  (central  organs  and  optic 

nerve),  occurring?  after  the  lapse  of  years,  and  jjrohal^ly  tiie  final 

outcome  of  the  vessel  lesions. 

7.  Focal  hyjx-ra'mias  and  inllammations  (meta.stases)  in  various 
dejrrees,  from  a  chronic  to  an  acute  hemorrhagic  ami  jiurulent  process, 
or  even  terminatinj;  in  acu:<'  fjanp-i-ne.  These  are  foutid  in  the 
int<'fiument  of  the  lids  (eruptions  sometimes  leadiufi  to  };an>;rene), 
the  sclera  (sclerotic  foci),  uvea  (disseminated  choroiditis  and  choroido- 
relinitis,  and  emholic  sup] )urat ions),  retina  (iM-nign,  but  usually  .sejjtic 
emholi),  orlnt  (metastatic  suppurations),  lacrymal  glands  (embolic 
abscesses  and  dacryoadenitis),  optic  ner\-e,  and  brain,  etc. 

S,  Specilic  neoplasms  (syphilis,  tulierde,  leprosy)  in  almost  every 
part  of  the  eye  ami  surrounding  structures,  and  in  the  central  nervous 
system. 
The  functional  result.s  of  these  lesions  are: 

1.  \isual  disorders  of  all  kinds,  of  peripheral,  intermediate,  ami 
central  origin. 

■_'.  I'aralysis  and  si>asm,'«  of  a  ceiitral,  nuclear,  and  |)eriplu  ral  char- 
acter, and  even  due  to  dinct  di-ease  of  the  muscles. 

;{.  Neuralgias,  ana'sth(sia.s,  i'lid  para-sthesias  of  every  po.ssible  mode 
of  origin. 

I.  ( (tlier  affections,  such  as  adhesions  of  the  lids  in  conjunctival 
catarrh,  disorders  of  lacrymal  secretion  and  conduction  in  aifections 
of  the  hicrymal  glands  and  canal,  etc.  In  infectious  diseases  which  are 
attended  with  high  fever  and  cimgestiun  of  the  meninges  and  cortex, 
visual  hallucinations  and  illusions  also  are  encountered.  These  dis- 
eases may  terminate  in  more  or  less  .severe  forms  of  in.sanity. 

The  eye  is  in  nire  instances  the  seat  of  the  primary  infection,  and 
not  infriMiu-ntly  presents  the  earliest  manifestations  of  di.sease  which 
attract  the  attention  of  t!ie  physician  or  attendant,  as  in  the  photo- 
pliubia  and  conjunctivitis  often  seen  during  the  period  of  i""abation 
ol  measles:  but  more  generally  eye  lesions,  when  found  in  association 
uiili  infectious  diseases,  are  a  direct  ••tTect  of  the  disease  itself  or  of 
s.iiiie  of  its  complications  or  sei,uela'. 

In  studving  the  great  v.ariety  of  eye  lesions  produced  by  infectious 
diseases,  it  is  well  to  bear  in  mind  ihe  marked  ditVerence  which  is  often 
to  l)i'  -loted  between  tnose  toUowing  an  acut(>  disea.se  and  those  resul.- 


tJlO 


nil:  i:  > ;;. 


ini;  t'niin  tlic  iiKirc  cliniiiic  iiniccssc.-..  An  intVclioii  iii;iy  \iv  so  inti-iisc 
tliMl,  MS  ill  acnii'  |it(piii,;iii<'-i»ii^niiiii}:.  llic  system  is  uvcrwhi'iiiicil.  and 
we  tin'l  at  till' aiitn|>sy,  in  assDciMliini  witli  llic  ntlicr  lesions,  exten- 
sive retinal  lienioiiliaf^e  as  tlie  only  (•■iilar  manifestation  of  a  disease 
wliicli.  liad  its  onset  l>e<ii  less  rapid,  would  have  ii'siilted  in  fatty 
de<;enei:ition  in  tlie  |>aieneliynia  of  the  liver,  kidiu-ysand  otlii'r  organs, 
;ind  the  assoeia'ed  ehaM<ies  in  tlie  vascular  system.  These  in  turn 
would,  in  the  more  <rradu;il  [iiocess  of  infection,  lie  accoin|);imed  hy 
fattv  de,t;eneratioii  in  the  choroid  and  retina  and  secondary  heinor- 
rlia"'es  in  these  str;ictnre,-  simil.ir  to  those  found  in  the  hraiii  and 
otiier  or}jans. 

Th-  profound  infections  wiiicli  we  often  ohserve  iii  such  diseases 
as  typhoid,  tyjihus,  and  yellow  fever,  aid  in  intense  malarial  poi- 
soiiiiiz.  are  accoinp;'iiied  hy  alterations  in  the  hlood.  and  at  times  tiy 
cha'ii^es  in  the  choroid,  retina,  and  optic  nerve,  the  exact  nature  o' 
whicii  cannot  he  said  to  Ix- entirely  understood,  althoujih  they  sed'i 
in  many  inst.-inces  to  iiear  :i  somewhat  direct  relation  to  the  special 
poisoM  c;uisin;i  the  disease  with  which  they  are  associated.  The  con- 
ditions attendiiifj;  tlu'  late  war  with  .'^p.iin  atforded  many  illustrations 
of  the  elTects  of  these  diseases  in  eausinj;  chaiiiies  in  the  fundus  of 
the  eye,  and  a  minilwrof  observers  have  made  valuable  contributions 
to  our  information  on  this  interesting  subject.' 

It  remains  to  Im-  demonstrated,  however,  whether  the  lesions  noted 
cat!  l)e  classed  as  part  of  the  morbid  anatomy  of  the  diseases  nien- 
tioi.ed,  or  siioiild  Im-  ascribed  to  intermediate  changes  de]M'ndent 
i'.pon  tiiem.  ami  possibly  common  to  other  maladies. 

in  the  niof'  chronic  processes  of  infection  in  which  the  interstitial 
coniu  I'tive  tissues  are  largely  alTected,  or  the  vessel  walls  have  umler- 
gone  grailual  degenerative  changes,  we  have  thrombosis  and  retinal 
heinorrhag's,  and  as  later  manifestations,  sometimes  making  their 
a|)pe:iraiice  years  after  the  original  lesion,  atrophy  of  theo|)tic  nerve 
ami  retina  associated  with  "videiic's  of  similar  sclerotic  changes  in 
tlie  brain  and  spinal  cord. 

A-  the  general  powers  of  resistance  of  the  patient  who  is  subjected 
to  an  infective  ]iroce<s  givatlv  modify  the  systemic  etTects  produceil. 
Ml  the  condition  of  the  eye  may  inlhience  the  course  of  the  disease  in 
that  oiiiaii.  An  old  iritis  with  a  jiosterior  synechia,  or  an  old  |H'iie- 
trating  wound  v>itli  entangled  iris  or  I'lis  capsule,  mav  iniike  the  eye 
far  more  vuiiieiaiile  than  d  otherwise  would  be,  and  lead  to  most 
-erioiis  conseciuelices  when  it  is  subjei-ted  to  the  dangiTs  of  an  infec- 
tious ill-i  :i-e, 

.\  >ubiect  of  <:reat  iiili'rest  in  comiection  with  inlretious  diseases  m 

their  reliitioii  to  il yes  is  th.it  which  concern-  the  route  by  which 

the  eve  i-  invailed  bv  the  micro-organism^  or  their  niorbitic  prodi;  •!•;. 
In  such  dise;i^es  .'i-  mpus  of  the  <kin  of  the  lids,  infection  may  take 
pl;ice  bv  direct  transmission  of  die  iiiiiiobes  or  their  products  irom 


Ko(!iTv.     OplitliHlmic  KfiHPl.  Oilnli.  r,  \'W. 


77//;  /v)/;  /.V  ITS  RELATIOS  To  CESKUAl.  li'SEAsK-S. 


Oil 


Is   to   til 


tlw   ll 
ii'iiti'  iii;iv 


mjiiiictiv;!, 


\vliil( 


n  siicii  diseases  as  erysipeias  tiie 


)V  wav  c't'  the  orliital  cellular  tissue  ami  untie  iierv 


:i-    \v 


:is   (il)serve(l    liv    llie  writer    ill 


a    w 


i: 

ell-iiiarkeil   case    in   a    man 


-ixciity  years  of  ajje,  who  diet!  of  iiieiiiii>iitis  as  tiu'  n'sult  of  facial 
erysipelas  which  jiroduced  orliital  cellulitis.  In  iiieiiiufiitis  the  route 
iiiM\',  as  ill  the  above  case,  he  by  the  optic  nerve,  or  in  some  instances 


ll 


I'liUfth  the  spheliol 


lal 


<inus  and  orliita!  ti>sui 


111   <lis 


pf  the  respiratory   tract    the  coiiiiiiunication   may  b 


(jiiectly  by  means  of   the   nasolacrymal    canal    to   the   conjunctival 

sac.  or  indirectly  throupii  tl rbit   by  involvement  of  the  frontal, 

ethmoidal,  maxillary,  or  sphenoidal  sinus. 


ll 


till 


diici) 


III  cases  ol  serious  );eneral  mleetioii,  ami  es|M'cially  m  those  m  whicl; 
there  is  ulcerative  endocarditis,  the  vessels  are  tlie  usual  means  of 
ii.iiismission.  and  either  the  enormous  vascular  expansion  of  the 
choroid  or  tiie  terminal  system  of  the  retina  becomes  the  seat  of 
,111  infectious  process. 

In  svplirniiiid.  wliicli  is  often  only  the  early  stajie  of  an  infective 
process  terminatinj;  in  pya'inia,  we  have  areas  of  fatty  defreneratiim 
■  iiid  heiiiorrhap's  into  the  retina.  The.se  are  of  J^^a^■e  inii)ort,  as 
iiidicatinji  the  exti'Ut  of  the  systemic  invasion. 

I'jiaiiiiii.  luiving  its  orijiin  in  an  inHainmatory  or  necrotic  jiiocess, 
liKiduciiiK  infective  emboli,  thrombi,  or  liemorrhafie-;,  may  result  in 
'lie  dcvelo|)ment  of  a  new  focus  of  infection  in  any  va.scular  portion 
111  the  eye  oi  orbit,  the  choroid  au''  retina  beiiij;  most  fre(|uently  the 
-I  ,ii  of  this  inelastatie  process,  which  may  orifrinate  in  ;ui  ulcerative 
'  iidocarditis  or  an  active  phlebitis. 

\\  liili-  Hotli  ims  anatomically  p'-oved  that  it  is  possible  to  have 
\\liat  mipht  Ik'  termed  a  benifrri  form  of  metastatic  jiurulent  retinitis 
which  does  not  extend  to  the  clioroid  or  vitreous,  it  will  readily  be 
understood  that  a  rapidly  exteiidiiifr  destructi\e  imrulent  intlam- 
iii.itiiiii  of  all  the  structures  of  the  eyeball  is  the  usual  result  of  metas- 
i.iiic  ini'ectioii  of  the  eye  in  pyaemia. 

In  the  l;ite  stag's  of  pya  mia,  even  wiien  no  septic  thrombus  has 
i'luiid  its  way  into  the  eye.  we  may  iiave  numerous  retinal  hemor- 
ih.iires  occurring  immediately  before  de.itii. 

Miilii/niiiil  puxhile  or  splmir  jcrir.  Ienne(|  also  ;inrhrax.  malijriiani 

ideiii.i,  ch;i'-!)on.  etc.,  is   somewliat    proni"  to  atTeet  the  <k'w  of  the 

iid-   and    l.i    c.iiise    entropion,    ectropion,    and    infiltration    of    the 

'inii'.i.      [t   may  even   produce  an  orbit.al  abscess,  and  severe  cases 

ll  ilnii'  i.ite  stafii's  tend  to  cause  retinal  hemorrhajics. 

Enisijuhis.  classed  iiy  some  writers  as  an  .atTection  of  the  skin, 
'u:w  properly  be  considered  amoiiji  the  infectious  diseases.  It  is 
ni  iiifir(|uently  seen  ill  the  lids,  thouirh  it  };''ii'''':il'.v  originates  else- 
\li"ti'.  ;iiid  extends  to  the  delic;ite  skill  ,'llld  loose  comiecli\('  tissue 
I'  ihese  structures,  where  it  causes  marked  ledenia,  and,  in  rare  iii- 
'.inces.  .abscess  and  necrosis,  which  may  lead  toeetro])ion.  Mrvsipelas 
!  ilie  lids  is  often  accompanied  by  slifiht  c.atarrh.-il  conjunctivitis  and 
'\\\v  cheiiiosis,  but  oiilv  in  n-ire  instances  bv  ulceration  of  the  cfirnea. 


G12 


Tin:  i:yi:. 


Acute  (hicryopystitis  may  Ix-  causcil  liy  crysiiK^las,  hut  is  ii(.t()l' 
fiiMiuiMit  occunvi'icf.  whilt  an  I'xafcrhalinii  of  a  clironic  iutlarniiiatidii 
(.1"  till'  lacrynial  sac,  or  tlic  .l('Vclo|)incnt  of  au  cry  ii»clatnus  iullatn- 
ination  as  a  coniplicatioii  of  a  iic>;lcctcil  (iacryoi'ystitls,  is  uot  very 
uiicoiMiuoM.  and  iu  such  cases  tiic  innlcrlyiuf;  cause  soiuct;  u  's  escapes 
detection,  or  the  diafrnosis  of  erysipelas  is  made  wiieii  W(  aave  only 
an  a-ifiravateil  case  of  cellulitis  due  to  retention  in  a  siini)le  purulent 
inllannnation  of  the  lacrymal  sac. 

An  extension  of  the  .-ellulilis  of  erysipelas  to  ih<"  tissues  ol  the 
orliit  is  seen  occasionally,  sometimes  takiuf:  the  form  of  an  orbital 
al)sces<  and  sometimes  of  a  serous  infiltration,  c.-iusinj;  eviilence  ot 
pressure  on  the  optic  nerv<'  and  motor  oculi.  In  the  more  severe 
<-aM-  there  may  he  extension  from  iheorhit  to  the  hiain,  with  resultiiif; 
menimiitis  or  simi-  thromho>is.  and  in  others  exo]>hthalmos  with  evi- 
,h-wv  of  comi.ressioii  in  optic  nenriti-.  with  defective  vision,  narrowinj; 
of  the  visual  liclds,  i^tc.  >ometimes  terminatin.n  in  atrophy  of  the 
nervi'  and  narmwinj:  of  iln'  retinal  vessels.  Throinho.sis  of  the  central 
vein  with  retinal  heinorrlia',re  has  heen  reporteil  in  several  casi-s,  and 
ptosis  and  pan-is  of  the  (Xtern.al  ocular  ,nus"le-,  and  i  ve:-,  of  theciliary 
mu<cle,  may  result.  Opacity  of  the  vitreou- and  ;jlaucom;i  li.ive  also 
l)een  seen  after  ery-ipel;i-.' 

.\  numtx'r  of  case-  lia\r  i.cr  ?i  recorded  in  which  ;in  attack  of  ery- 
.-ipelas  lias  S(>rved  to  ll.a-leii  leeiivei'y  in  I  r.aelli  .ma  and  diseases  ot 
tlie  uv  al  tract.  ,and  tiii>  is  in  keepini:  with  wli.at  h.as  hecn  oh- 
served  occasionallv  ii;  patli-p|oL;ic;tl  proce-M<  in  other  poitioiisof  the 
h^.dy. 

Whethei-  we  classify  rlieuniatisiu  as  an  infect ion-ilisease,  or  aiihere 
to  one  of  the  other  iiiiineiMU>  theories  .a-  to  its  origin,  it  is  certain 
that  in  -oiiie  of  the  nianife^talions  of  the  acute  articular  form 
we  are  dealing  with  an  i?ifeitious  proci'ss.  and  it  is  |)rol)ahle  that  in 
many  inst.ince-  tin'  din  :i~es  ..f  the  eye-  which  ociair  ihiriiifj;  an  attack 
<if  rheumatism  are  trace.ihle  to  this  cause,  it  is  not  clillicult  to  recofr- 
ui/.e  the  action  of  ,an  acute  infection  in  the  associateil  eye  lesions  ot 
ponorrhna!  rheumatism,  tmr  in  the  lanholi-m  of  the  central  artery 
of  the  retin.i  which  i-  so  Imiuenlly  the  rcMilt  of  ulcerative  endocar- 
•  lili<,  hut  there  are  m;ih\  ci-es  of  diseases  of  the  e\es  associated  with 
;thno>l  imperceptihie  rheumatic  m.anifestation-  in  wliii  li  the  operation 

of  ,all    infectious   pt'oce--    is   Hot    so  apparent. 

lierurrinf;  attacks  nf  iiiti-.  sometimes  allernalin>i  with  the  disturh- 
;ince  in  the  joints,  c^-cliti-.  seleiitis,  episcleritis,  tenonitis,  inflam- 
mation of  the  hulhar  poMii.n  ot  the  ocailo-orhital  fascia,  petechi.il 
coniu!ieti\  itis.  ;ind  iven  p.ii:il\-is  of  the  motor  ocaili,  may  follow 
attack-  of  .acuii    ;irti(ailaf  rheiim.atism. 

(ilauconia,  -omelimes  uiiforlun.ately  associ:ited  with  chronic  iritis, 
is  vt  time- seen  in  the  snjijects  of  chronic  rheum.alistM  not  necessarily 
;irlicular  in  ch:iracter,  atid  in  these  cases  it  is  ditiicult   to  avoid  the 


I 


,.^^t■I^   Mid.  opl-.  !•  -■"«■ 


wm 


Tl[]:  HYi:  IS  ITS  HELATKjS  to  (iHSERAL  DISEASES.       613 


inclusion  tliat  thoro  is  stmif  o 


tiler  cicincnt  in  addition  to  tlic  infir- 


timi 


wiiicii  we  rt'ciifinizc  in 


tiic  more  acute  forms  of  the  disease 


M, 


\i\  I 


iiial 
am 


ts  prodromal  stajre  is  apt  to  be  accompanied  i)y  well- 

.ked  catarrhal  coiijmictivitis,  with  the  accompanying  pliotophohia 

1  lacrymation,  and  throujihout  the  course  of  the  disease  and  often 

lonji  time  after  the  fever  has  suhsided,  asthenojHc  symj)toms. 


uilh  weakness  of  aci(imm< 


)dation,  a  tendency  to  niarj;inal  i)leph 
arilis,  superficial  vascular  keratitis,  and  obstinate  phlyctemilar  con- 
iunctivitis  and  keratitis  are  observed.     This  is  esiM-cially  apt  to  be 
in  cases  of  hyperopia  or  asti>;matisin,  and  in  such  patients  local 


1 1  IK 

am 


1  constitutional  treatment  fienerally  fail  to  afford  relief,  unless  tlu 
(•fraction  error  is  first  corrected.    These  manif<'stations  are  seen  most 
.  ..tly  amoiif?  those  who  are  strumous  or  tubercular,  though  they 
t  times  observed  in  patients  in  whom  it   is  difhcult  to  di.^coyer 
lences  of  tuberculosis,     (i.-mprene  of  tlu;  lids,  tcrminatiuK 


Irequen 
are  ;i 
nilier  evH 


in  ('ctnipioii,  h 


sult«'d  in  a  few  instances. 


•  ■ra 
lia- 


riiere  have  been  reconli'd  several  well-authenticated  cases  of  bilat- 

1  optic  neuritis  with  resulting  blindness,  which  hi  some  instances 

been   Dermanent.     Thev  have  occasionally  been   the  result   of 


uasilar  meniiifiitis  following  mea.sles,  and  hi  a  few  rare    instances 
tlcv  h.ive  been  secondary  to  purulent  otitis  media. 

.Ubumimiric  retinitis  after  mea.slos  is  extreniely  rare. 

SidHdlitiit  is  at  times  accompanied  by  conjunctivitis,  but  this  is 
nut  so  f-ecpiently  a  complication  as  in  measles,  and  is  not  so  valuable 
as  an  ai  I  to  early  diaj;nosis.  In  the  course  of  an  attack  of  scarlatina, 
c-pecially  when"  it  is  .severe,  active  phlyctenular  conjunctivitis  ami 
kiiatitis  niay  occur,  sometimes  n'sulting  in  extensive  corneal  ulcers. 

Dacryocys'titis  is  not  vi'ry  uncommon,  and  in  rare  instances  we 
have  orbital  cellulitis  with  its  usual  conseiiuenees,  even  resulting  in 
aiiophy  of  the  optic  nerve,  and  in  a  few  ca.-es  purulent  inflammation 
..1  the  lacrviiial  pland  has  lieeii  reixirtod. 

When  we  consider  the  fre<iuency  of  renal  comi)lications,  eye  lesions 
iiic  to  this  cause  are  relatively  rare,  though  then'  are  many  recorded 
.■a<es  of  ura'iiiii'  amaurosis  and  amblyopia. 

After  describing  a  number  of  well-observed  ca.ses,  J.  H.  Storey, 
innliiig  Koerster,  maki's  an  admirable  summny  which  seems  to  be 
■'.:  keeping  with  the  views  of  other  careful  observers.     In  all  of  the 

:,-cs  reviewed  by  the  last-named  authority  "  albuminuria  was  present. 

II. I  tjie  amimiosis  i.ccurred  in  the  destiuamation  stage  after  a  lu'riod 

I  Lreiieraiiy  favorable  symptoms.     The  amaurosis  was  ushered  in  by 

.  i-.liral  symptoms,  headache,  convulsions,  vomiting,  and  stupor.     It 
' mic  nil  sudiienlv.  was  bilateral,  and  for  a  time  was  complete.     No 

;  liili.almoscopic'lesions  were  detected,  and  the  blindness  gradually 

rared  otT.     There  cim  be  iio  doubt  that  these  cases  must  be  da.ssed 

-  ur.i'iiiic." 
W  iici,  ciiroiiie  iiephrilis  re-  uHs  from  scarlatina,  we  may.  of  cotii-se. 

:    I  lati  r  period  have  liie  '!sual  retinal  and  nerve  h'sions  of  albu- 

•iinitria.     Meningitis  following  .scarlatina  may  result  in  paralysis  of 


G14 


rut:  icYi:. 


tilt'  dptii'  iHTvc  and.  rarely,  in  partial  or  niinplctc  paralysis  of  out'  or 
niort'  of  tlif  ticular  iimsflfs. 

lAfM  whfii  iiti  rt'iial  dist-asi'  lias  f:;istt'il  ami  im  alljiiiiiiii  lia>  lufii 
ft)iintl  ill  till-  uriiif,  iii'iiforctinitis  lias  bffii  ohst'rvt'il. 

Puriilfiit  otitis  iiifdia,  wliicli  occurs  so  tiv(|iifiitly  afttT  scarlatina, 
may.  hy  fxtt-nsioii  of  tlif  inllainiiiation  to  tlic  incninfii's  or  tin-  tlfVclo|)- 
inciit  (if  a  sinus  tlironilxois.  lead  to  |iaraiysis  of  tiic  ojitic  ncrvf  or 
of  tlif  fxtt-rnal  ocular  imi.scli's,  to  secondary  infection  of  the  retina 
or  clioroiil,  or  to  ahscess  of  tlie  orbit. 

Acconimoilative  astlienopi.a  is  not  uneoinmon  after  scarlatina,  as 
after  all  of  the  exantheiiiala.  and  is  iiuicli  intire  prone  to  reciu-  if, 
as  is  often  the  case,  there  is  a  pre-exislinj;  error  of  refraction. 

Dililithrriii  may  l>e  accompanied  hy  ;i  most  ileslructive  form  of 
conjunctivitis  with  a  ch.-tracliristic  densi'  intiit ration  in  the  siihcoii- 
junctioil  tissue;  hut  this  ccimplication  is,  fortunately,  of  extremely 
rare  ticcurreiice  in  this  country. 

The  ocular  lesion  most  frei|Uently  met  with,  and  one  of  extreme 
clinical  interest,  is  the  p.artial  or,  nirely.  complete  paralysis  of  accom- 
modation, which  comes  oi   rapidly,  and  at  times  sudileiily,  from  three 

to  six  weeks  after  the  a|),)earain f  the  pharyii<;eal  lesion.  ;ind  from 

two  to  three  weeks  after  apparent  recovery.  It  is  much  more  fre- 
«lU('iit  ill  children  than  in  adults,  and  often  apjx'ars  after  ca.ses  of 
diphtheritic  infection  in  any  part  of  the  hoily,  and  which  may  1m'  .so 
mild  as  to  have  entirely  escajM'tl   detection. 

The  paralysis  is  almost  always  liilateral,  thoufih  there  are  excei)- 
tioiis.  and  it  rarely  ;ifTects  the  iris.  It  lasts  sometimes  for  months, 
disai>pearin<;};radually,  even  when  not  treated,  thoUf;h  the  correct  .on 
of  refraction  errors  which  impo.se  an  lidi lit ional  Imnlen  upon  thecili.iry 
iiiasch',  an.i  the  internal  administration  of  stryclmine  and  iron,  exert 
a  favorahle  influence  and  shorten  the  ])eriod  of  its  duratitiii. 

Complete  or.  more  freijueiitly.  jiartial  jiaralysis  of  the  external 
ocular  muscles,  indicated  hy  tropi.a  and  ptosis,  is  not  very  uncommon. 
Neurojiaralytic  keratitis  from  involvement  of  the  fifth  nerve  has 
been  reported,  and  .also  ;i  nuinher  ()f  cases  of  concentric  contraction  of 
the  visual  field,  with  defective  color  visitin,  which  latter  Koeni^  h.as 
attributed  to  retinal  aiia'sthesia. 

\\  hile  in  r.are  instances  henioniiajies  ha\('  been  observed  post-mor- 
tem, near  and  even  in  the  nucleus  of  the  third  nerve,  it  seems  more 
p-ob:ibie  that,  as  Voelckers  has  jxiint.  d  out,  the  se;it  of  the  lesion  is 
in  the  nerve  terminations  in  the  affected  niu.scles.  Knies  has  foind 
it  dillicult  to  account  for  the  plieiitiinena  of  diphtheritic  |)aralysis  of 
accommodation,  exceptiiij;  on  the  theory  that  "a  definite  i)tomaiiie 
is  produced.  ;ind  th;it  thishns  a  paralytic  action  upon  accommodation, 
while  it  has  no  influence  upon  the  movements  of  the  pupil." 

N'ariola  before  the  introijuction  of  vacciiuition  u.is  a  most  prolilic 
cause  of  blindness,  it  h.ivin^  been  estimated  that  in  (iermany  .T)  per 
cent,  of  all  cas(>s  of  blindness  were  due  to  this  tliseiise.  This  per- 
centajre  has  now  been  trnatly  reducctl,  raiiffins,  acconhnji  to  ruclis, 


■■■■H 


mmm 


Tin:  i:yi-:  is  its  helatios  to  oeseral  diseases.     01.-) 


Inim  2  IMT  cent,  to  .■{.(■)  jxt  ci'iit.  The  same  iiiithorily  states  that 
llic  eyes  arc  atTcctol  in  frniii  1  per  cent,  tn  11  per  eent.  of  all  eases 
111  variola,  aeeor<lin>!;  to  the  statislies  of  various  ohservers.  Altliou^th 
MJniost  every  portion  of  the  eye  may  be  affi'Cted,  vision  is  most 
tn'(|iieiitly  lost  by  extension  of  the  inHamniatory  jmu-ess  from  the 
ccinjuiietiva  to  the  cornea. 

Tiie  skin  of  the  litis  is  a  fre(|uent  seat  of  tlie  eruptioii,  and  it  may 
cause  (edeiiiatoiis  swellinft,  hi-morrhafiic  intiltration,  ah.-ces.ses,  phlep- 
nions.  and  furuncles  or  h.calized  loss  of  tissue,  which  latter  is  especially 
-erious  if  the  pustules  form  on  the  lid  margins,  where  Ihey  are  i\\\X 


lo   l( 


ad  to  trichiasis  and  ectropion 


After  the  eruption  has  subsided 


Hicre  is  a  tendency  to  the  formation  of  abscesses,  boils,  and  disturb- 
ance of    the   filanduiar   structures  of  tlie  skin  in  other  portions  of 
id  tills  is  seen  also  in  the  lids,  where  we  have  iiiarpinal 
■ilyes.  obstruction  of  the  .Meibomian  frlaiids.  fctropion, 
nd  permanent  thickening  of  the  lids,  or,  if  the  destructive 


llie 


tiicl 


body, 
ihariti 
liasis,  a 


proce: 
in  some  c 


has  iM-en  extc'isiv(>.  gr 


real  distortion  or  loss  of  lid  ti.ssue,  and, 


ases.  even  p'riostitis  and  caries  of  the  rim  of  tlie  orbit  have 
been  repnrteil. 
\s  in  mi-asies  and  scarlatina,  the  conjunctiva  is  a|it  to  be  congested, 

not 
and  there  is  not  iiifre(|ueiitly  iiillammation 


;ind  we    may  havi-  catarrhal  conjunctivitis  even  when  the  eye 
die  seat  of  the  erupti( 


the  miicou> 


membrane  of  the  lacrymal  i>a,'<saf:os 


The  pustules  of  smallpox  iray  form  on  any  portion  of  the  bulbar 
jimctiva,  and  rarely  on  the  palpebral  mucous  membrane:  but  their 


'■III'.. 

favorite  location  is  near  the  corneal  maiftin,  when 

I 


th 


'V  are  sm  i 


Her 


iiaii  when  seen  on  the  skin,  .and  jiresent  the  appearance  of  cor.junctiyal 
tenules.     There  is  s<'vere  inflammation,  with  chemosis  and  aciive 


lily( 
seen 


■tion,  as  in  pundent  conjunctivitis,  and  secondary  corneal  infeo 
lion  is  very  apt  to  follow  ([uickly,  v.itli  hypopyon  and  all  that  such 
a  destructiv-  priK-es.'  means. 
Some  authorities  deny  that  tiie  primary  erujjtion  is  over  seen  upt 


cornea,  and  occurring,  as  it  u.su 


the 


appearance  ol 


!dlv  d( 


nianv  davs  after 


til. 


f  the  cutaneous  eruption,  or  even  during  corivalescencf 


s  probable  that  the  corneal  infection  is  a  secondary  jirocess  w 


It     IS] 

a-   Kl 


hich 


has  suggested,  may  be  held  in  check  by  the  diligent  use 


of  ase]itic  and  antiseptic  treatment. 

JA-eii  when  there  is  no  conjimctivii:  nor  evidence  of  eruption  on 
the  eveball,  we  may  htive  corneal  involvement,  due  ap])arently  to 
In.a!  infection  by  morbid  material  circulating  in  the  blood.  Indeed, 
this  is  bv  some  authorities  said  to  Iw  the  most  fre(|uent  type  of  cor- 
nt  (Sturvl.     It  occurs  usually  as  a  late  manifestatinn. 


Ileal  mvolvemi 


.an 


I  is  aj)t  to  be  :iss( 


iciated  with  or  followed  by  ,';uch  serious  comi 


lii- 


ilions  in  otlier  organ 


that  a  fatal  termination  is  not  imcommon. 


Iritis,  u.sually  as  ;i  part  of  an  anterior  uveitis  involving  a  low  grade  of 
t  is.  vitreous  opacities,  and  more  or  less  involvement  of  the  choroid 


rvcll 


1-  not  an  uniisua 


IHl! 


1  nianifestii'''in  during  the  lute  stages  of  variola,  and 
ated  areas  of  choroiditis  an-  sometimes,  althougli  rarely,  observed. 


' 


(Jl(i 


THE  EYK. 


\  few  cases  (>f  iiiMirorclinilis  ami  lii-iiinrrliafics  iiitu  tlir  (iplic  iicrvo 
liavt  IxM'ii  ili'sciil It'll,  ami  imin>  wuiiiil  prniialily  lie  n  |>iiil('il  if  u|)liilial- 
ni()>('i>|m'  ('\aniiiiatinii~  wvyv  iiior*'  ciiiiiiiuin. 

Sccniidary  ii('|p|iiiiis  is  (•uiiipaialivfly  rare,  hut  is  sdinrtiim's  iiicscnt, 
ami  may  Im-  a('C(tiii|i,irii('il  by  uia-iiiic  aiiiaiiiosis  ainl  alhiiiiiimiric 
iftiiiilis. 

ViKvlnutiitH.  like  ntluT  iiii'i'ctiitiis  pniccsscs,  may  cause  ilisease  of 
llie  I'yes.  llczema  ul'  the  lace  and  plilycteliular  discas.'  ol  tlu-  cdIi- 
juiK'liva  aiul  curnea.  wiiicii  sdnieti'iies  follow  or  accoiii|iany  va<'ciiia- 
lioii.  are  of  comparativi'ly  sli;;lit  importance  in  healthy  jiatients,  hut 
in  children  and  others  of  feeble  tonstitiiiion  ihi-y  may  puisne  a 
tedious  course.  Accidental  vaccitiaiioii  of  the  lids,  conjunctiv.a,  and 
rted  man*"  times,  and.  whether  from  a  vaccine 


coiiiea  has  heeii  rep 
I'ustule  or  from  a  lymph  tu!i<'.  produces  a  most  serious  inf.'clioii.  If 
the  cornea  is  .Mliecied.  it  is  a|it  tolwcomethe  seat  of  active  infiltration, 
stroiijzly  resemblinir  a  vaccine  pustule. 

W  hile  the  tr.'iiismissiou  of  other  <liseases  by  vaccinaiion  is  not  so 
I'oniinon  as  is  jienerally  suppoM'd,  it  is  by  no  lueaiis  impossible  for 
such  a  result  to  follow  when  the  conditions  are  favorable,  and  when 
syphilis  is  transmitted  we  may  have  iritis  and  the  other  usual  luani- 
fesl.itious  of  thai  disease  Ml  the  eve. 


V 


iiririlld    nsrelv    can 


ics   (>\-e   complications,    but    on(>    instance    is 


recorded  of  iritis  accoiiipaiiieil  !)y  hy))opy((n. 

TiipliDhI  Fivrr.  \  dcfiree  of  hypera'inia  or  conjunctivitis  may 
occur  in  typhoid  as  in  other  fevers,  and  phlyctemilar  conjimctiviti.s 
and  keratitis  are  not  uucotninon  dnriii!;  convalescence.  Kerato- 
malaci.'i  may  result  in  serious  cases,  and,  with  the  profound  and  pro- 
loni;i'c|  <onniolence  which  is  sometimes  a  characteristic  of  the  late 
stages,  we  often  have  xerosis  of  the  cornea  accompanied  by  infection 
from  exposure.  .\  ;;anjiren(ius  iiiflatmnation  of  the  lid  which  rarely 
makes  its  appearance  is  apt,  if  the  patient  survives,  to  lend  to  I'ctro- 
pi<in. 

While  noT  very  common,  v.arious  afTections  if  the  laeal  tract  an 
s.imetinies  pn-seiit.  as  anterior  u\'eiti>.  pl.islic  iiiti-  i\clitis.  choroi- 
dilis.  ;ind  choroidoretinitis,  with  their  :iccompan\in!.;  changes  iti  the 
vitreous  .III  1  later  in  the  lens. 

The  ireneral  nuis<'ular  weakness  wiiich  often  char.acterizos  the 
|>eriod  of  convalescence  after  tyjihoid  IVvcr  manifests  itself  in  the 
eyes  as  proloiiireil  .and  sometimes  extreme  v.e.ikness  of  accominod.i- 
tioii,  produciu}:  much  more  marked  symptoms  if  i^iijxm.itisni  orhvper- 
metropi/i  is  present.  In  addition  to  accon.nioil.itive  we  often  have 
muscular  asthenopia,  esjiecially  if  a  manifest  or  latent  imbalance  of 
the  external  ocular  muscles  is  jiresent.  'I'm,'  i  aralysis  of  the  external 
muscles,  with  deviation  or  ptosis,  is  rarely,  th,.u!ih  'onuMimes  seen  .is 
a  conse(|uence  of  typhoid  feviT,  juid,  as  Knies  has  well  said,  sh(iuld 
siiirtrest  a  careful  study  of  the  urine. 

The  \-;iiious  diseases  of  the  br;iin  .Hid  spinal  cord  which  are  <\fi-\- 
sionally  seen  ,is  seipiela'  of  typhoid  fever  iMa>    be  accompanied  i)y 


Tin:  HYt:  IS  ITS  iu:l  \tios  to  hhskral  diseases.     «i7 


cliaiaclcrislic  Www  of  tin-  "I'tic  i»i'rv<-  anil  retina.  I'.ithiT  dnriii); 
or  after  tlie  attack  w--  may  liave  retro!,  illiar  neuritis,  followed 
ill  some  instanci-s  hy  atrophy:  and  neuroretinitis  with  macular 
li(  iiinrrhane  has  lieeii  reiiorted,  as  have  also  cases  of  amaurosis  and 
hriiiianopsia,  ap|iarently  due  to  cortical  disease. 

T'liilni^  jcrrr  is  known  sometimes  to  cause  catarrhal  conjunctivitis, 
iiillammation  of  the  rveal  tia<-t,  and  oth<r  lesions  similar  to  th.x- 
,.i.-.(  ived  in  typhoid  fever,  hut   few  instances  of  such  complications 

1ki\c  liei'll  ]iul)lislied. 

Tfii'liKs  nri(rri'i,.<  or  rilniisiini  frnr,  like  typhoi<l  and  olher  fevers, 
(MUses   more  or  less  catarrhal    conjunct ivitis,  and    may  he  .•iccom- 
paiiied  hv  phlvctenular  conjunctivitis  and  keratitis.     It   lead-  also 
lu  def^r'nerat'ou  .and  wi-akness  of  the  nnis.  iilar  system,  which  result 
in   accommodiuive  .■'iii    muscular  asthenopia,  especially    noticeahlo 
durinj:  convalescence.       Directly  or  iitdirecliy.   the   poison    of    this 
irver^may   so    alfecl    the   vi.-ual    centres,    the    tract,   or    the   optic 
mrve.  a<    to    cause    temp.rary  or   per!iiaiieni    hiindne-s;    hut    this 
i~    of    rare    occurrence    when    compared    wiiii    the    le-ions    of    the 
uveal   tract  which  often   make   their  ap|)e;irance   as  la!i'  manitVsta- 
lions  or,  more  properly,  as  .se(|uehe  of  lyphus  recurrL'ii.s.  _  A  ditfuse 
iiillammalit.n    of    the    uvea,    and    especially   of    th.'  ciliary    hody, 
varying    in    intensity    from    little    more    than    a    mild  hypera'tiiia 
i(.  an  active  purulent  cyclitis.  may  he  found,  and  tiiis  complication 
in:iv  result  in  only  a  slight  clouding  of  the  anterior  portion  of  the 
Mireous.  which  will  clear  away  comi)l«'tely  in  the  course  of  a  h-w 
weeks,  or  it  may  lead  to  an  active  choroiditis  anil  retinitis,  with  puru- 
hnt   inhltration"  of  the  vitreous  and  suhsequent  phthisis  liull)i.     It 
nv.|iientlv  assumes  the  form  of  an  anterior  uveitis  (serous  iritisi, 
111  1  sometimes  is  accompanied  hy  hypopyon.     <  >ne  or  both  eyes  niay 
..■   iffected,  .and  while  its  occurrence  as  a  complication  is  not  iioces- 
irily  dependent   ui'oii  the  severity  of  the  general  di^easi-,  ocular 
ie-o'iis  are  of  far  more  frociuont  occurrence  in  some  e])iilcmics  than  in 
ethers, 

Kiiies,  who  has  written  quite  fully  on  this  sul)ject,  [.omts  out  the 

'    IV  import.iiit   fact  that   analogous  clianges  jinihahly  take  i)lace  in 

he  pia  mater,  hut  those  appearing  in  the  uveal  tract,  owing  to  its  inti- 

!i  .i|.'  lel.ition  with  the  retina  .ind  vitreous,  are  much  more  apparent, 

W  liile  occlusion  of  the  pupil  hy  the  exudate  from  the  ciliary  lM)dy 

iihl  in- and  den-i  upacitie- of  thV  vitreous,  oi  even  secondary  detuch- 

Ill  ,,r  the  retina,  may  re-ult  in  severe  eases  and  lead  to  blindness, 

■'le  prognosis  is  not  generally  utifavoraiiie,  as  'lu'  ring  of  faint  vitreous 

iMiities  is.  in  a  large  proportion  of  cases,  sulii^  'ciitly  ai)sorl)ed  to 

■iiiiit  of  good  vision. 

Miiliu-nt  may  modily  various  disi-is-s  of  the  eyes  which  are  due  to 

■  ihi'r  causes  and  giv"-  a  p-ri  idicity  ti)  their  manifestations  whic!i 

.Ids  to  111"  action  of  quinine,     [t  may  produ'"  disease-  of  other 

ri,',iiis  wiiich  indirectly  affect  till   eye-,  or  it  may  ho  the  directcau.se 

!   di-;'ase  of  the  eves. 


1 1" 


HI 

1 } ' 


lii 


i; 


i 


g 


<{I8 


J  III.  j:i  /:. 


l*cTi,Mli<-  iii«(iiiiaal  M-'iiral;;iu,  p  arnillynf  the  siipra-urhital  liraiich, 
i>  '|i  ■•'•  <'"iiiiiinii.  aii.l  .M-,  .i,i,,ii.illy  inic  ciliarv  ii.MiraIi;ia  i-.  .Im-  I,,  llii.^ 

caii-c. 

(   'iijuncMviiis  an. I  |.laMic  iritis  havi-  Ix't-u  ilc  ■  ■  '  i',|.  hut  ari'  rare, 

Wliilr     k.-|;,!iti,     is     ,,|-    .otupaMtiwIv     ilv. |ll.-lll     .  .     ill'lvilc,.        \..||rn- 

paralylic   :,>A   nil.T,|iii;  '    k.Talilis  arc  scfii   at    liii.o     !.m,    ,.,    „„„.,, 

!""""."""  '"'"'  '■■  "li'  :   '-    ''11 1  .l.'ii.lritio  k.'ralilis.  w|,i-h  prcsnilv 

itsi-ll  as  a  MiiM-rticial  iiililtralic.n  with  iiarr-' v  irrrj;iiiar  >lr.'aks 
ra.lialirii.'  Irm,,  it,  soturtiiiii-  a-iin.iii>r  lli."  jnriii  „i  a  s..r|.i.n,„',„s 
Hirer.  Ulirli  l|,|s  |,,rir  ..t  ...rural  illtiltralioll  is  IuuimI  ;,>-c„i  ilr.l 
with  trn,lrr..rs,s  HI,  |.rr»u.r  .,vrr  tl,r  sii|,ra-url.ital  tirrvs,  nuii.i;i<. 
HI  hill  ilos.s  is  ii„l„;,lr,|,  in  a.|.iili,,i,  t(.  siirh  ..thcr  h.ral  aii.l  Kriirral 
tn'aim.'iit  a-<  ip  iv  !..•  luiin.i  a|.|.r,.pria<r.  l|,i,,rti<-  coriiral  r-ii|.tiuiis 
arr  aIsM  <.itn<.|i,M,w  srrii  alirr  |.r<)l..iif;r,l  attacks  of  malarial  Icvrr 

Muscular  paralysis  has  ranly  |,r,.|i  tM,tr,|.  au-l  trmpnrarv  aii.i  rvrn 
pcrniaiicnf  ainl.jyupia  aihl  aiiiaiiruM-.  arc  „(  i,„|  vcrv  ■iiilfrnii,.|it 
occiirrci.c.-.  Ihr  ainl.|y,>pia  may  i.r  arr„i>ipaMir,|  |,v  ,;•„!, -mata  ..r 
cyt<trarltnll  n|    ihr  prriph.Ty  „i  thr   visual   lirl.l.       I'rrmailct.t   (IcIVcK 

<'l  the  vi-.ual  hrM  arr  ,!,|c  U,  partial  atruphv  of  th.'  optic  iktvi-   ati.l 
occur  imly  m  ihr  morr  srvrrc  cases  of  malarial  |.oisoiiiiij;. 

As  Kiiirs  has  poititr.l  out,  a  hirjj;.-  proportion  of  r ^rs'^of  malarial 
iiml)lyopi.i  ,111.1  amaurosis  arr  prol.ahlv  ..f  .•riitn,!  j.^i,,  .„i,|  when 
OccuiTMlj;  at  tl,..  o„.s,.t  of  tl„.  attack  he  co„si.|,,s  thrui  to  h-  thr 
rrsult  ..f  pt..in,am.-pois,.i,ii,}:.  .\  f,.w  i„staiir.s  of  malarial  hrmian- 
oi.sia  havr  I,  „  n.p..rt.Ml.  T..rporof  thr  rrtina  .•im.,ui.tiiifr  t..  iii.rht 
l.lm.liirss  occurs  (lot  mfiv,|uci.ily  iu  chronic  malarial  poisonii..-  fm.l 
Haas  has  ol.scrv.i  a  cas..  of  hluc  visi..i,  apprarii.j;  with  a  n-uulir 
prrio,!.,  ity,  with  ..th.r  ovi.lciiccs  of  iiifrmittcnt  frvr  au.l  .lis^o,. 
pcaniiK  .ait.'r  thr  a.lmiiistrati.m  of  <|uiiiiii.'.  ' 

The  pr.,!rn,,>is  ,,f  ,n;,larial  aml.ly.ipia  ati.i  amaur-.sis 'is  cf-ncrillv 
not  v.Tv  irravr,  ali!,.,uuh  in  rare  instanc...  serious  ,1,-fccts  of  vision 
may  na.i.m.  My  inr  thr  most  imp..rlant  h'sions  rrsultiuR  from 
nialaiial  mt.rtion  app,.,,r  m  thr  uvral  tract,  n-tina,  an.l  optic  nerve 
(.i-av.'  cas.'s  .,1   malarial   p.,is.,iiiiijr  arc  son„.titnrs  accompatiir.l  hv 

mtra-ocularl„.m..rrli.i!:es\vhi.htnayappearattl uset  of  the  .lis,,,s; 

Mit  ar.'  moiv  .•,,,,Hn,,u  it>  tl,.-  lat.T  sta..:.s:  au.l  l>,.nc..t  has  estal.lishci 
tl.r    act  that  tiie  accomp,auyin^r  ehaiijr,.s  in  the  choroi.l  an.l  retina 

•"'■  ''"'■  !"  <'''^"'icti.,M  of  thr  c: larirs  an.l  smalirr  ves.sels  l.v  i.iir- 

■"•■>it  tiak.'s  an.  oth.r  ahnormal  eLmietits  in  the  l.loo.l.  Me  f..un.| 
.m  aut..psy  •■,,., Irma.  h.in..rrhajr.'>.  I.'si.,ns  „f  th.-  walls  of  tli.'  v.'s.cl-. 
an.l  thr.„„l,..s,s  ,.,,.i  stnall  inllan.matorv  fori  with  an.l  without  pi.- 

Thr  "iircus  opaciti.w.  ..xu.lativ  retinitis  an.l  c!,..roi.litis  an.l 
hemor,  ha-.' or  .Au.latiot.  int..  il„  ,,,,tic  n.Tv..  mav  r.sult  iti  seri,„,s 
•1^  t..<.ts  ot  visi.,n,  hut  f,.rt.mat..|y  s„rh  r,-,;h.  ar-  ..f  infrciuent  occur- 
rence, ' 

Injhionza.  whi.'h  mav  h,.  an  imp.  vumi  f.-ctor  in  ti,e  causation  ..f 
.lis.-ases  .,f  alm,,s!  ,.v..,v  .„•-„,  in  t|.,    h.,.ly,  makes  no  e-'eptior,  of 


TUK  KYK  I.\  JTS  IIKLATIOS  To  HESEIt.lL  DISEASES       ,jij, 


ilic  f'vc;  Itiil  wliilf  ill  its  iTnilif  cmirsc  it  niMy  pnnlncr  an  tiliiutst 
inliiiiti'  varii'ty  i>f  ryi'  ^ymiildiii',  tlnTi-  is  liiilc  iiiiil'nrmily  in  tlicir 
•liaraclcr.  ami  U'W  nf  tlirni  a|iiH':ir  wilii  ^w\\  tictnifn<y  as  to  make 


ilicni  txpical  inaiiilrstati<iti>-  uf  this  disfasc 
ill 


i|  |iliiiti 


('iiiijiiiictival  li,\'|i<  lairna,  with  iiinri'  nr  less  lacryiiiatKni  am 

|ili<>liia,  is  (if  rxtrfiiicly  tfciiiicnt  ncciirrciicf  as  an  early  niaiiilisiatiun, 

and,  <'s|M-cially  when  tin-  lia^al  iniiciiiis  incnililaiii'  is  acti\''iy  iiivcihcd, 

M'   may   have  an   a:aitc  catarrlial   or  iiiiicciptirnlciil    i-iuijiiiictivitis. 


I'l 


'•-existing;  ciinjiinciiv  itis  in  its  varnnis  lornis  is  apt  ti>  ni'  acirra- 


vatctl,  u'ljcnia  nl  the  cnnjunctiNa  may  !"•  |irrsciit.  aiiil  sniiictimfs 
we  have  a  niimlicr  of  minute  extra  vasal  inns  nf  hlood  intn  the  con- 
jniictiva  as  a  re>iilt  of  the  attaeks  nf  severe  (•iinjriiinfr. 

(ICdenia  nf  the  ii|)|)er  lid-  is  sumetiines  iireseni  in  the  |ieriud  (if 
eiinvalescence,  and  rarely  intlammalimi  (if  the  lacrymal  fjlaiid  has 

lieeli   kiKiWn   til  de\('l(ip. 

A  deep  aliscess  (if  the  lids  is  seen  at  limes  ;is  a  late  inanifestatinn, 
and  has  lieeii  atlriluiieil  tu  inxdivement  of  the  frontal  ^imis;  and 
Imrdcdla  are  of  not  infr((|iient  (lectirrence.  while  enilmlie  nrliital  swp- 
pnratidii  has  lieen  recd^nizeil  in  rare  cases. 

Dacrvdcyslitis  is  apt  td  develop  if  a  stenosis  has  already  existed. 

I'aresis  df  aecdiiiniddatidn  as  a  se(|uela  nf  inlhienza  is  not  very 
luieommon,  Imt  true  paralysis  is  rare,  and  nuclear  or  peripheral 
paralysis  df  the  extrinsic  ocular  muscles,  allhouftli  sdinetimes  seen, 
is  df  very  iiifre(|uent  dccurrence.  resulting;  in  trdpia  orjitosis.  Hle|ih- 
aii /s]ia.sm  is  found  iiKire  fre(|uenlly.  The  iienraljric  pain  and  ten- 
derness of  till"  <'ye  and  its  surrmindinjis  are  proli.-ilily  due  in  lar>;i! 
part,  as  Knies  lias  suf;j;'''^t''<l-  t"  i'  '"W  form  of  orhital  periostitis, 
resultinji  from  disease  of  the  mucous  lining;  of  the  frontal  sinus  and 
other  periorbital  cavities. 

Phlyctenular  keratitis,  at  times  associated  with  phlyctenular  ron- 
junctivitis.  has  occasion.ally  Im-cii  reported:  and  alsd  iiiinctatesuper- 
ticial  keratitis  and  herpes  df  the  lid  .■iiid  cornea,  in  the  latter  situation 
Sdinetimes  a.ssuiniiis  the  form  to  which  the  term  dendritic  has  lieeii 


ipi 


ilied. 


Varidiis  affections  of  the  uveal  tnict  have  lieen  reported,  althoiisili 
il  is  not  so  fre(|ii<'ntly  involved  as  we  would  exjiect  when  we  remeni- 
lier  how  often  influenza  occurs  in  those  of  such  ap"  us  to  have  vul- 
neralile  lildodvssels. 

.I'.idjliiiK  liy  his  persdn:'!  experirtu"',  the  autliiir  Wduld  say  that  ;i 
low  jrrade  of  hytilitis  is  the  most  fre(|uent  iii;inifest;ition  of  involve- 
t  of  the  uveal  tract  as  a  s''i|url;i  of  itiflueii!!;i,  altliouftli  liyperinnia 


men 


if  the 


plastic  iritis,  omholic  liilocyclitis.  purulent  uveitis  with 


lypojiyon.  and  even  paiiophtl 


lann 


tis.  h 


lave  iM-en  n 


ported,  and  cases 


ve  heen  descrilied  which  result(>d  in  thi>  development  of  !i  purulent 


lenomlis 


Non-se|itic  einhdlism  of  the  central  retinal  artery  has  lu-en  reported 
in  ;i  lew  cases,  hut  in  so  rare  a  complication  we  slioutd  hear  in  mind 
the  possibility  of  a  coincident  cau.se.    Although  not  of  fre(iuent  occur- 


MICROCOPY    RESOLUTION    TEST   CHART 

ANSI  ond  ISO  TfST  CHART  No    2! 


1.0 


I  2.8 


12.5 


Si    ^        ^ 

r_   la     112.2 


I.I 


■-         ■■■■ 


2.0 


1.8 


1.25 


1.4 


1.6 


.=     APPLIED  ItVHGE     Inc 


G20 


THE  EYE. 


'W 

i    ! 


iviii-c,  :i  imiiihcr  (if  instaiicos  of  o)  w  neuritis  li;ivc  he('i\  recorded, 
sdiiie  n'sultiiifi  ill  pailiai.  and  otiieis  in  cdniplete  atropiiy  of  tiie  optic 
nTve:  and  B.T<;er  menlions  several  cases  of  temporary  amaurosis 
wliieh  were  proliahly  due  to  tlie  toxic  effect  of  tiie  ptomaines  devel- 
oped diirinj;  an  attactc  of  inllueiiza. 

(ilaucoma  lias  been  known  to  l)e  p.recipitated  liy  an  attaci<  of  iii- 
lluenza,  i)Ut  it  is  prol)al)le  tliat  defective  bloodvessels  and  other 
nnravorai)le  condition^  contributed  to  this  result. 

Wliniipiirl-c'iiifili.  (\injuiictival  iiije('tions,  photophol)ia,  and  lacry- 
niatiiiii  are  not  iincominon  in  the  early  stages  of  pertussis,  and  phlyc- 
tenular disi-ase  of  the  conjunctiva  and  cornea,  sometimes  occurs  as  a 

sei|iii'la.  .     .  . 

But  while  we  occasionally  meet  with  evidences  of  disease  ni  the 
eyes  which  may  be  -^aid  to  result  from  indirect  action  of  the  in- 
fective agiMit,  i)V  far  the  larp;er  proportion  of  the  ocular  mani- 
festations are  of" purely  mechanical  origin,  and  result  from  the  in- 
creaseil  iiilravascular  tension  due  to  the  si)asinoiiic  cough.  Hemor- 
rhages in  the  con,iuiictiva  and  lids  are  absorbed  within  a  few  weeks, 
leaving  no  trace,  ami  small  hemorrhages  in  the  orbit  may  escape 
notice? while  large  ones,  which  fortunately  are  rare,  may  cause  e.voph- 
thalmos. 

I'aralysis  of  the  ocular  mr.sc!'.  s  may  occur,  with  couseiiueut  stra- 
bismus or  jitosis.  and  is  due  to  hemorrhages. 

Convergent  siiiiint.  the  earliest  aiipearauce  of  which  so  frequently 
follows  the  various  infectious  dise-ises  of  childhood,  seems  to  occur 
with  great  frequency  after  whooping-cough,  though  it  is  seldom  due 
to  paralysis,  and  is"  associated  usually  with,  and  in  a  large  niea.sure 
depi  ndent  upon,  hyi)ermetroi)ia. 

Mkidjix.  In  adilitiou  to  o'di'ma  of  the  lids,  conjunctivitis,  kera- 
titis, and  rarely  iritis,  mumps  may,  like  other  infectious  (Mseases. 
occasionally  be  the  cause  of  serious  congestion  or  even  iiiflaii'matioii 
of  the  optic  nerve  and  retina,  or  primary  optic  nerve  atrophy.  Par(>sis 
of  the  ocular  muscles  and  of  accommodation  may  result,  and  metas- 
tatic iriilocvclitis  has  been  reported. 

Liki'  the  testiel(>,  the  lacrvinal  gland  may  be  the  seat  of  an  inflani- 
malioii  ajiparently  due  to  the  same  -ources  of  mfection  as  that  which 
produces  the  parotitis,  or  at  least  secondary  to  inliammation  of  the 
parotid  gland. 

('Iinhrii.  With  the  sudden  onsi-t  of  emaciation  and  great  lo.ss  (li 
blood  serum  which  are  characteristic  of  it.  cholera  produces  a  striking 
•iiaiige  in  the  expression  of  the  eyes,  and  often  is  accomiianied  by 
pn.founil  lesions  in  the  deeper  structures  which,  to  a  limited  degree, 
m:iy  be  seen  in  severe  ca-^es  ,,f  other  forms  <if  diseas"  of  the  gastro 
inti'siinnl  tract,  -udi  as  choleni  inf.uitum  ami  ordinary  choli-ra  nmr- 
biis.  The  cyanosis  ami  shrinking  of  the  eyeballs  into  the  orbit,  with 
shrink.ige  of  the  lids  due  to  tibsorp'ion  of  fluid,  and  the  weakness 
ot  the  orbicularis  palpebrarum  muscle,  uilh  il>  resulting  inipirfect 
closure  nf  the  palpebral  fissure,  give  to  these  cases  a  most  striking 


rut:  EYE  IS  ITS  RELATIOS  TO  OESEIiAl.  DISEASEX.       G21 


ami  alarmiiijj;  ("xprcssio-.  Tlicrc  is  a  lack  of  secrotum,  result iu«  in 
<;r('at  drviicss  of  tlir  coiijuiictiva  and  cornea,  and  it  is  said  liiat 
niMllicr  tlic  fircat  pain  imr  the  i-ontact  of  irritatin;^  suiistanccs  is 
sntlicicnt  to  provoke  laeryniation. 

Wliile  by  a  great  effort  tlie  i)atient  can  elose  the  lids,  they  habitually 
remain  i)artially  open,  exposing  thi'  inferior  bulbar  eonjunetiva  and 
lower  i)ortioii  (if  the  a|)turned  eornea,  which  often  beconies  the  seat 
of  an  111 -IT  and,  if  the  patient  recovers,  of  a  leucoina.  The exposed 
conjunctiva  niav  be  merely  injected  or  in  more  severe  cases  inHained 
and  xerotic.  A  peculiar  "form  of  irregular  grayish  patches,  some- 
times isolated  and  sometimes  conHuent,  is  seen  about  the  corneal 
border  in  severe  cases.  They  are  attributed  by  Knies  to  choi(ii<lal 
hemorrhages  shining  through  the  thinned  sclera,  and  are  of  grave 
prognostic  significance,  as  are  also  the  spontaneous  hemorrhages 
which  at  tinu's  ai)iiear  beneath  the  conjunctiva. 

.Myosis  seems  mor"  common  than  mydriasis,  thougii  the  latter  is 
sometimes  observed.  Active  reaction  to  light  is  a  favorable  prog- 
nostic sign,  while  even  in  apparently  mild  ca.ses  innnovalile  pupils 
almost  certainlv  indicate  a  fatal  termination.  Owing  to  the  weakness 
of  the  cardiac  imisrle  and  the  marked  lowering  of  the  general  intra- 
vascular |)ressure  when  the  disease  is  in  the  algid  stage,  great  varia- 
tions in  the  appearance  of  the  fundus  are  to  be  noted  on  light  digital 
press\n-e  <luring  an  oi)hthalmoscopic  examination.  An  interrui)tion 
,,f  the  blood  current  and  intermittent  circulation  is  someliin.'<  ob- 
served res(>ml)ling  that  which  accompanies  restoration  of  the  .  rmal 
movemiMit  after  an  einlxilism  of  the  central  retinal  artery  has  been 
displaced. 

Ydloir  Fever.  While  many  cases  of  yellow  fever  exhibit  no  char- 
acteristic eye  lesions,  we  may  have  intra-ocular  hemorrhage  with  its 
serious  consefiuenct-s  in  unpaired  vision,  or  ura'inic  amaurosis  asso- 
ciated with  cerebral  symptoms,  and  in  either  case  the  prognosis  is 

"■I'.'IX'C. 

""  S!ii)!iilis  in  all  of  its  stages  may  atTect  the  eyes,  and  while  the 
course  it  jnirsues  in  this  organ  depends  much  upon  the  virulence  and 
the  stage  of  the  general  infective  process  at  the  time  the  eye  is  in- 
volved, and  upon  the  part  affected,  no  portion  entirely  escapes  its 
ravages,  although  the  uveal  tract,  because  of  its  great  vascularity, 
sei'ins  to  be  its  more  usual  jjoint  of  selection  in  the  ac((uired  form, 
.•md  iritis,  eyclitis,  choroiditis',  and  hyalitis  are  its  more  common 
ocular  manifi'stations. 

Sy])hilis  does  not  very  frecjuently  pmihice  absolute  loss  of  sight, 
Mangus  having  found  2.2  per  cent,  of  blindness  (hie  to  this  cause;  but, 
especially  in  large  cities,  where  syphilis  is  more  or  less  common,  it 
is  a  freciuent  cause  of  marked  impairment  of  vision.  Alexander,  from 
,1  studv  of  the  statistics  of  eight  (Jerman  oi)hthalmological  clinics, 
has  estimated  that  L'.K)  per  cent,  of  diseases  of  the  eye  are  the  result 
,..f  svpliilis  This  would  probably  ho  a  high  estimate  if  it  applied  to 
botii  hospital  and  private  practice,  at  least  in  America. 


(i2-2 


Tin:  i:yi:. 


Our  attention  will  iirst  1)0  diir.-tcl  to  acMjuircd  syphilis  m  its  varicms 
forms,  the  suhjirt  of  conf^fiiital  or  liciv.litary  sypliilis  hciiif;  consid- 
ered later. 

The  initial  lesion  may  be  fonnd  uiion  some  portion  ot  the  eye  or 
its  appi-iidaires.and,  if  we  except  the  <;enital  orfians  and  tiie  mouth, 
this  is  relaiivelv  a  frciiuent  iioiut  of  jjrimary  infection.  Hard 
ciiancres  have  Ikhmi  foimd  upon  the  lids,  especially  at  the  fre(>  maifini 
whi-re  the  cutaneous  and  mucous  surfaces  join,  upon  the  iialjiehral 
conjunctiva,  the  plica  semilunaris,  the  caruncle,  in  the  retrotarsal 
fujiis.  very  rarelv  upon  the  bulbar  coiijum  liva,  and  even  upon  the 
corne  the  most  common  locations  seem  to  1k'  the  caruncle  and 
free  margin  at  tiie  inner  canthus  and  along  the  lower  lid.  Infection 
may  l>e  tlie  result  of  a  kiss  from  an  individual  with  a  mucous  patch 
on  "the  mouth,  or  from  contact  of  infected  fingers.  Instances 
liave  been  recorded  ill  which  attendants  and  physicians  were 
infected  in  tlie  latter  manner  while  treating  syi)hilitic  patient.'^.  The 
characteristic  hard  sore  (level  -,  first  jiresenting  the  ai)i)earancc  of 
a  pimple,  which  later  breaks  wn  into  a  sliallow  ulcer  with  rounded 
edges  and  an  indurated  liase.  Th;'  enlargement  of  the  lymphatic 
glmids  :it  the  angle  of  tlie  jaw  and  in  front  of  the  ear,  which  is 
([uite  diaracteristic  and  sometimes  extensive,  should  aid  in  distin- 
guishing a  chancre  from  simple  ulcerations  due  to  other  causes. 
Though  recovery  mav  be  (|uite  complete,  the  induration  often  con- 
tinues for  nianv  niuiiths,  which  is  ajit  to  be  mislead  ng,  unless  the 
ca.se  is  carefully  observed.  Hard  chancre  of  the  lids  may  b(>  confused 
witii  epitlieliai  cancer,  and  chancroid  may  be  found  in  the  same 
locations,  making  it  necessary  at  times  to  await  the  dcvelopniont  of 
secoiidarv  manifestations  to  determine  the  cause. 

Secondary  manifi'stations  in  the  form  of  roseola  or  acne-like 
eruptions  liiav  aflect  the  skin  of  the  lids  and  cause  loss  of  the 
lashes,  and  characteristic  ulcerations  of  the  tertiary  .stage  nun- 
appear  later. 

Rarely  there  are  mucous  patclies  on  the  pali)ebral  and  even  upon 
the  bulbar  conjunctiva,  and  gummy  tumors  of  the  ocular  conjunc- 
tiva have  been  seen,  ile  Schweinitz  mentions  an  inflammation  of 
the  conjunctiva  assuming  the  form  of  a  catarrhal  conjunctivitis  (ir 
fc.Uicular  trachoma,  develojiiiig  "in  an  •Muemic  and  rather  colloid- 
looking  conjunctiva,"  which  yielded  only  to  antisypliilitic  treat- 
ment. 

.\n  interstitial  or  gummatous  inflammation  of  the  lacrymal  gland 
has  been  seen  in  rare  instances,  and  syphilitic  disease  of  the  perios- 
teum and  secondarily  of  the  bony  walls  and  orbital  c(mtents  is  of 
relatively  frei|uent  occurrence,  causing  protrusion  or  fixation  of  the 
globe  and  'ill  of  the  evidences  of  exudative  disease  or  tumor  in  this 
region,  sometimes  going  on  to  sujipuration  .and  the  formation  of 
fi.'^t.uhe. 

A  careful  stmly  of  the  history  and  other  manifestations  of  svjihihs 
is  necessary  to  determine  the  true  nature  of  sucii  cases,  and  a  po.sitive 


rilK  EYE  IS  ITS  UELATIOS  TO  HESERAL  DISEASES.      62:3 

iliiilliiosis  is  sonictiini's  made  only  after  tin-  syinptonis  liavc  yielded  to 
alterative  treatment. 

>y|ihilitic  disease  of  i  nose  not  infre(|uently  li'ads  to  disease 
(if  the  inneous  linin<;.  periosteutn,  and  Ixmy  walls  of  the  lacryinal 
liassap';*.  liroduein};;  dacryocystitis,  and  later  firm  stenosis  or  hony 
ufclusioii. 

The  uveal  tract,  as  has  been  stated,  is  the  point  of  selection 
lor  syi)hilis  of  the  eye,  especially  in  the  seeonchiry  stafi'".  and.  owinji 
III  the  inthnate  relation  of  the  choroid  and  retina,  and  the  deix'ii- 
dence  of  the  vitremis  humor  upon  the  uveal  tract  for  its  nutrition, 
we  are  apt  to  find  an  extensive  inilammat ion  of  one  luirtion.  inyolv- 
\n<i  the  others  to  a  j;reater  or  less  dcfiree.  This  is  more  especially 
true  of  chronic  disea.ses,  in  which  prolonfjed  impairment  of  nutrition 
plays  an  important  i)art :  but  it  is  jirobable  that  the  ditTerence  is 
only  one  of  defrree,  and  even  in  an  acute  i)lastic  iritis  wo  have,  to 
-lime  exte'.ii,  a  secondary  involvement  of  the  whole  uveal  trad  and 
incipient  chanjies  in  the  retina  and  vitreous. 

Triedenwald'  has  demonstratf^l  that  in  every  case  of  iritis  a  prop- 
erly conducted  examination  will  reveal  deposits  upon  Descemet's 
iiK^mbrane,  which  is  the  only  j)art  of  the  uveal  tract,  in  addition  to 
die  iris,  in  which  .such  an  investigation  can  be  satisfactorily  made 
duiing  the  active  stage  of  iritis. 

Plastic  iritis  as  an  early  manifestation  of  general  syphilis  com- 
monly makes  its  appearance  between  the  second  and  ninth  month 
after  the  initial  lesion,  though  it  may  appear  many  months  later. 
Hoth  eyes  may  be  attacked  simultaneously,  though  it  often  liai)pens 
iliat    pVomjit    and    vigorous    treatment    will    jirevent    involyenient 
(if  the  second  eve.     Authorities  differ  as  to  the  fretjuency  of  iritis  in 
-yphilis,  some  placing  it  as  low  as  0.42,  while  others  state  that  5.37 
|ier  cent,  of  sv])hilitic  patients  have  iritis.     Alexander,  who  has  made 
all  extensive"researcli  into  the  statistics-,  of  sy])hilis,  i)laces  the  pro- 
portion of  cii.ses  of  iritis  in  which  syiihilis  can  be  assigned  as  the  can.sf 
It  from  ;«)  to  m  per  cent.     Simple,  plastic  iritis  of  syphilitic  origin 
!.as  no  characti'ristics  which  of  them.selves  prove  its  etiology,  and  the 
iamiosis  of  syiihilis  nnist  be  ba,se<l  upon  other  evidence:  but  in  a 
rtain  proportion  of  cases,  variously  estimated  at  b')  to  20  per  cent., 
■\i'  hiive  "iritis   gummosa,   papulosa,   or   condyhimatosa,   which   is 
illicientlv  tvpic.al  to  afTord  a  fair  basis  for  a  diagnosis."    Often  asso- 
iateil  with  a  small  hypopyon,  we  find  in  these  cases  a  yellow  or  dull 
I ;mge-colored  nodule,  generally  situated  near  the  lower  margin  of 
he  pupil  ami  surrounded  by  a  narrow  zone  of  red.     In  the  later 
asres  of  severe  svphilitic  infection,  we  sometimes  hav(>  large  giuniiiy 
;mors,  almost   tilling  the  anterior  chamber.     With  the  exception 
the  cryst:  Mine  lens,  any  ])ortion  of  the  eye  may  bo  the  seat  of  a 
philitic  \i->.  .;.  taking  tlie  form  of  a  gumma  or  interstitial  inflam- 
lation  accompanied  by  atheromatous  thickening  of  the  intima  of 


'  Arch.  ilOiihtalmiil.,  vol.  xxv.  p.  191. 


624 


77/ A'  /.TA'. 


i 


the  l)l<H)(lvcss(<ls,  vvhicli  rUm  ivsults  in  occlusion:  and  as  those  vas- 
cular lesions  .In  not  entirely  (lisai)|)ear  un.ler  treatment,  tl.<-y  some- 
times lea.l  in  the  eve,  as  they  .lo  in  the  hrain,  t..  the  nni.ancl  nutri- 
tion, h.'inorrhases.'etc,  whidi  account  for  many  ot  the  m.lirect  late 
manit'estations  of  .syphilis.  . 

It  is  of  "i-eat  imi-ortance  to  hear  in  muul  that  antisyi.iuhtic  treat- 
ment can  have  little  elTect  upon  such  late  lesions,  and  it  l)y  no  means 
follows  that  a  lesi<.n  of  lonj;  standing  is  not  of  syphilitic  on^'in  because 
it  fails  to  respond  to  aiitisvi)hilitic  treatment,  .\nterior  uveitis  ol 
the  form  sometimes  si-oken  of  as  serous  iritis  or  descemetitis  may 
l.e  fomid  as  a  result  of  syphilitic  infection  of  an  asthenic  ty|)e,  Dut 
.<ucli  <'ases  are  of  rare  occurrence. 

Svi)hilitic  cvditis  and  choroiditis  of  almost  every  decree  of  seven  y 
npp'ear  with  relative  fre-iuency,  and  the  latter  is  associat.;d  usually 
with  r  Mnitis  and  hvalitis.     While  a  lar^c  proportion  ol  ca-  -^  ol 
choroiunis  have  their  orifjin  in  syphilis,  it  is  the  opinion  ot  the  writer 
tint  thi'  t(>xt-l>ooks  on  ophlhalmolofiy  have  pven  undue  weifilit  to 
this  disease  as  an  etiological  factor;  and  thoufih  stress  has  heeii  laul 
upon  n'l-tain  ''laracteristics  as  in.licatinfi  such  a  caus(-,  there  are  no 
infallil)le  ophthalmoscopic  app.-arances  which,  t.iken  alone,  will  war- 
rant a  diaiinosis  of  svphilis.     In  deference  to  the  opinion  of  some 
lii-h   authorities,   it   should,  how.'ver,  he  stated  that   d.^    •miuate.l 
choroiditis,  and  especiallv  svmmetrical  choroiditis  areolata,  and  the 
,-xisteiKv  of  large  (luantiiies  oi"  line,  dust-like  vuivous  opacitu's    are 
„f  not  infre(iuent  occurrence,  an.  1  are  by  many  reffir.led  as  pathog- 
nomonic of  syphilis.  .     ,    ,  i  „ 
lutlammation  of  the  clioroi.l,  which  may  he  .hssemmate.l ..!  areolar 
ill  tvi).-   is  s.)in.-tinies  mil.l,  hut  more  fre.iuently  severe  m  character 
W  h.'r.  it  apiH'ars  in  tli.>  earlier  stag.-s  .)f  the  infection  an. I  is  treate.l 
un.miitlv  an.l  thoroughlv.  svi>hititic  chor.nditis  often  yiel.ls  readily; 
l)Ut    as  "in  other  structures,  in  the  later  stages  of  the  .liseasc,  when 
extensive  changes  havt>  taken  place  in  the  vessel  walls,  wo  cannot 
expi'ct  prompt  responso  t.)  alterative^  treatment,  however  active  it 

'"'in  ass,)ciati.)n  with  svphilitic  cvclilis  and  iritis,  syphilitic  choroid- 
itis ii,,t  infre.iu.iitly  results  m  entire  l.-ss  of  sight,  .letachment  of  the 
retina   s„iteinng,  and  phthisis  bullii.     It  is  alm.ist  invariably  accom- 
pani.-.i  bv  more  or  less  extensive  ivtinitis,  an.l  is  i)roi)crly  .l<>signateil 
•IS  ch.)roi.lor<'tinitis.     Unless  the  m.icular  rogi.m  is  involved  or  vit- 
ro.)Us  ..pa.itii's  are  present,  ch.iroi.litis   an.l   cli.)roi.l..rotmitis.  oven 
tliongh  >iuit.>  extensive,  air  apt  t.i  escape  the  attention  of  the  patient; 
but  when  .•eiitnd.  the  earlier  stay:es  are  nianifeste.1  by  a  variety  .>f 
more  or  l.'ss  pronouiKv.l  subjectiw  symi)t.)ms,  .wi.lently  .lue  to  irri- 
tation an.l  .listurbance  .  f  the  outer  layers  of  the  retina  by  the  .lisease.l 
.•li..r.,i.l      l'h..l.. phobia,  sparks  !)ef..r.-  the  eyes,  micropsia,  metam..r- 
,|,„,,v,-i   -abjective  colore.l  vision,  etc..  s'.on  give  j.lace  to  diininish.'.l 
visual  acnitv.  torjuir  of  the  o,..er  layers  of  the  retina,  an.l  often  a 
positive  scotoma,  f.)llowe.l  bv  g.Mieral  cl.ui.Ung  .lue  to  vitreous  dust 


THE  EYE  IS  ITS  RELATIOS  TO  QENERAL  DISEASES.        625 

or  larger  opacities.  As  the  disease  progresses  and  produces  more  and 
more  disturbance  of  the  pigment  ej)ithelium,  we  liave  a  variety  of 
opiithahnoscopic  pictures  of  retinitis,  some  to  a  degree  resembling 
retinitis  pigmentosa,  in  which  at  the  point  of  ailhesion  between  the 
choroid  and  retina  the  pigment  of  the  former  emigrates  into  the 
latter,  some  due  to  areas  of  dense  retinal  opacity,  and  others  in  which 
the  characteristic  specific  exuilation  has  producetl  changes  in  the 
appearance  of  the  retinal  vessels.  The  dast-like  opacities  of  the  vit- 
reous, sometimes  spoken  of  as  pathognomonic  of  syphilis,  the  writer 
has  found  in  many  cases  which  were  undoubtedly  due  to  other  causes. 
While  .sometimes  appearing  as  early  as  six  months  after  the  pri- 
mary infection,  syphilitic  choroidoretinitis  is  asually  a  late  mani- 
testation. 

The  prognosis  as  to  vision  must  depend  largely  upon  the  stage  at 
which  treatment  is  undertaken  and  the  jjart  of  the  retina  ii  volved. 
If  the  macular  region  is  the  seat  of  the  disease,  we  almost  invariably 
iiave  serious  iinj)airment  of  vision. 

The  cornea,  sclera,  and  oculo-orbital  fascia  may  be  the  seat  of 
acquired  syphilis,  but  involvement  of  these  structures  is  of  rare 
uccurrence,  and  is  generally  secondary  to  disea.se  of  other  parts  of 
the  eve. 

.Syphilitic  optic  neuritis,  not  secondary  to  disease  at  the  base  of  the 
i)iaia  or  in  the  other  structures  of  the  eye,  though  of  rare  occurrence, 
has  been  ob.-*erveil,  and  simple  ilouble  atrophy  of  the  optic  nerves  is 
said  to  occur  at  times  unaccompanied  by  spinal  symptoms. 

.\n  almost  infinite  variety  of  lesions  in  the  cortex,  at  the  base,  and, 
indeed,  in  every  [)ortion  of'the  brain,  may  result  from  syphilis,  mani- 
festing themselves  in  the  production  of  cortical  symptoms,  such  as 
licmianopsia,  etc.,  and  by  their  effect  upon  the  optic  nerve  and  retina 
and  the  motor  and  sensory  nerves  of  the  eyes.  This  subject  is  more 
properly  dealt  with  in  the  i<ectio-i  on  disea.ses  of  the  nervous  sy.«tem, 
hut  a  brief  review  will  here  be  given  of  the  mo  >  important  considera- 
tions in  connection  with  svphilitic  i)aralysis  of  t.e  ocular  nniscl(>s. 

The  paralysis  is  usuafly  peripheral.  Th  ■  muscle  itself  may  be 
the  seat  of  the  diseitse,  or" a  gununatous  growth  may  develop  in  the 
iieifrhborhood  of  the  nerve  as  it  piusse^i  through  the  orbit  or  at 
the  base  of  the  brain,  or  a  siiecific  lesion  may  affect  the  nuclei  or 
the  i)oiiit  of  origin  of  the  nerve  in  the  third  or  fourth  ventricle  or  in 
the  a(|U('duct  of  Svlvius. 

According  to  .\lexiinder,  59.4  per  cent,  of  paralyses  of  the  ocular 
imiscles  are  due  to  svphilis.  They  are  usually  late  manifestations, 
rarely  appearing  iluring  the  first  six  months,  and  while  they  may 
ieveiop  rai)idlv  or  come  on  very  gradually,  they  usually  respond  to 
tieatment  nither  slowly  in  those  ca.ses  whicli  prove  to  be  curable. 
Naunvn,  cpiotcd  by  Knies,  reports  70  per  cent,  ^f  recoveries,  but  states 
that  if  improvement  does  not  manifest  itself  within  two  weeks  under 
vigoroas  treatment  there  is  no  hope  of  rei-  vi  i\ .  Other  aiithoiiiies, 
!io\vever,  encourage  perseverance  for  a  nm-  .i  longer  period.     Relapses 

•Itt 


026 


arc  unconimon 

of  lime 


niE  eyl: 


if  tlie  troatment  is  inaintaintMl  for  a  .suffificiit  IciiKtli 


While  ill  soiuo  instances  it  may  be  tiic  first  symptoin  of  sypiiilis, 
and  tiicrt'f<)r(>  of  (^.n'lit  diagnostic  iniportaiicc,  paralysis  of  an  <)cular 
iiuisdc  is  found  more  frcciucntly  in  association  with  other  evidences 
of  this  disease.     AccoidiiiK  to  Kiiies,  the  isolated  paralyses  "are  duo 


either  to  neuritis  and  perineuriti 


f  the  nerve  mots  and  at  the  Ikuso 


)f  the  brain,  or  thev  are  nuclear  in  origin;  other  causes  are  excej^ 


tioiia 


rnil.i 


•al 


ih 


)f  the  b 


dies  of  the  third 


supplying 


nerve 
the  sphincter  of  the  iris  and  the  ciliary  muscle  is  not  unconimon. 
I'aralvsis  of  the  fourth  and  facial  nerves  is  rare,  represent iiij;  about 
1  to  2  yivr  cent,  each  of  all  Ciuses  due  to  syphilis,  while  the  .sixth  is 
affected  in  about  25  per  cent.,  and  the  oculomotor  in  75  per  cent. 
I'aralysis  of  the  fourth  and  seventh  nerves  when  present  is  apt  to  be 
associated  with  paralysis  of  the  third  or  sixth. 

In  considering  the  question  of  the  presence  of  syphilis  in  a  jjiven 
ca.se  of  di.sea.se  of  the  eye,  it  should  b((  remembered  tiiat  we  are  largely 
dependent  upon  collateral  evidence,  as  the  cases  are  very  rare  in 
which  the  ocular  lesions  taken  alone  are  ])athogiiom(mie.  Thera- 
peutic measures  as  a  means  of  diaf^nosis  are  at  times  of  f^reat  value; 
but  while,  on  the  one  hand,  many  non-,syi)hilitic  lesions  are  favorably 
influenced  by  the  use  of  the  so-cajled  alterative  treatment,  it  is  a  well- 
recofjnized  fact,  which  has  already  been  referred  to.  that  there  are 
certain  late  manifestations  or  results  of  syjjhilis,  esi)ecially  in  the 
nervous  system  and  eye,  upon  which,  owing  to  sectindary  changes 
in  the  vessel  walls  or  the  non-Vii.scular  nature  of  the  tissues  affected, 
the  iodides  ami  .salts  of  mercury  appear  t(r  exercise  no  influence. 
Patients  whos<'  tissues  have  undergone  such  changes,  though  no 
longer,  properly  speaking,  the  subjects  of  active  syphilis,  may  develop 
erratic  attacks  of  various  forms  of  ocular  paralysis  somewhat  resem- 
bling true  syphilitic  i)araly.sis,  but  more  like  those  seen  in  multiiile 
sclerosis.  These  diymptoms  will  not  yield  to  anti.syphilitic  treat- 
ment. 

Cont/enilal  Suphilis.  Owing  possibly  to  attenuation  of  the  specific 
poison  in  transmission  through  the  tissues  of  the  mother,  or  to  a 
lirocess  of  selection  by  which  only  the  less  s(>ri(ms  cases  survive,  con- 
genital sy],>hilis  is  usually  a  milder  disease  in  its  effects  u|)on  the  eyes 
than  is  the  ac(|uired  form,  and  it  runs  ([uite  a  different  course,  althcmgh 
it  is  often  far  more  obstinate  and  unyielding  to  treatment.  Intra- 
uterine sy])hilis,  on  the  other  hand,  is  said  to  run  its  course  much 
more  rajtidly,  the  f(etus  in  many  instances  dying  of  tertiary  syphilis. 

,\s  in  the  ac(|uired  form,  it  is  the  uveal  tract  that  is  the  point  of 
.selection  in  congenital  sy|>liilis,  and  while  diffuse  interstitial  or  "par- 
eiicliymat(»us"  keratitis  is  its  most  common  and  easily  observed 
manifestation,  this  is  what  has  been  termeil  an  emigration  keratitis, 
and  is  .secondary  to  and  in  association  with  other  lesions  of  the  uveal 
tract. 


nii:  EYE  IS  ITU  UELATloy  TO  OE.\L'KAL  DISEASES.       027 


Clioroiililis  ill  its  viirious  forms,  ami  mild  or  most  sovcrc  plastic 
iritis,  iridocyclitis,  and  iridoclioroiditis  develop  in  some  iristaiici's,  and 
.irc  accomp.uii'  i  oy  softeniiij;  of  the  eyeball. 

As  the  various  structures  of  the  eye  may  he  jirimarily  or  secondarily 
allVcted,  either  in  ulcro  or  in  early  childhood,  it  will  be  readily  under- 
stood that  opacities  of  th.e  cornea,  occlusion  of  the  i)upil,  cataract, 
opacities  of  (he  vitreous,  and  atrophy  of  the  choroid,  retina  and  optic 

ve  are  not   infre<iueiitly  met  with  in  congenital  sy])liilis.     Con- 


ncri 


;;cnital  atro|)hy  of  the  oi)tic  nerve  or  neuritis  is  not  infreciuently  the 
result  of  intra-uterine  meningitis  of  sy])hilitic  orifiin. 

.Vs  in  actjuired  syphilis,  wo  sometimes  find  in  the  congenital  form 
liiat  periostitis  or  caries  of  the  walls  of  the  orbit  leads  to  most  troul)l(  - 
some  sym|)toms,  among  which  persist.-nt  occlusion  of  the  nasal  duct 
is  of  not  infre(|uent  occurrence. 

Paralyses  of  the  ocular  nmsdes  may  also  occur,  but  arc  rare.  By 
tar  the  most  fre(|uent  ocular  manifestation  of  congenital  syphilis, 
;is  has  been  stated  abovi  ,  is  (hffuse  interstitial  keratitis,  and  while 
I  his  may  Iw  due  to  other  causes,  its  presence  should  always  lead  to  a 
caiiful  investigation.  The  evidences  of  the  inheritance  of  a  syphilitic 
taint  are  too  well  known  to  re(|uire  consideration  here;  but  while 
nrtain  Continental  writers  have  been  inclined  to  accejit  with  many 
•  |iialihcations  the  indications  pointed  out  by  Hutchinson  in  the 
peculi.ar  formation  of  the  incisor  teeth,  and  while  other  di.seases 
■  liMibtless  may,  in  rare  instance-,  prodvice  shnilar  changes,  the  writer 
|],is  foutid  them  so  frequently  associated  with  congenital  syphilis 
tlial  when  present  he  regards  them  as  of  the  greatest  diagnostic  value. 

As  in  all  late  manifestations  of  .syj  hilis.  many  of  the  symi)toms  of 
the  hereditary  form  of  the  disease,  esix-cially  those  a]>pearing  after 
re  due  to  secondarv  ch-''    "«    ■>  ot  the  innnediate  result  of 


iiilancv,  a 


the  infection,  and  it  is  a  nustr 
tiratment,  such  as  inav  be  obt 


t  results  from  alterative 
earlier  years  of  ac(|uired 
.1"  of  the  iodides  and  mer- 


ipiiilis.  Too  great  persistence  i. 
uials  ill  such  cases  may  <lo  gred  h..n:!;  but,  on  the  other  hand,  the 
tcr  is  convinced  by  liis  own  expeiience  that  judgment  and  dis- 
nation  should  be  exercised  in  this  as  in  all  (luestions  of  therapeu- 


Al'l 


mill 


iiid  the  above  principle  mu; 


it  not  be  too  slavishlv  adhered  to 


it  not  infre(iuently  hapi)ens  that  brilliant  results  are  obtained  by 
!■  discreet   use  of   these  remedies  even   in   subjects  of  congenital 
philis  who  are  no  longer  young. 
l.iproKji  often  has  a  very  long  period  of  incubation,  and  the  jirimary 


-loll  IS  apt  to  escajie  attention 


It  is  very  prone  to  affect  the  lids 


1  brows;  the  former,  according  to  Lopez,  being  involved  at  some 
line  in  the  course  of  almost  every  case  of  this  disease.  Mkluiul  has 
'aled  that  infection  often  occurs  in  the  conji.nctival  sac  from  the 
I  the  bacilli  of  leprosy,  resembling  those  of  tuber- 


if  t( 


a  IK 


ilosis,  have  been  found  in  the  tears. 

The  eyebrows  and  lids  may  be  the  seat  of  ana'sthetic  patches  or 

idules," which  lead  to  loss  of  the  hair  of  the  brows  and  the  eyelashes, 


.  i 

i  1 


11 


«28 


THE  EYE. 


and  when  ulciTation  takes  place  we  are  apt  to  hav  ectropion  or  en- 
tropion. Lopez  calls  attention  to  the  occurrenn  ot  lagophthahnos 
due  to  involvement  of  the  terminal  motor  nerve  elements  ilistrihuted 
to  the  orbicularis  nmscle. 

In  the  conjunctiva  leprosy  produces  aniesthesia,  followed  liy  chronic 
conjunctivitis:  ami  pterygia  and  tubercles  may  develop,  which  fre- 
(luently  lead  to  keratitis  and  pannus,  especially  of  the  lower  half  of  the 
cornea'.  The  tulx-rcles  of  tli'  conjunctiva  may  terminate  abru])tly  at 
thi"  corneal  margin  and  li'ad  to  secondary  clouding  and  other  degen- 
erative changes,  or  the  deeper  layers  of  the  cornea  may  be  the  seat  of 
the  le[)rous  tubercles.  In  a  later  period  of  the  (hsease  we  may  have 
distinct  involvement  of  the  cornea,  resembling  interstitial  keratitis, 
and  ulcers  are  not  uncommon. 

Involvement  of  the  iris  may  be  secondary  to  keratitis,  but  is  some- 
times an  early  manifestation,  and  may  take  the  form  of  an  acute  iritis 
or  the  develo|)meut  of  grayish  nodules  or  tubercles,  esi)ecially  near 
the  periphery  in  tli  •  lower  half.  If  the  disea.'^e  reaches  the  iris,  we  are 
apt  to  Hud  vitreous  n|)acities,  cyclitis,  and  choroiditis,  with  secondary 
cataract;  and  in  the  late  stages  there  may  also  Im'  involvement  of  the 
choroid  and  retina.  The  progress  of  le])rosy  is  slow,  and  the  fact  that 
small  nodules  in  the  iris  have  been  known  to  disapjH'ar  under  treat- 
ment is  r-ferred  to  by  Knies. 

TuiHTCulosis.  While  primary  tubercular  infection  of  tlie  eye  is 
sometimes  observed,  it  is  of  not  very  frequent  occurrence,  but  second- 
ary involvement  is  far  mon?  connuon. 

Lupus,  which  is  generally  conceded  to  be  of  tul>ercular  origin,  may 
ai)pear  ui)iin  the  lid  as  an  ulcerated  area,  with  red  granular  i)atches, 
and  later  may  extend  to  the  conjunctiva,  and  finally  to  the  eyeball, 
causing  its  destruction.  The  conjunctiva,  if  the  surface  is  broken, 
may  be  the  seal  of  primary  infection.  This,  although  uimsual,  has 
been  well  estaiiiished  in  a  small  number  of  cases.  In  some  instances 
we  iiave  tubei.  ular  infection  of  the  conjunctiva,  which  in  ap]«'arance 
for  a  time  resembles  trachoma,  althcmgh  its  later  course,  the  fact  that 
it  will  not  yield  to  ordinary  treatment,  and  its  frfvpient  association 
with  nasal  and  laryngeal  tuberculosis  will  determine  its  char- 
acter. More  fre(|ucntly  we  find  "caseating"  ulcers  with  irregular 
raised  edges,  sonietimes  covered  with  grayish  nodules,  showing  a 
tendemy  to  slough.  This  m;iy  l)e  associated  with  considerable  swell- 
ih't  of  tiie  lids:  there  is  enlargetneiit  of  the  lymphatic  glands  of  the 
cnrrespondiiig  side,  and  the  patients  are  apt  to  sliow  other  evidences 
of  tuberculosis. 

Tli(>  diagnosis  may  be  made  more  certai..  in-  the  microscoi)ic 
examination  of  small  pieces  of  tissue  or  particles  of  tiie  cheesy  con- 
tents of  the  nodules  or  by  inoculation. 

Tubercles  of  the  iris  containing  the  characteristic  l)acilli,  and  also 
giant  cells,  an-  fwuiiil  riceasionally  a-  an  ai>parei-t!!y  'Titntiry  manifcs- 
tati(m  of  the  disease,  .\ccording  to  Kyre.  it  does  not  usually  imi)licate 
the  cornea  until  lute  in  the  course  of  the  disease,  and  the  iris  still  later. 


THE  EYE  /.V  ITS  RELATIOS  TO  OESERAL  DISEASES.       629 

Iindlvcmoiit  of  tlic  iris,  as  wfll  ;is  otiu-r  tubercular dispiuscs  of  tin;  eyes, 
i-  iiinrc  (•oiiimon  in  chililrcii  tliim  in  lulults. 

In  cases  of  >;eiieral  tul)ereulosis  the  uveal  tract  ami  the  choroid 
es|iecially  is  soiuetiiiies  involved,  the  o|)iithalinosco|)e  revealinK  yel- 
lowish-whito  spots,  often  appearing  to  he  not  more  than  ■)ne  or  two 
niillinietres  in  diameter,  and  difhcult  to  detect.  Large  tubercular 
mmors  resenil)iiriR  sarcomata  are  seen  also  at  times.  ('hon>'dal 
tubercles  visible  with  the  ophthalmoscope,  if  .seen  at  all,  so  o.ien 
appear  in  the  late  stages  of  the  di.si  use  that  they  are  of  only  sligiit 
diafinostic  value. 

riie  development  of  tubercles  within  the  eye  is  ofti-ii  associated 
with  reduced  iiitra-ocular  tension,  but  in  a  few  instances  increased 
K'lisioii  has  been  noted,  and  Lubowski  has  reported  one  case  of 
iibsolute   glaucoma. 


DISEASES  OF  THE  3KIN. 

The  conjunctiva  and  superficial  layrs  of  the  cornea  being  con- 
timious  with  and  anatomically  and  embryologically  closely  related 
I.  the  skin,  it  is  only  natural  to  infer  that  many  of  the  disea.ses  of 
ihe  latter  should  present  themselves  in  a  modified  form  in  these 
|)ortioiis  of  the  eye  and  often  lead  to  comitlications  in  the  deeper 
structures.  This  "inference  is  found  to  be  correct,  especially  in  the 
case  of  such  diseases  as  eczema  and  herpes:  while  diseases  such  as 
lupus  and  ei-uhelioma  frwiuently  extend  from  the  lids  into  the  eye: 
lid  the  i)arasitic  and  other  cutaneous  affections  a.ssume  a  slightly 
modified  form  in  the  lids,  owing  to  the  fact  that  the  skin  here  differs 
ill  some  respects  from  other  portions  of  the  integument. 

Eczema,  which  assumes  such  a  variety  of  forms  in  various  portions 
of  tiie  cutaneous  .-urface,  freciuently  affects  the  eyes;  and  here,  as 
.■Isewhere,  it  presents  itself  in  forms  that  differ  so  widely  as  to  be 
somewhat  confusing  to  (me  of  limited  clinical  experience.  It  may 
artect  the  lids,  conjunctiva,  or  cornea,  and  while  of  very  freiiuent 
occun-eiice  in  childhood,  is  more  rare  in  patients  of  advanced  years, 
although  in  those  subject  to  gout  and  rheumatism  it  is  sometimes 
associated  with  conjunctivitis,  and  proves  most  obstinate  and  dis- 
tressing. In  adults  it  is  apt  to  present  it.self  (m  the  surface  of  the  lid 
in  the  form  of  eczema  s(|Uamosum,  but  it  is  among  children  that  we 
meet  with  large  numbers  of  cases  of  this  di.sease,  and  here,  while  the 
Miiface  of  the  lids  often  is  affected,  it  is  the  conjunctiva  and  cornea 
which  deserve  most  carefi  '  study. 

Owing  prubablv  to  the  ease  with  which  the  conjun.  ival  and  cor- 
ii.al  epmielium  is  roken,  we  seldom  meet  with  true  vesicles,  but 
pnints  of  infiltration  assuming  the  form  of  i>inkish-y<'llow  elevitions 
ill  tli<>  bulbar  conjunctiva,  and  grayish  or  grayisli-yellow  infiltrations 
ill  tlie  cornea,  are  verv  comnion.  These  are  gt-nerally  sjK>kpn  of  as 
phlvcteimla.',  and  often  are  found  in  association  with  eczematous 


O.'li) 


THE  EYE. 


■■    I 


dis«'iisc of  tho  inucoufl  inc>inl)r!iiic  uf  tin'  iioko,  ami  ospcpi.-illy  in  IuImtcu- 
Idus  or  "scrofulous"  cliililri'ii  with  (•(•/.cniiitouf*  erupt  inns  about  tin- 
tiosc  aixl  mouth,  and  adi-noids,  liy|«rtro|>hicd  tonsils,  and  fulargcd 
postcfrvical  jjlaiids. 

Herpes  lOSter  of  tin-  integument  of  the  lids  may  oeeur  under  eon- 
ditions  favorinn  its  (levelopmcnt  elsewhi-rc  on  tin-  faee,  esiM'eially 
when  vesicles  are  found  on  the  side  of  the  nose,  and  herpes  of  the 
cornea  is  not  very  uncommon.  'I'he  latter  assumes  the  form  of 
herpes  zoster  ophthalmicus,  sometimes  eorresixindinn  to  what  is 
termed  neuroparalytic  keniiitis,  :mii  l>y  seeonilary  infection  may  lead 
to  extensive  and  dangerous  ulceration.  The  rieuraljjie  and  hurninn 
pain  induced  by  herpes  zoster  may  precede  and  contirme  for  a  lonj; 
time  after  the  ei'    iitioii  has  dis;ippeared. 

Herpes  vulgaris  or  (ebrilis,  which  is  a  more  connnon  di-^c.i-e  of  the 
cornea  than  herpes  zoster,  is  often  found  in  assix'ialion  wiili  ritarrhal 
diseases  of  the  digestive  or  respiratory  tract,  and  is  ch.irai  terized 
l>y  the  formation  of  one  or  more  small  vesicles  which  often  are  broken 
before  their  character  is  reco>;nizi'd.  The  surface  of  these  ulcers 
may  b"  ana'sthetic.  but  not  the  surroundinn  |iortions  of  the  cornea, 
ami  while  ilcy  often  pursue  a  sluj;>lisi»  course,  infection  from  the  con- 
junctival sac  fr('i|iiently  occurs,  and  r.'iay  lead  to  the  development  of  a 
destructive  serpi>;inous  ulcer.  What  is  termi'il  k-irnlilis  tlnulrilirn  or 
ktnititis  nimijiirmis,  is  by  some  authorities  cl;issilied  as  a  varii'ty  of 
herpes  cornea',  althoufth  it  is  more  probable  that  it  is  dependent  for 
its  characteristic  form  upon  a  special  inicro-orKanism. 

Seborrhoea,  which  is  characterizi-il  by  the  development  of  .acne  in 
other  |)ortions  of  the  face,  when  it  involves  the  sel)a<'eous  jjlands  of 
the  bonlers  of  thi'  lids  produces  hordeolum  or  stye.  The  larjre  size  of 
the  filandr-'  in  this  re>;ion.  the  nature  of  the  si.. -omidinji  tissues,  and 
the  ea.se  with  which  infection  may  take  pl.ace,  account  for  the  ilitTer- 
ence  between  hordeolum  and  acne  as  it  a|)pears  in  othi'r  jiortioiis  of 
the  integument. 

Favus,  lichen  ruber,  acne  rosacea,  milium,  and  erjrthema  multi- 
forme, all  may  ajipe.-ir  on  tlie  skin  of  the  lids,  but  they  |)re.sent  few 
characteristics  difTerinji  from  those  seen  when  they  are  foimd  in  other 
portions  of  the  face. 

Furuncle  is  <K'casionally  .-ieen  in  th'  uttper  lid,  causin<;  marked 
tumefaction  ;md  redness. 

MoUuscum  contagiosom  may  appear  o  le  lids,  ni  d  Mittendorf 
has  oi iservei I  two  epidemics  occurrinj;  in  a  n(    |»ital. 

Elephantiasis  arabum  is  sometimes  confine<|  to  the  lids,  though 
jrenerally  appearinj;  with  a  similar  condition  in  other  parts  of  the  body. 

Pemphigus  of  the  conjuiy  tiva  is  occasionally  observed,  ami 
ichthyosis,  in  addition  to  cansinj;  shorteiiin<;  of  the  lids,  may  extend 
to  the  conjunctiva  ;inil  eyeball. 

PhthiriaSiS  "f   the   edire<   nf   th.e   lids   m.av  sometimes   be  reeoCIlized 

by  the  presence  of  nits  upon  the  eyelashes,  anil  sycosis  and  other 
]iarasitic  affections  are  occasionally  found  in  this  rejiion. 


TUE  EYE  IS  ITS  HELATIOS  TO  OllSEHAL  ttnEASES.      6;U 

Purpura  may  provoke  snmll  licinorrliaRfs  in  tlic  skin  of  tlif  lid  ami 
iiiidcr  till-  coiij'unftiva  and  into  tho  n-tina,  as  well  -is  in  (ttluT  portionM 
of  till'  l)ody. 

Impetigo  and  psoriasis  somi'tinios  invade  the  skin  of  the  lids,  tlio 
(•uiiiniictiva  and  conjunctival  portions  of  the  con -a. 

Urticaria  is  fouml  occasionally  on  the  lids,  and  iritis  and  paralysis 
of  acconinKMlation  may  Ih"  present  as  a  result  of  the  toxic  I'lenicnt 
caiisinji  the  skin  eruption. 

Alopecia  of  the  hrows  and  lashes,  often  complete,  may  i)e  found 
ciilicr  with  or  without  manirestatiohs  dsewhiTe. 

Lupus  as  ii  local  manifestation  of  tulmculosis  is  more  ])roperly 
triiited  under  the  head  of  infectious  diseases,  where  erysii>elas  is  also 
con-idered. 

Pellagra,  dui'  to  ingestion  of  a  fundus  of  maize  by  poorly  nourished 
iiiilividiials,  accordinj;  to  Hampoldi,  pnxhices  tor|)oi  of  the  retina. 
iiiinitis  pifrmentosa,  atrophy  of  tlu-  optic  nerve,  di-aiipear!  "-e  of  the 
cliiiididal  pifrment,  marantic  ulcers  and  necrosis  of  the  i'  '  ica,  and 
opacities  of  the  lens  and  vitreous. 


DISEASES  OF  THE  BRAIN  AND  SPINAL  COKD. 


Cerebral  Hyperaemia  and  Ansemia.  With  the  exception  of  cer- 
t;iiii  condiiinns  acconi|)anied  hy  jirolonjjjed  venous  hyperaemia  or 
(•(iii>:estion  of  till'  brain,  as  is  sometimes  seen  in  epih'psy  of  long 
^landiu};,  we  look  in  vain  to  the  ophthalmoscoix'  for  information  as 
tn  the  condition  of  the  cerebral  circulation,  although  it  is  of  the 
utniost  value  in  studying  di.seases  of  the  bloodvessels,  as  in  such 
conditions  as  arterio-capillary  sclerosis,  etc..  pronounced  hyper- 
emia or  ana-mia  of  the  brain  may  coexist  with  a  normal  fundus, 
,iiid  the  exist.'iU'  of  hypera'i  lia  of  the  retina  may  not  be  accepted 
.1^  proof  that  a  corres|M)nding  condition  will  be  fimnd  in  the 
liniin.  Those  unfamiliar  with  the  ]>!iy,siological  variations  in  the 
■i|i|pearance  of  tlie  nornuil  fundus  not  infre(|Uently  fall  into  serious 
■  rnir  in  the  inferences  they  dr.aw  as  to  the  condition  of  the  cerebral 
<irculation.  Indeed,  the  author  has  known  high  authorities  on  di.s- 
r:is  ■>  of  the  nervous  system,  but  with  limited  experience  in  the  use 
of  tiie  ophthalinoscoi>e,  to  be  entirely  misled,  and  tn  base  a  most  grave 
prognosis  upon  the  apparent  congestion  of  the  retinal  vessels  familiar 
t(,  v\i'Y\  experienced  ophthalmologi.st  as  one  of  the  characteristics 
of  high  degrees  of  hypermetroi)ia. 

While,  if  taken  ah>ne,  1;  .pera'inia  or  aiuemia  of  the  retina  is  not 
to  be  relied  ui)on  as  evidence  of  a  simil.ar  condition  of  the  brain,  if 
found  associated  with  otiier  symptoms,  it  may  be  of  considerable 
\  :ilue. 

.\n;eniia  of  the  brain  is  often  accomjjanied  by  inactivity  of  the 
i'upillary  reflex  with  lilatation.  wiiile  contraction  of  tlie  pupils  is 
cliaracteristic  of  cerebral  congestiim. 


»>' 


g;j2 


THE  EYE. 


\v 


si 


i  t 

if 


Cerebral  Hemorrhage.  In  ."stiniatiuR  tlio  rolativo  nnportanco  aiul 
si.r,ntin,ncc  ..f  the  vuri-us  ..cular  n.anitVstatu.ns  ..t  (•..rcl.ra  hcmor- 
;.;  1!.  or  a,.o,.l..xv.  tlu-  nm,,.l.-x  uatun-  ..f  tho  H.na.t.nus  vv.tl.  wind 

.;,r  .lealins  slu.uia  cmstantly  Ik-  k^.t  in.  nun.  .     llu-  l-^tum  u 
,1,.  l„.,uonl.af:.>.  the  ."Xtn.t  ..f  th.-  ..xtravasation   ,h.'  su.l.  on..  ■>^  u 
wl.i.l,  it  ...ak.-s  its  appearance.  a..,l  the  t..ne  that  has  elaps.M  suce 

'  oecn.Te,u-e  sl.oul.l  iJl  he  tak.-.,  into  a.-eou..t,  a...!  we  ,..us  re.ne.,|ber 
that  «.n.e  ..f  the  eve  sv.ni.t.....s  ...ay  be  .hie  t.)  ahsokite  .lestruc- 
ti.m  .,f  e.-rtai..  porti.u.s  .-.f  the  hrai..  tissue,  while  ..thers  are  tlje  result 
of  paralysis  .1. .-  t..  te...i...rary  p.vssure  in  a  zone  su.;r..u...ln.>r  th 
el,  a.-i  ..the.-s  ajjah.  are  P.  he  attrilmte.l  t„  the  .rntat..m  wh.eh 
;,eeu.s  \n  a  z.u.e  still  fartiter  re,.,..vea  fro.n  the  seat  ut  actual  lu>.u<jr- 

''"f  s.i.I.len  an.l  ..v.-rwhelniinff  hen...rrhage  ...ay  at  first  abolish  the 
fu.*,rti,...  ..!•  both  he...ispheres.  wluTe.vs  the  later  .level..p...e..ts,  . 
.l,.ath  <lo..s  n..t  e..su.'.  will  show  ....  which  si.l  the  l.'s  ..u  is  to  be 
toun.l  an.l  f..r  a  sl...rt  ti.ne  we  may  have  l,oni..ny.....us  h.-nuanops.a 
in  the  visual  tiel.l  on  the  si.le  <.pp..site  the  luMnorrhaRe  Co.ijugate 
,lev.ati..n  of  the  hea.l  an.!  ey.-s  t.nvar.l  the  si.le  of  th.-  lesi..n  is  also 
„f  frcpient  ...'currence.  This  is  attributed  by  Knies  t.)  irntal.on 
occur.-iiis  in  the  opposite  hon.isphere. 

Hc.orrhaso  into  the  visual  cortex  may  in  some  instances  cause 
very  few  ..f  the  svmptonis  usually  associate.l  with  apoplexy-  ll^^re 
niaV  be  only  te,np..rary  vertip.  with  a  su.l.l.Mi  attack  of  homony- 
mous he..iianoi.sia.  If  "the  hemia.ioi^sia  is  per..ianent  we  may  inter 
that  the  heniorrha-.-  has  been  of  such  a  character  as  to  .lestroy  the 
entire  visual  c(>..t.'e.  .  „,,.+„ 

Shoul.l  the  hem..rrl.age  be  not  t.,o  extensive,  a  fairly  accurate 
.liagn.xis  niav  <om..tinu-s  be  ma.le  at  the  bepnnniS  of  an  attack. 
hef..re  the  ...on-  or  less  confusi.ip:  secon.lary  an.l  remote  symi)toms 
hive  .l.-veloi,e.l,  .,r  after  thes.-  symptoms  have  run  their  course:  but 
a.irin.'  their  pn-sence  it  is  .lifficult  accurately  to  differentiate  th.-m 
f.-...i.  the  syinpt..i..s  which  are  the  essential  an.l  permanent  results 

of  the  lesion.  ,    ,       ,  -  t    i^ 

Hemorrhase  into  th.'  subarach.ioMl  or  sub.lural  sj.ace  is  .apt  to 
nro.luc<-  symi.t.)n.s  whi.-h  i-.-s.-mbl.'  th..se  ..f  ...emnsitis.  Mydnasis. 
I,ccasi..nai'lv  as  th.>  r.'sult  of  in-itatio.i  ..f  the  sympathetic,  but  >:eiier- 
allv  .lue  t.M)r<'ssure  up..n  an.l  i-aralysis  of  the  .....tor  .,cul..  .s  n.,  mtre- 
„ue..tlv  s,-,-n.  Mv..sisis..f  rare  occurr.M.ce ;  it  r.-s..lts  t.-(m.  h.-m...-- 
■,-h,-.-'.-"i..t..  th.'  v.-nt.-icl<-s.  an.l  in  s..m.-  instancs.  pr..bably  fro... 
irritation  p.-.Hluc.-d  liv  hein..!-rl.a-.-.  causing  pn>ssure  upon  the  nuclei 
of  th.'  ...ular  ..ms.-l.-s."  If  a  li."m..r.-l.a<je  is  of  such  extent  as  to  .lestroy 
the  !  .in.a.-v  ..ptic  fian-lia.  th.-  chiasm,  or  optic  tracts,  we  may  hav.' 
partial  or  ciupiet.'  atr.iphv  .if  the  oj.tic  nerv.-s. 

Optic  .i.Mi.-itis,  cl...k.-.l  .lisk.  a.i.l  partial  ..r  .-.m.pl.'te  atr.)phy  o 
th.-  ..ptic  n.TV.'s  an-  seen  ,-eca:^ion:.lly  in  <-ere!,r:i!  h.-morrhaffe:  hut 
evi.l.-.ice  supplie.l  by  the  opl.thal..i..sc..pe  is  .if  far  less  value  in  this 
.lisease  than  in  the  case  of  tumors  or  i.iemi.Kit.s. 


THE  EYE  /-V  ITS  KELATIOS  TO  UESEBAL  DISEASES.       633 

It  should  lie  rcmciiibcrcd  tliat  disoasos  such  as  albuniimiria,  dia- 
l)ctcs,  atlicroma  of  tlic  bloodvessels,  etc.,  which  may  predispose  to 
(•(■rei)ia!  hemorrhage  often  i)roduce  hemorrhajies  and  other  character- 
i~lic  lesions  of  the  retina  and  oi)tic  nerve,  independently  .  th()se 
which  mav  n^sult  from  extravasations  into  the  tissues  of  the  brain, 
and  in  old  people  the  condition  of  the  bloodvessels  which  favors 
cvtravasation  into  the  Imiin  is  indicated  not  infre<iuently  by  recurring 
attacks  of  coTijunctival  hemorrhajje. 

Embolism  and  Thrombosis  of  the  Cerebral  Vessels.  A  cerebral 
embolism,  if  not  infectious,  leads  to  dcfteiieratioii  or  softenin;:  and 
necrosis  of  the  brain  tissue  sujiijlied  by  the  vessel  whose  cour-  it 
..hstru  -,  and  a  non-infectious  thrombosis  or  a  circumscribed  hemor- 
ihMfie  will  produce  similar  effects,  though  the  clear-cut  and  well- 
d(tine<l  lesion  i)roduced  by  an  embolus  often  renders  it  pos.sible  to 
determine  (juite  accurately  its  location  by  the  resulting  focal  symp- 
toms; and  if  it  is  situated  in  the  visual  cortex,  in  the  occipital  lobe, 
ill  the  ])riinary  optic  ganglia,  or  in  the  course  of  the  optic  tracts,  in 
the  cortical  centres  or  primary  ganglia  of  the  motor  nerves  of  the 
eye.  the  characteristic  jjaralytic  symptoms  will  develop  promi)tly 
after  a  brief  period  of  reaction.  Symmetrical,  bilateral  softening  of 
the  optic  centres  has  been  reported  in  a  mnnlM-r  of  instances,  and 
Wilbrand  mentions  one  case  in  which  double  choked  disk  occurred 
I  Knies). 

.\n  infectious  embolus  or  thrombosis  leads  to  the  formation  of  a 
cerebral  abscess  with  its  characteristic  symi)toms,  while  an  infectious 
thrombosis  of  the  cavernous  sinus  may,  in  additi(m  to  the  other 
symptoms  of  an  abscess  at  the  base  of  the  l)rain,  result  in  ori)ital 
sMpi)uration  with  its  long  train  of  disastrous  etTects.  The  eyeball  is 
protruiled  and  fixed  by  infiltration  of  the  orbital  tissues,  the  conjunc- 
tiva becomes  chemotic,  the  lids  swollen,  and  there  follows  blindness 
with  a  widelv  (hlated  and  iimnovable  pui)il.  M  the  thrombotic 
process  inclui'les  the  ophtlialmic  vein,  the  ophthalmoscope  reveals 
distended  retinal  veins,  with  injection  of  the  nerv(>  head  and  retinal 
iiiiiiorrhages.  b.ater,  as  the  infectious  process  extends,  we  have 
npacity  and  ulceration  of  the  cornea,  und  finally  i)anoplithalmitis. 

In  the  early  stages  of  the  infectious  pr ss.  and  during  the  progress 

Ml'  a  non-infective  or  marantic  ihnimbosis  of  the  cavernous  sinus. 
I  he  o])hthalmoscope  renders  most  valuable  assistance,  especially  in 
li-iinguisiiing  the  latter  condition  from  meningitis.  In  both  m<'nin- 
miis  and  non-infectious  thrombosis  of  the  cavernous  sinus  there  may 
lie  p.aralysisof  the  motor  nerves,  insensibility  of  the  trigemiims.  with. 
its  eonseiiuences  in  conjunctival  and  corneal  ana'sthesia.  i)artial  or 
'omplete  paralysis  of  the  optic  nerve,  and  more  or  less  o'dema  of  the 
lid^.  and  protrusion  of  the  eyeball  from  involvement  of  the  orbit. 
Ill  meningitis  we  may  have  congestion  and  even  jminounced  optic 
neuritis:  "but  the  m.arkecl  stasis  of  the  retinal  veins  which  is  found 
111  throml)osis  ,if  the  sinus  with  thrombosis  of  the  ophthalmic  vein 
is  never  observed"  (Kniesi. 


If 


III 


H 


634 


THE  i:yk. 


Abscess  of  the  Brain.  Tli(>  ocular  syinptonis  pnKliicod  by  ahspcss 
of  tlu'  biaiii  may  hv  tlic  same  as  those  about  to  be  ciiunuTatcd  as 
rcsultiiifr  Ironi  tumor:  but,  in  addition,  there  is  tiie  S'-nerai  evideii,-e 
of  an  infiTtive  proeess  aetinji  as  a  eause:  an<l  it  should  l)e  borne  in 
mind  that  some  of  the  oeular  manifestations,  sueh  as  septie  ehoroid- 
itis,  embolism,  and  tiirombosis,  may  result  direetly  from  this  infective 
jjrocess  rather  ilian  from  the  coincident  cerebral  al)scess. 

As  in  tumor,  we  may  find  diiTuse  and  local  etTeets  nlanifested  in 
choked  disk  and  obstructive  neuritis,  which  latter  is  apt  to  be  bilat- 
eral, and  is  the  most  chara-'teristic  oi)hthalmoscopic  manifestation. 
There  mav  be  iiaralysis  of  llie  motor  and  sensory  nerves,  ])receded 
1)V  spastic  contractions  of  muscles  and  other  evidences  of  theexi-'tence 
of  a  zone  of  irritation  near  the  abscess.  As  the  .absce.ss  may  be  prac- 
tically stationary  or  rapidly  jjrofiressixc,  the  various  ocular  manifes- 
tations may  be  of  proh)nfied  duration  or  follow  one  another  in  (juick 
succession,  and  in  the  event  of  a  rujiture  we  may  have  a  fatal  ter- 
miTiation  preceded  by  the  ocular  and  <;eneral  eviilences  of  purulent 
meniufiitis.  with  jiaralysis  of  the  fifth  nerve,  neuroparalytic  keratitis, 
etc.  Perforation  into  the  ventricles  may  be  attended  by  marked 
mvosis,  which  is  attributed  by  Knies  to  direct  irritation  of  llie 
.sphincter  nuclei. 

The  projinosis  after  operation,  so  far  as  the  eye  is  concerned, 
<lei>ends  upon  the  location  and  extent  of  the  dama<;e  to  the  brain 
tissue.  The  irritativ<'  symptoms  may  subside.  ;is  may  the  oi)tic 
neinitis,  and  to  some  extent  vision  may  be  restored:  but  if  the  visual 
cortex  has  been  seriously  involved,  we  are  apt  to  have  not  only  im- 
])aired  vision  and  limit.-ition  of  the  visual  helds,  but  also  defective 
color  sense  ( IvniesK 

Tumors  of  the  Brain.  .Minost  all  forms  of  neopl;ism  are  found  in 
the  crani.'il  cavily,  alth()U<j;h  some,  such  as  lipoma,  which  are  common 
in  other  localities,  very  rarely  ajijiear  in  the  brain.  Tubercular 
tumors  ai'e  inoi-e  conuuon  in  the  br.ain  than  elsewhere,  and  sarcomata 
and  syphilitic  tumors  aie  of  frecpient  occurrence,  the  latter  beinj: 
often  associated  with  fiunun.itous  meninfritis.  (ilioma  is  almost  ex- 
clusi\-elv  a  cei'ebral  tumor,  beiufr  found  in  the  brain  and  spinal  cord, 
and  in  no  other  jiart  of  the  bod>',  exceptinir  the  retina,  from  which 
it  often  exli'iids  to  the  brain. 

'I'lie  symptoms  produi'i'd  in  the  eye,  as  in  other  parts  of  the  perijih- 
eral  nervous  system,  dilVer  };r<'atly  in  accordance  with  the  siz(>,  period 
of  firowth,  and  location  of  the  tumor;  and  it  sometimes  hitpjiens  that 
a  firowth  whi<-h  later  causes  irritation,  and  fin.ally  destruction  of  the 
|)arts  with  which  it  lies  in  contact,  may  in  the  earlier  stapes  of  its 
di'velopment  produce  only  jreiieral  symptoms  of  dit'fusi'  inli'acranial 
pressure,  'i'lmiors  of  the  .'interior  and  middle  fossa  may  invadi'  the 
orbit  and  (••■mse  exophthalmos. 

Chokeu  disi^  or  ,.|)lic  lil■initi^.  usu;i!ly  dou!)!!-.  ;nitl  .'ittaoks  (if  teiii- 
)iorary  total  loss  of  sijihl  due  to  {leiieral  intracrani.il  pressure,  indicate 
the  ]iresence  of  a  tumor  of  the  br.iiii.  althoujrh  other  evidence  is  ne('<'s- 


IvT, 


THE  EYE  IS  ITS  RELATIOS  TO  llESERAL  DISEASES.       635 

saiy  to  cuahlc  lis  to  form  ;ui  ()i)inion  as  to  its  location,      i;.^"  size  of 

a  tiiiiior  seems  to  have  little  influence,  and  the  choked  disk  oi  .  ,)tic 

neuritis  which  appears  is  not  merely  the  result  of  mechanical  pressure. 

Ill  addition  to  the  g(>neral  symptoms  of  cerebral  coni|.ression  accom- 

panyiiifi  brain  tumor,  such  as  headache,  hebetude,  drowsiness,  voniit- 

iiifi."  a  .slow  pulse,  and  dilatation  of  the  pupils,  there  is  sometimes 

c\-id(  !ice  of  pressure  on  jjarts  far  removed  from  the  seat  of  the  growth, 

which  is  apt  to  be  very  mish-adiiig  in  our  attemjjts  at  localization. 

( IwiiiK  to  its  long  course,  the  sixth  nerve  is  especially  apt  to  be  affected 

by  such  indirect  jH-essure,  producing  paraly.sis  of  tl  "  external  rectus. 

If  the  tumor  is  of  .such  a  nature  as  to  jirovoke  irritation  as  well 

as  pressure,  we  may  have  conjugate  deviation  of  tli(>  eyes  and  head, 

coiiceiitric  narrowing  of  the  visual  iields,  and  paroxy.smal  attacks  of 

liilatcial  blindness. 

Wiiile  choked  disk  is  not  always  one  of  the  early  symptoms  of 
l)niiii  tumor,  it  is  one  of  the  most  important,  appearing  at  some 
st.ige  in  about  SO  per  cent,  of  the  ca.ses:  and  if  this  symptom  is  not 
fnuTid  in  some  stage,  the  otiier  evidence  on  which  the  diagnosis  of 
I'livbral  neoplasm  '  based  .sjioiild  be  very  convincing.  It  is  said  to 
br  iiii.r,'  fre(|uent  in  tumors  of  the  cerebellum  than  in  those  of  the 
t'lmtal  lobes,  and  may  be  |)roduced  l)y  a  tumor  in  any  i)art  of  the 
I  !  iiri,  although,  if  the  neoplasm  is  in  the  membranes  on  the  convexity 
.ml  iiuiviv  comjiresses  the  brain,  it  is  less  ai)t  to  produce  choked 
.li-^k  or  optic  neuritis  than  when  it  invades  the  cerebral  tissues 
(Ciiwers).  Choked  disk  is  sometimes  found  even  in  tumorof  the  spinal 
i'diil.  Some  eminent  writers  on  nervous  diseases  ignore  the  distinc- 
tion between  choked  disk  and  obstructive  neuritis,  but  it  is.  neverthe- 
l('-<,  an  important  one,  for.  while  undoubtedly  some  degree  of  neuritis 
liiialiv  (levelojis  in  almost  every  ciise  of  choked  disk.  ther<>  often 
exists  ill  the  early  stages  a  true  ledema  of  the  nerve  head  in  which 
ilie  tissues  are  (luite  translucent  and  do  not  present  the  ai)i)earance 
ol  vascularity  and  inllaniniation  seen  in  optic  neuritis.  This  (cdema 
i-  iioi  necessarily  accomi>aiiied  by  marked  imi)ainiieiit  of  vision. 
Clidked  disk  with'  tumorof  the  liraiii  is  usually,  altliimgh  not  always, 
l.ilateral,  and  it  does  not  necessarily  indicate  tliat  the  growth  is  large 
'ir  is  located  near  tli'  '•  parts  of  the  brain  which  are  especially  con- 
iciiied  with  vision.  "eil,  while  rajiidly  growing  and  large  tumors 

:iiv  apt  to  produce  it,  small  growths  by  causing,  as  they  often  do, 
•  Inipsy  of  the  ventricles,  are  accompanied  not  infrecjuently  by  marked 
u'dema  of  the  nerve  head. 

Choked  disk  and  optic  neuritis,  if  maintained  for  a  sufficient  length 
nt  time,  will  almost  inevitably  hnid  to  contraction  of  the  visual  field, 
with  extension  of  the  l)lind  sjxit,  and  sometimes  central  scotoma, 
i.'lldwed  by  atrophy  of  the  ojitic  nerve  and  blindness.  Kxceptions 
•<>  tills  are  found  in  those  rare  cases  in  which  a  cure  is  effected  by 
:.pii;;ti\'-  "r  otiier  measures,  ;(nd  especi.ally  in  neophi-^ms  of  syphilitic 
•ligiii.  when  in  the  proper  stage  active  treatment  with  mercurials 
iiid  iodides  succeeds  in  bringing  about  absorpticm. 


••v'«J  _..IL  - 


(J.JG 


TIl£  EYE. 


|1 


s 


III  :i  nunibor  of  instances'  wlioro  operative  interference  has  been 
unsuccessful  so  far  as  removal  of  the  tumor  was  concerned,  marked 
freedom  from  ;  lin  and  restoration  of  vision  have  followed  the  relief 
from  i)ressurc  on  the  cerebral  tissue. 

While  choked  disk  is  one  of  the  most  positive  indications  of  the 
presence  of  an  intracranial  growth,  it  s-hould  be  borne  in  mind  that 
it  is  simi)lv  an  cedema  of  the  nerve  head  accompanied  by  distention 
of  the  sheath  of  the  nerve,  and  that  there  are  other  conditions  as 
well  as  tumor  which  may  produce  it  occasionally,  .\mong  these  may 
be  mentioned  abscess  of  the  brain  and  cerebral  hemorrhage.  It  has 
also  been  seen  after  profuse  hemorrhag.'  in  other  |)ortions  of  the  body 
and  in  cases  of  leuka'mia.  albuminuria,  and  diabetes;  but  there  is 
u-uallv  other  evidence  to  aid  in  establishing  the  diagnosis. 

Tuniors  of  the  brain  in  a  certain  proportion  of  cases  cause  optic 
neuritis,  followed  by  atrophy  without  choked  disk  "Oppenhcim 
observed  tyi)ical  chdked  disk"fourt(>en  times,  neuritis  five  times,  and 
hyperainia  of  the  pajnlla  once  "  ( Kni(>s).  .Vnd  we  may  in  some  cases 
have  atroi)hy  of  the  nerve  without  either  choked  disk  or  neuritis. 

Taken  with  other  evidence,  choked  disk,  obstructive  neuritis,  simple' 
optic  neuritis,  and  [irogressive  atr()i)hy  of  the  optic  nerve  are  (jf  great 
value  in  determining  the  character  of  a  brain  lesiim:  but  alone  they 
should  not  be  considered  as  a  sufficient  ba.sis  on  which  to  make  a 
positive  diagp.o.sis. 

Aneurism,  ')y  pressure  and  irritation,  produces  effect.s  upon  the  eyes 
similar  to  tho.se  resulting  from  other  tumors,  and  in  very  rare  and 
exceptional  instances  a  tumor  may  be  .so  situated  as  to  produce  a 
group  of  h.cal  eye  symptoms  almost  a.s  clearly  defined  as  those  some- 
times observed  in  ca.ses  of  embolism  and  softening.  These  symi)toni.s 
ii.ay  present  themselves  in  the  form  of  cortical  blindness  or  hemian- 
op.sia,  mind  blindness,  alexia,  visual  ai)hii.sia,  dyslexia,  amnesic  color 
blindness,  and  visual  hallucinations,  or  cortical  disturbance  of  the 
ocular  movements,  such  as  conjugate  deviation  of  the  eyes,  often 
accom])anied  by  deviation  of  the  head  in  the  .sai.ie  diri'ction.  If  the 
tumor  happens  to  press  u]ion  the  gray  matter  around  the  aqueduct 
of  Sylvius  or  in  the  floor  of  the  fourth  ventricle,  it  produces  nuclear 
ocular  palsy  or  ophthalmoplegia — external  if  affectitig  the  orbital 
muscles,  as  the  recti  and  oblicpie  muscles;  or  internal  if  affecting  the 
iris  and  ciliary  muscle.  If  the  tumor  lies  in  such  a  jMisition  as  to 
alfect  the  efferent  fibres  of  tin-  dcular  nerves  in  the  cms  cerebri  it 
j)ons,  between  the  nuclei  and  theii'  point  of  emergence  at  the  ba.se  of 
the  brain,  we  have  what  is  termed  fitscirular  jKirnljisix  of  the  third, 
fifth,  sixth,  or  seventh  nerve,  which  is  sometimes  spoken  of  as  crossed 
<ir  alternate  i)aialysis.  Anil  when  situated  a*  the  ba.se,  in  addition 
to  its  ctTect  upon  the  optic  tract.  !i  tumor  may  cause  paralysis  of  any 
or  all  of  the  nerves  sujiplying  thi'  external  and  internal  ocular  muscles, 
as  well  as  the  fifth  nerve. 


1  Svrniizy.  in  Niirris  ami  Oliver's  S.v»tt'in  of  l>Ut'ns<"«  iif  ihe  Eyi',  vi>l.  iv.  p.  .'il.'). 


ly-J.    •i^Vt.'A-.-tJfM 


rili:  KYE  IS  ITS  RELATTry  TO  GENERAL  JJlHEASEH.       037 

If  found  in  the  corpora  (luadripeniina,  a  tumor  may  produce  oculo- 
motor paralysis,  a  reeling  sait,  with  possibly  blindness  and  deafness. 
The  differential  diagnosis  between  tumor  and  abscess  of  the  brain 
is  not  always  easily  made.  They  may  have  in  eonnnon  headache 
vomiting,  choked  disk,  or  optic  neuritis  (generally  double),  and 
mental  disturbance;  while  tumor  is  ai)t  to  cause  m  addition  the  well- 
marked  focal  svmptoms  enumerated  above,  with,  at  times,  hemiph  ;ia. 
\\-\oT  and  rigor  favor  abscess.  The  cau.'se  of  abscess  is  often  v\-ry 
clear,  being  freciuentlv  traceable  to  a  focus  of  suppuration,  sm-i  as 
uuruien*  otitis  media.'while  that  of  tumor  is  obscure. 

Meningitis  in  its  various  forms  gives  rise  to  a  variety  of  ocular 
1,'sions  of  the  mo.^t  serious  character.  In  general  they  are  the  direct 
result  of  the  action  of  the  exudate  upon  the  visual  c(>ntres,  ganglia, 
,.r  oi)tic  tracts,  and  ui)on  the  iioints  of  origin  or  trunks  of  the  motor 
and  sensory  nerves;  or  they  may  be  due  to  secondary  inf<>ction  of  the 
,.  •(.  from  the  septic  material  which  is  characteristic  of  the  mening.al 
inflammation.  If  the  process  is  extensive,  we  may  find  the  eye 
congest<>d  hvpera'sthetic,  and  sensitive  to  lijiht  in  the  early  stages; 
.,11,1  soon  svmi>toms  will  develop  which  indicat.'  whether  the  inflam- 
mitorv  pnicess  affects  the  convexity  of  the  bram  or  the  base.  It  the 
formei-  we  mav  have  in  the  earlv  stages  an  homonymous  hemianopsia 
with  the  pupiliarv  reaction  to  light  preserved,  or  both  cortical  centres 
mav  be  involve(i,"affecting  both  halves  of  the  retina  of  each  eye. 

In  acute  cases  th(>  inflammatory  i)rocesS  usually  ext-'iids  rapidly, 
s„  tiiat  conjugate  deviation  and  other  symjjtoms  pointing  to  a  cor- 
tical lesion  are  transitory  in  character;  and  as  in  a  large  proportu-..  ot 
cases  of  meningitis  there  is  an  exudate  at  the  base  of  the  brain  the 
ocular  manifestations  are  apt  to  be  i)erii)heral  and  the  result  o 
cither  irritation  or  paralysis  of  the  n(«rv<'  trunks  which  are  embedded 
ill  the  exudate  and  reach  the  eye  through  the  apex  of  the  orbit. 

The  abducens  is  attacked  most  fre(|uently,  the  motor  oculi  rarely; 
and  the  presence  of  hypera-sthesia,  para-sthesia,  and  amesthesia  in 
tlw  cutaneous  surface  of  the  face,  with  neuroparalytic  keratitis, 
indicates  involvement  of  the  trigeminus. 

\mong  the  symptoms  .)f  irritation  we  may  have  contraction  ot  the 
ocular  uuisdes",  producing  various  forms  of  strabismus,  and  rarely 

iivstagnuis.  ,    ,    1  t  •  1 

'  I'lralvsisofthe  facial  nerve,  leading  to  lagophthalmos.  which  ma\ 
!„.  accompanied  bv  deafness  from  involvement  of  the  auditory  nerve, 
i~  one  of  the  iK.ssii)le  results  when  the  exudate  is  found  in  the  middle 
inssa  In  basilar  lu-ningitis  vision  may  be  affected  by  involvenu'iit 
of  the  tractus,  bv  optic  neuritis,  extension  to  the  orbits,  genera  ly 
'ong  the  veins,  producing  chemosis,  and  perhai)s  later  orbita  ceMu- 
litis  Hxation.  ami  protrusion  of  the  eyeballs,  etc.,  or  Dy  the  j-roductum 
of  a  seroplastic  or  purulent  choroiditis  sonu-times,  though  rarely, 
iiiiiiiiiaiing  in  panoiihthahiiitis. 

\  d(<gm>   of   optic  neuritis  presents  itself   in   some   stage  of   the 
i::a.iorityof  cases  of  cerebral  meningitis,  and  although,  unfortunately, 


638 


rUK  EYE. 


! 


it  somotiinos  liapixTis  that  it  caniK 


it  1)0  (Ictrctcil  sulficioiitly  early  to 


1^ 


m\ 


he  the  lucaiis  of  cstahlishiiiK  the  diajtiiosis,  in  many  instances  it  is  of 
the  utmost  value.     When  fully  developed,  it  is  generally  bilateral. 

Doubt  as  to  the  ditferential  diagnosis  between  typhoid  fever  or 
pneumonia  on  the  one  hand,  and  meningitis  on  the  other,  may  isoine- 
times  be  deeidetl  by  means  of  the  oi)htlialmoseope. 

Optie  ni-uritis,  as  seen  wi.h  the  ophthalmoscope,  may  vary  in 
degree  from  simple  hypera-mia  to  a  decided  pajjillitis.  although  great 
swelling  of  the  (Usk  is  not  often  seen,  as  in  cerebnd  tumor  and  soint^ 
cases  of  ab-cess.  There  is  u.sually  an  absence  of  jmniounced  exudation 
and  hemorrhage:  but  :'  certain  cloudiness  of  the  tissues  .  the  nerve 
head,  with  blurring  and  indistinctness  of  its  outlines,  is  in  keeping  with 
the  fact  that  the  micro.scope  reveals  infiltration  of  tiie  jnal  sheath 
and  coimective  tissue,  especially  toward  the  jK'riphery  (Knies). 

A  dense,  chalky-white  disk  with  sharp  outlines  and  marked  nar- 
rowing of  the  bloodvessels,  is  seen  in  the  atrophic  stage,  with  often 
complete  blindness,  though  in  some  Cii-ses  the  amount  of  vision  re- 
maining seems  entirely  oi  t  of  ])roportion  to  the  evidences  of  atrophy 
as  seen  with  the  oi)hthalmoscoi)e.  When  some  vision  remains,  how- 
ever, we  are  apt  to  have  irregular  narrowing  of  the  visual  fields, 
scotoinata,  and  defective  color  sense. 

A  septic  ("metastatic")  exudative  choroiditis  sometimes  develoi)s 
in  the  early  stages  of  simple  meningitis,  especially  in  young  children, 
although  il  may  also  appear  at  a  lat(>  period  and  in  other  forms  of 
tlie  disease:  or  it  may  be  disc;)vered  after  the  active  symptoms  have 
ubsided.  It  is  generally  unilateral,  although  both  eyes  may  bo 
affected:  and  it  is  said  to  be  of  embolic  origin,  sometimes  being 
found  in  cases  of  ulcerative  endocanhtis,  in  puerperal  fever,  recurrent 
fever,  tyi)hoid  fever,  scarlatina,  mumps,  erysipelas,  etc.  (\oyes). 

This  condition  of  the  eye  not  infnviuently  escapes  the  attention  of 
the  attending  physician  during  the  active  period  of  the  disease  to 
wnieli  it  owes  its  origin,  but  usually  presents  w:'ll-marked  and  easily 
discoverable  local  sympton.s  of  a  low  grade  of  irido-cyelo-choroiditis, 
sometimes  accomijanied  by  markeil  ciliary  injection,  iritic  exudation 
and  adhesions,  parenchymatous  keratitis,  and  even  hypopyon.  If 
the  above  symi)toms  of  iritis  and  keratitis  are  abse.a,  the  ophthalmo- 
scoiie.  or  sometimes  ol)li(iue  illumination,  will  reveal  the  purulent 
exudate  in  the  choroid  .and  retina,  which  often  extends  so  f.ar  forwanl 
in  the  vitreous  chamber  as  to  lie  in  contact  with  the  posterior  surface 
of  the  lens.  atid.  especially  when  bloodvessels  develop  on  its  surface, 
it  clo.sely  resembles  glioma  of  the  retin.i  -psciidixiliomn.  Such  eyes 
are  usuallv  soft  and  easily  irritated,  but  sometimes  r(>tain  their  normal 
exter-ial  apiiearance.  although  often  in  later  years  they  undergo  degen- 
erative changes,  becoming  (piadrate  und'r  the  pressure  of  the  recti 
tmisdes,  and  developing  (legenerative  keratitis  and  calcihcation  of  the 
crystalline  lens. 

Instances  hav  been  recorded  in  which,  after  the  formation  of  a 
moderate  amount  of  exuilate,  absorption  has  taken  place  and  vision 


THE  EYE  IS  ITS  RELATION  TO  UESERAL  DlHEASEii.      «a<> 

liMs  Im'cii  riistorcil,  thoufili  sucli  cases  must  Im-  cxtrciui'ly  rare.  We 
iiiiiy  also  liave  in  iiieiiiiij^itis,  as  in  certain  otlier  diseases  i.c-cunipanied 
liy  tyi)lu)i(l  syiMptoiiis,  mild  jrrades  of  cyciitis  and  choroiditis,  wiiicli 
-niiietiines  n"cov<     witliout  leaving  serious  impairment  of  vision. 

Aviitr  hihcrciiltii  mininnitiy  is  in  about  15  per  cent,  of  the  cases 
accomiianied  l)y  miliary  tnhercles  in  the  choroid,  which  may  1  ■  made 
(lilt  with  the  ophthahn<i.scope  as  pale  yehowish  s|)ots  which  are  s«me- 
\\ii:it  prominent  and  vary  in  size  from  O.o  nun.  to  2.5  mm.  They 
all  unaccom|)anied  by  i)i};mentation.  and  seem  to  be  more  connnon 
ill  I  lie  neigliborhood  of  the  macula  lutea  and  disk.  More  are  often 
liiiiiid  i)ost-m.)rtem. 

I'andyses  of  the  ocular  nmsdes  are  often  seen  in  tubercular  menin- 
j;ilis,  asit  is  prone  to  attack  the  bas(>  of  the  brain,  and  optic  iKMuitis 
i>  more  common  in  this  than  in  atiy  other  form,  especially  if  the 
Uii)ercular  exudate  at  any  point  api)ears  as  a  tumor. 

('enhro-spinal  mcniiKji'ti'^  is  very  apt  at  some  stage  to  be  the  cause 
III  most  serious  involvement  of  the  eyes.  In  the  early  stages  we  may 
have  swelling  of  the  lids,  conjunctivitis  with  (edema,  and  photoiil'.ibia 
with  contracted  or  dilated  pupils  which  are  often  une(|ual.  Keratitis 
i-  not  uiiconmion,  and  iridochoroiditis  and  retinitis  with  optic  neu- 
ritis, or  paralysis  of  the  optic  nerve  without  apparent  neuritis,  are 
111  Irciju-'ut  occurrence.  What  has  been  said  under  the  head  of  septic 
<.r  metastatic  choroiditis  as  occurring  in  meningitis  in  general,  applies 
especially  to  this  form  of  the  di.sease. 

Whether  or  not  the  ])neumococci  r(>ach  the  eye  through  the  lymph 

|i,ices  of  the  optic  nerve  has  not  as  yet  been  proved  (.\xenfeld); 

liut  that,  in  <5oino  instances,  they  reach  it  by  way  of  the  circulation 

ihiougii  general  systemic  embolic    poisoning    has  been  estab''shed.' 

The  prognosis  as  to  life,  and  especially  as  to  s  sjlit.  is  most  grave. 

l'ii<-hi/mcnin(iilis  produces  eye  syni|)toms  which  vary  with  its  loca- 

lidii.     .Vs  it  is  most  fretpiently  found  on  the  convexity  of  the  brain. 

I  he  eye  symptoms  are  a\)\.  to  be  cortical  in  nature,  tiiough  when 

i-s(iciateil  with  hemorrhage  the  more  dittuse  symptoms  usually  seen 

vith  the  tumor  may  be  addeil. 

A  circumscribed  meningitis  presenting  few  of  the  other  synii)toms 
I Miiiid  with  more  general  inflannnation  of  the  membranes  may  be 
nriimpaiiied  in  the  early  stages  by  color  phantasms,  nyctalopia,  etc., 
lid  ;it  a  later  jieriod  cause  impaired  vision,  scotomata,  limitation  of 
'lie  visual  lields,  and  disturbance  of  color  sense.  The  ophthalmoscojie 
ii.iy  at  first  reveal  neuritis,  which  is  followed  by  more  or  less  com- 
'  I'tr  atroi)iiy  of  the  optic  nerve  (Knie.-;). 

Mitd^tnlic  piiriilcnl  incninqitiK  may  result  from  purulent  inflamma- 
!iin  of  the  eye,  es|)ecially  from  traumatic  |)aiiophthalmitis. 

A  number  of  instances  have  been  recorded,  some  of  wiiich  have 
"•iiiire(|  after  enucleation,  and  this  has  been  used  as  an  argmnent 
j::iiii>;t  enucleation  in  j-anophthalm'tis;    hut  both    logic  and  expe- 


Swanzy.  In  N'onis  and  Oliver's  System  of  Diseases  of  the  I-ye. 


Hi 


».  I 


I! 

ili 


640 


TUE  EYE. 


rii'iu-c  teach  us  that  thocasc  must  he  an  unusual  one.  in.lood,  in  which 
removal  of  sucli  a  source  of  infection  will  not  mcrease  the  i)atient  s 
chalice  of  escaping  iiieiiin>;itis.  _ 

Insanity.  While  the  insomnia  and  excitement  incident  to  many 
forms  of  insanitv  mav  lead  to  marked  injection  of  tiie  bulhar  con- 
junctiva and  vvliile  variations  in  th."  iiupil  may  be  noted,  and  atrophic 
and  degenerative  disease  of  the  nerve,  retina,  and  choroid  l)e  tound 
ks  the  result  of  a  di:<ease  wliicii  is  a  direct  or  indirect  cause  of  menta 
thsorders,  it  cannot  properly  be  said  that  there  is  any  affection  ol 
the  eve  which  can  b(>  directiv  attributed  to  insanity. 

Hallucinations  of  sight  which  are  visual  perceptions  not  founded 
on  an  obective  realitv.  and  visual  illusions  which  are  misinterpre- 
tations of  sensory  images,  when  they  cease  to  be  recognized  by  the 
subject  iis  hallucinations  and  illusions,  are  among  the  nion- common 
manifestations  of  insanity. 

Fo<t-operative  delirium,  and  even  insanity  are  by  no  means  uncom- 
mon after  iridectomv  and  the  extraction  of  cataract:  and  when  we 
consider  tiie  prolonged  suspense,  the  state  of  mental  excitement  witli 
phvsical  inav'»ivitv  incident  to  the  operation  and  after-tr.>atment. 
•iiid  the  fact  that  all  light  is  generallv  excluded,  it  is  not  strange  that 
judgment  sometimes  cea.ses  to  hold  sway  over  the  hallucinations 
excited  bv  such  an  ordeal.  It  is  a  fact,  however,  that  such  mental 
disturbances  seldom  manifest  themselves  excepting  among  those 
p|•('di^•^()sed  to  such  affections. 

It  sometimes  happens  after  oi)eration  upon  the  eye  that  the  ten- 
dency to  delirium  is  greatly  iiicreas(>d  by  the  eft'ect  of  atropine,  used 
to  prevent  the  formation  oi"  iritie  ailhesions,  and  caution  in  its  admin- 
istration may  prevent  the  development  of  most  troublesome  symp- 
toms. .  •  1     1-     -i    »• 

General  Paralysis  of  the  Insane.  In  view  ( )f  th(>  wu le  <  hst nliution 
and  character  of  the  cerel)ral  lesions  in  iiaretic  dementia,  it  is  not 
strangi-  that  we  should  have  a  variety  of  eye  symi)ioms  which,  owing 
to  the  fact  that  they  often  make  their  appearance  at  an  early  i)enod, 
are  of  the  greatest  diagnostic  ami  jjrognostic  value. 

Trophic  and  vasomotor  disorders  occur  in  tlic  eye  as  elsewhere: 
but  it  is  to  tiie  cortical  visual  disturbances,  mind  blindness,  and 
hi  .liaiiopsia.  paroxvsmal  or  ix-rmanent,  and  to  atrophy  of  the  optic 
nerve,  and  especially  disturbances  of  innervation  of  the  intrinsic  and 
extrinsic  ocular  muscles,  that  our  attention  will  be  directed. 

Paralysis  of  the  orbital  muscles,  cyclo|)legia.  ai';i  i)ui>illary  anoni- 
ali  .  suVh  as  mvdriasis.  myosis,  irregularity  of  shape,  inequality  m 
tlie  two  eves,  ainl  disturbance  of  the  pupillary  ivllex  often  appear 
in  the  pnidromal  stage:  but,  as  a  great  variety  of  cerebral  lesion- 
due  to  widelv  dilTerent  causes  may  proiluce  similar  symptoms,  tlir 
largest  ex!)erii'nce  and  the  utiiust  cauti<in  and  judgment  are  often 
nr'cessary  to  enable  tiie  observer  to  interpret  tiu'in  correclly.  Then 
V  'ue  shoulil  carefully  be  estim.ateil  when  taken  in  connection  with 
the  evidence  derived  from  other  sources. 


TllK  EYE  IS  ITS  RELATION  TO  OESEIi.iL  VIHEAHES.       (JJl 

Many  striking  caM-s  arc  on  record  in  which  some  coinpiiratively 
t*linht  pupillary  anonwlv  has  served  as  the  warning  note  of  :ip|)roach- 
iiig  insanity;  but  every  ophthalmologist  of  wide  experience  sees 
numerous  cu^es  of  pupillary  anomalies  and  unaccountable  paralysis 
of  the  extrinsic  ocular  muscles  which  are  nevi>r  followed  by  such 
dire  conse«|uences:  and  while  these  symptoms  are  undoubtedly  of 
great  significance,  the  necessarily  complicateil  nature  of  the  subject 
and  the  Hniitations  of  our  knowledge  of  the  brain  should  warn  us 
to  exercise  caution  in  our  attempts  to  interpret  them. 

Mind  blindness  when  present  in  dem.uitia  is  generally,  though  not 
always,  found  in  the  later  stages.  Schweigger  reports  a  most  remark- 
able "ca-e  treated  bv  Wernicke  in  which,  "with  gooil  acuteness  of 
vision  anil  without  "any  absolute  def  t  in  the  field,  there  were  dis- 
tributed over  a  great  portion  of  the  tield  a  number  of  relative  scoto- 
mata,  within  the  area  of  any  one  of  which,  although  objects  could 
be  seen  by  the  patient,  y-t  he  could  not  tell  what  they  were.'" 

Mind  blindness  mav  be  paroxysmal,  continuing  for  .several  days 
and  then  disaiijiearing.  Though  it  is  always  tentporary,  it  is  ai)t  to 
!>(■  followeil  by  actual  blindness  iis  the  disease  progresses.  Hallucina- 
tions of  sight,  in  some  cases  unilateral,  are  very  common,  and  some- 
times appear  as  earlv  symptoms. 

.\trophy  of  the  o])t\c  nerve  may  occur  in  the  early  stages  or  even 
precede  mental  disturbance,  but  is  usually  a  late  symi)tom.  It 
appears  merely  as  an  incident  in  the  course  of  the  organic  cerebral 
lesions,  of  which  the  general  paralysis  and  insanity  are  symiKoms, 
and  is  not  of  very  freijuent  occurrence,  being  found,  according  to 
Cudden,  in  about  4.9  jier  cent,  of  a  series  of  l.'iS()  cases. 

Ilypera-mia  of  the  i)apilla,  and  even  a  slight  degr(>e  of  oi)tic  neuntis, 
liav("'  i)een  observed  in  a  verv  small  jjercentage  of  ca.«es. 

I'lipillarv  anomalies  and  disturbances  of  the  ciliar>'  and  orbital 
iimsries  are  the  most  significant  ocular  symi)toms  in  general  paralysis 
<il  the  insane.  The  pupils  are  usually  contracted  in  the  early  stages, 
.ilthough  later  thev  are  often  more  or  less  dilated;  but  what  is  termed 
ivHex  rigiditvof  the  pupils,  in  which  response  to  light  stnnulus  may 
Ih'  diminishcil  or  absent,  and  lat.T  reaction  to  convergence  and  aceom- 
inndation  mav  fail,  or  in  which  the  pupils  are  eciual.  or  one  or  both 
n^suiue  an  irregular  shape,  is  one  of  the  most  valuable  of  the  early 
^vmptoms.  .\mong  m)  ca.ses  Moeli  found  reflex  rigidity  present  in 
17  pel'  cent  ,  doubtful  reaction  in  4  per  c(>nt.,  and  sluggish  reaction 
in  10  iKT  cent. ;  and  among  20,-)  i)atients  witii  reflex  pui)illary  rigidity 
Thonis'-n  found  S,3  per  cent,  of  general  paresis  (Knies).  It  should  be 
.rniembereii.  however,  that  although  other  diseases  rarely  produce  this 
-\inptom,  absence  of  puinllary  reaction  to  light  and  reflex  rigidity 
.if  the  i)upil  are  among  the  more  common  ear  symiitoms  of  tabes 
dorsalis  as  well  as  of  general  i)aralysis  nf  the  in.sine. 
The  studv  of  pupillary  reactions  in  i    rvous  diseases  is  necessarily 


1  9vf«aiy,  m  Norrto  and  Oliver's  System  of  Dtaeaaes  of  the  Eye. 
41 


(>4^ 


TUK  km:. 


intricate  am 
iiiiirc  coiiiDli 


I  inviilvcd,  liiit  it  lias  liv  sdiiir  writers  Wecii  rciiilered  still 
iitteutiou  to  uiiii'-portaiit  details. 


■dl) 


•oriaiii  (I 
i'aralvsis  of  accoiiiiiiodatioii  is  of  far  less  fret|ueiit  oeeurreiice  than 
pupillary  anomalies,  heiiij;  found  by  Mi>eli  in  aiiout  1.')  per  cent,  of 
all  oases  (Knies). 

Altiiounii  not  so  cominon  a  syinptoiii  as  iiiydri!i.sis.  nuclear  paralysis 
or  paralysis  of  the  orbital  niuscies  is  occasionally  seen.  It  may  result 
in  loss  of  power  in  the  third,  fonrtli,  or  more  fretiuently  the  sixth 
nerve,  with  the  accompanying  diploina  and  strabismus  or  pt().sis. 
While  usimllv  temporary,  it"  is  not  always  so,  and  is  prone  to  relai)se. 
.\ccordinR  toSchutz.  SiemerinK,  and  Hoediker,  the  al)ove  oculomotor 
paralyses  are  "caused  by  .h'K«'"<'i"!itive  chanjies  in  the  central  gray 
matter  of  the  aqueduct  of  Sylvius  and  fourth  ventricle."' 

Ptosis,  twitchiii};  of  the  eyeli.ls,  and  transii'iit  uystanmus  may  all 
be  found  in  a  limited  numl)i'r  of  ca.ses,  and  among  other  motor  dis- 
turbances of  cortical  origin  we  not  iiifn'«iuenlly  have  conjugate 
deviation  of  the  head  ami  I'ves. 

Several  writers  have  mentioned  ocular  migraine  or  scintillating 
scotoma  as  a  not  infrei|uent  premonitory  symptom  of  paretic  demen- 
tia, but  this  is  of  such  friMiuent  occurrence  in  other  conditions  that 
it  is  certainly  not  a  symptom  of  great  diagnostic  value. 

Diffuse  cerebral  sclerosis  is  apt  to  be  accompanietl  by  impaired 
pupillary  re.iction.  and  cases  of  paralysis  of  the  sixth  nerve  and 
nystagmus,  as  well  as  optic  ni'uritis,  have  been  reported. 
"  In  paralysis  agitans,  or  Wilkinson  s  disease,  a  bilateral  or  rarely  a 
unilateral  tremor  may  solnetiims  be  noticed  in  the  muscles  (tf  the 
margin  of  the  upper  lid.  This  is  more  marked  when  the  lids  are 
closed,  and  is  accoin])anied  by  a  degree  of  rigidity  on  attempting  to 
ojM'ii  them.     Nystagmus  is  a  rare  symptom. 

.Vcording  to  Gowers,  the  slowm  -  of  motion  which  is  notice- ble 
in  other  portions  of  the  muscular  sy.stem  rarely  atTects  the  (.;.  al 
muscles.  The  patient  will  turn  the  eyes  instantly  i.:  any  desired 
direction,  and  follow  them  slowly  with  the  heiwl  by  the  action  of  the 
inu-sdes  of  the  m^ck. 

Si)asm  of  iicconunodation  lias  been  noted  in  several  cases  by  Koenig. 
and  gray  atr()])hy  and  bilateral  ptosis  have  occasionally  been  reported. 
Disseminated  sclerosis  in  a  large  proportion  of  ca.ses  is  accom- 
panied by  very  significant  and  characteristic  eye  symptoms  which 
may  be  of  great  diagnostic  value.  They  manifest  theniselves  in  d(  fec- 
tive  vision,  a  variety  of  forms  of  limitation  of  the  visual  and  color 
fields,  color,  and,  in  rare  instances,  absolute  scotomata,  variations  in 
th<'  ophtlialmosco])ic  appearance  of  th(>  disk,  and  disturbances  of  the 
ocular  and  orbital  muscles.  The  onset  of  these  symijtoms  may  be 
gradual,  but  more  often  they  come  on  suddenly.  They  niay  atTect 
one  or  both  eyes,  and  they  Vary  in  degree,  sometimes  disappearing 
entirely,  and  in  other  instances  relap,sing  after  an  interval  of  many 


'  9w«iizy,  in  Norrir'  and  Ol'ver's  System  of  Diseases  of  the  Eye. 


TliK  EYE  IS  ITS  RELATlOS  To  tlKSEHAL  DISEASES.       (j  t;{ 

wiiks.  Aiii.iiinisis,  which  i;*  rarely  complete  and  |MTmaiii-iit,  may 
Kiiitinuc  for  r^cvoral  months,  and,  after  prolonged  remission.  a|)iK'ar 
i,'.iiii  (Charcot).  It  is  apt  to  lie  accompanied  hy  the  sensation  of  a 
mi-t  before  the  eyes,  and  even  when  scotomata  are  present  these  are 
iMiily  alisolute.  hire  cases  of  disseminated  sclerosis  jire  not  accom- 
pMiiied  hy  hemianojisia.  and  this  tends  to  prove  that  tin- lesions,  like 
those  of  retrohulhar  neuritis,  are  not  in  the  chiasm  or  optic  tracts. 
Wilt  in  till'  o|)tic  nerve  itself. 

\isiial  <lefects  and  changes  in  the  appearance  of  the  optic  disk  may 
imcede  the  other  symjitoms  of  disserninated  .sclerosis  hy  months  or 
yiiirs,  or  they  may  make  their  appi-arance  in  the  early  stap's;  Imt 
ihiy  are  usually  found  only  after  the  general  symjjtoms  are  well 
iliveloped.' 

Anion}!  the  most  striking  ocular  manifestations  of  di.s.s(>minated 
-cliio^is  are  the  disorders  of  the  ocular  and  orbital  mu.scles.  and  of 
ilicse  the  mo.st  important  are  the  nystagmus,  ataxic  nystagmic 
iwiichiiigs,  and  tremors  attributed  by  Knies  to  insudicieiit  cortical 
iiiiiiTvation  of  the  nuclei,  which  he  believes  to  be  due  in  the  main  to 
I'liimidear  foci  in  the  fibres  of  the  corona  radiata. 

Nystagmus,  which  is  very  rare  in  other  forms  of  nervous  disease, 
I-  s.iid  to  occur  in  about  one-half  of  the  cases  of  dis,seminated  .sclerosis. 
Hither  with  or  without  nystagmus  we  may  have  disonlers  of  the 
;i-s()ciated  nioveineiits  of  the  eyes.  This  was  observed  by  rtlioff  in 
iliree  out  of  KK)  ca.ses.  Isolated  jiaralysis  of  the  external  ocular 
muscles  and  nuclear  paralysis  may  occur,  an  "xample  of  the  l.-itter 
liiing  defective  conjugate  motion  to  the  right  or  left  and  paresis  of 
ihe  ])ower  of  convergence  (Swanzy).  The  peripheral  n(>rves  have  been 
I  lUiid  in  a  number  of  instances  to  be  the  seat  of  sclerotic  foci,  I'thofT 
li.iviiig  noted  four  ca.ses  of  unilateral  abducena  paralysis  and  three 
■  tises  of  partial  paraly.sis  of  the  motor  oculi.  Moderate  degrees  of 
impairment  of  motility  are  very  common.  As  in  the  ca.se  of  jiaralysis 
nl  the  optic  nerv '.  the  motor  affections  are  much  more  freciuently 
-'•111  after  the  other  symptoms  are  well  developed,  but  they  may  occur 
III  the  e.'riy  stages,  or  even  l)ofore  any  other  evidences  of  the  di.sea.se 
Ikivc  ap] cared. 

Abiioriiial  pu|)illary  reaction  is  uncommon  in  dis.seininated  sch-rosis, 

'>n\  a  few  ca.ses  have  been  ob.served  including  reflex  rigidity  of  the 

i'ii|)ils.  myosis  in  the  advaiiced  stiiges,  impaired  light  and  conyer- 

iT'iice  reaction,  inecjuality  of  size,  and  hippus.     Uthoff  found  sight 

li'viations  from  the  normal  in  16  jxr  cent,  of  the  cases  .studied  hy 

^ini. 

As  Swanzy  has  pointed  out,  the  fact  that  ophthalmo.ieoi)ic  clianges 

I  the  disk  may  be  ob-served   in  alx)ut  50  \)0t  cent,  of   the  cases  is 

I  value  m  establishing  the  diagnosis  between  disseminated  sclerosis 

Hid  hysteria,  in  which  wo  sometimes  find  symptoms  resembling  those 

:  tiie  earlier  stage  of  the  former  diseiisi'.     And  we  are  also  tussislt-d 


1  Swanzy.  la  Norrm  and  OllTer'i  System  of  Diseaaes  of  the  Eye. 


644 


TIIK  EYE. 


f 


I    f 


1)V  till-  rarity  of  central  -coloiiia  ami  tin-  irregular  and  erratic  cliar- 
actvr  of  the  visual  ami  color  tirl.ls  in  hysteria,  as  compared  with 
tints*'  of  liisseiiiinated  sclerosis  which.  altlioU(tli  narrow,  follow  the 
regular  |)hvsiolonical  order. 

In  amaurosis,  sc  lomata,  and  impairment  ol  the  visual  nelds  the 
symptoms  indicate  retrohulhar  disease  of  the  ojitic  nerve,  and  granular 
d"en<-neration  of  the  me<hillary  sheaths,  with  intact  axis-cylinders,  inuy 
he  found  with  other  evidence  of  interstitial  neuritis.  l)«'Renerutive 
foci  are  undouhte.llv  some  times  found  in  the  primary  optic  tjanglion, 
and  rarely  in  the  rhiu.sin  and  traetus,  but  they  are  of  far  more  fre<|uent 
occurrence  in  th<'  optic  nerves. 

Accoriling  to  Kriies.  the  pathological  p..  in  the  optic  nerve 

•'.stands   midway    iM-tween   pronounced   optic    .leurltis   and   simple 

t'trophv." 

Wliile  the  medullary  slwaths  are  destroyed,  a  large  pro|)ortion  of 
the  axis-cylindors  esca"pe.  although  from  time  to  time  in  tlu'  progress 
of  the  dis<'iv.se  th'.r  conductivity  may  he  impainMl.  This  accounts 
for  the  fact  that  the  -.isturhance"  .i  vision  or  the  defect  in  the  visual 
field  may  he  very  pronounced,  while  the  oi)tic  disk  appears  normal, 
and  that  vision  mav  var-  from  time  to  time,  or  he  in  a  meiusure 
restored  so  long  as  the  !\xis-cylinders  wliich  pa.ss  through  the  sderose.l 
patches  are  not  actuahy  destroyed.  Optic  neuritis,  according  to 
rthoff,  is  found  in  about  5  per  cent,  of  the  cjuses,  hut  the  ophthal- 
moscope  reveals  no  retinaratrophy,  and  there  may  he  no  visible  evi- 
deiKv  whatever  of  a  defect  of  tin-  optic  nerve.  Decided  atrophy 
occurs  in  only  about  A  per  cent,  of  the  cases,  and  evim  |)artial  atrophy- 
in  only  1!>  jxT  cent.  In  a  considerable  luimlMT  of  cases  (about  l.S 
|)er  cent.)  an  uphthalmuscopic  picture  is  observed  closely  resembling 
that  of  toxic  ainblyoi)i  i.  'I'liis,  however,  i-  not  in  every  case  accom- 
]ianied  bv  tiie  characteristic  central  scotoma. 

When  111''  ntrin>ic  and  extrinsic  ocular  muscles  !ire  affected,  the 
lesions  are  in  the  main  nuclear,  although  in  a  luimber  of  instances 
sclerotic  foci  have  been  found  in  th<'  iieripheial  nerves.  I, cube  saw- 
both  motor  oculi  nerves  converted  into  thick  gray  bands  (Knies). 

Deformities  of  the  skull  following  chronic  meningitis  in  infaiits. 
producing  premature  ossification  of  the  crani.-il  bones  and  narroving 
of  tlieoi)7ic  foramina,  rc.'^ult  first  in  ojitic  neuritis  and  laler  in  atrophy 
of  the  opt'c  nerve. 

Hydrocephalus  .-is  seen  in  infancy  may  be  accom|):mied  by  optir- 
neuritis  or  atrojihy  i>f  the  optic  nerves,  but  this  is  not  (if  fi-c(|uent 
occurrence:  while"  hydrocephalus  appearing  lat.r  in  life,  when  th< 
sutures  are  more  firmly  united,  is  as  a  rule  accompanied  by  such 
symptoms  ami  by  evidences  of  jiressure  closely  resembling  tiuise  of 
tumor  of  the  brain. 

S\v:in7.v,  in  Xorris  and  Oliver's  Sjisloii  <>j  Disease.^-  oj  Ihr  Eye,  calls 
attention  to  the  occurrence  of  bitemporal  henuaiiopsia  in  hydro- 
cephalus, due  to  pressure  on  the  optic  commi.ssure  by  the  disteiidei! 
floor  of  the  third  veiii.icle. 


riiK  KYt:  IS  ITS  HEirruis  ra  oeskhm-  DistcAsK.s.     m:, 

In  th.'  v.ui.ais  furiiis  of  iiirniiinitis  as  wrll  as  in  liy.ln...-|.lialus, 
iImiv  is  ..Itfii  such  a  lower.-.!  stall'  of  vitality  an  to  U-ml  to  tin  .l.v<-l..|.- 
iiiriit  of  ixcialilisaiid  (•oiijm><'''vitis.  . 

Porencephalus  (cvsts  orcavitics  inth.TortfX)  may  lM'a<T..m|miiicil 
l,v  .v.-  svin|.t..inrt  s.',iii  what  siinlar  to  tiios  •  whi.'h  a|.|K-ar  in  soll.-ii- 
iiit:  ■  Nystagmus,  ptosis,  r.'llcx  ri  -i.lity  of  tlu-  I'Upil,  and  Kiay  atr.i|.hy 
,.|  the  ojiti.' IHTV.' have  all  Im-  .1  <   .-"rv.'.!. 

Bulbar  paralysU  in  its  typicai  form  is  not  acooinpanuMJ  »)y  oyi- 
-yniptonis.  l.iit  ilii.'.as  it  is. "to  patiiol..p.-al  pnurss.'s  in  ih.-  ni.'.lulla 
,,'l,l(,iij;ata,  it  sonii'liin.'s  lias  jissociat.-.l  with  it  l.-sioiis  ot  tin-  visual 
;,ii<|  I'^sp.riallv  tli<-  motor  (•.■ntr.'s  of  the  vyr.  Opii.'  iicrvo  atrophy 
l,a>  Im'.ii  ohscrvi'.!.  and  sfv.'ial  writers  have  reported  .as.r  of  paralysis 
,,f  the  o.'iilar  and  orhital  imis<-l.-s,  with  n-stiltiiiK  dilatation  and  tixa- 
iiMii  of  the  imiiils,  nvstanmns.  .i-ular  d.-viation  .ir  fixation,  ami  even 

;,  ,|.%'r f  .•xophthalm.is.     ("o.ijnuate  .levialioii   and   paralysis  of 

ihiMiciilar  hraiieh  of  the  facial  have  Ite.-n  noted,  and  while  th.Mlis<'ase 
I-  al  its  hei;;ht  coiic'ritri.-  limitation  of  the  visual  field  and  slijiht 
iin|i:iiriHeiil  of  vision  inav  o.Tiir.  Straininski,  of  Wiina.  reports  a 
,  :,>e  .if  this  kin.l  followini;  iiillueiiza,  ami  terininatinj:  in  re.-overy  in 

nine  iiioiitlis  . 

Progressive  ophthalmoplegia,  or  what  in  rontradistinction  to  pure 
l.iill.ar  paralvsis  has  Ix'eii  .lesignati'd  as  snperi.)r  poliencei.hahtis  in 
lis  acute  for.il,  is  due  to  hemorrhagic  intlainination  of  ih.'  gray  matter 
in  the  floor  of  ih.' fourth  ventriel  aii.l  the  a<|ue(liict  of  Sylvius  (Knies). 
In  a.l.lition  to  the  somnolence,  which  is  characteristic,  th.-re  is  pro- 
_'i.s>iv.'  paralysis  of  the  ocular  muscl.'s.  and  this  may  in  a  short  tiiiie 
!..■  .|uite  complete. 

Ill  the  chroni''  form  there  is  dejieiieratioii,  which  may  all.'ct  the 
nuclei,  nerves.  ■  muscles,  |)ro(lucinn  proRrofive  paralyses,  which  are 
Msiiallv  hilat.Tal.  although  irr<'j;ular.  and  may  Im-  complet.-  ..r  inconi- 
|.lete."  Thes.-  paralvses,  with  the  resultiiift  convergenc.-,  divergence, 
nvstafrmiis.  refli'X  rigidity  of  the  pupil,  -t.'..  may  disappei-r  in  whole 
,1  in  p;ut,onlvt.)ap|iearafiainHiuli'ontimieti.  advance  (K  les). 

Syringomyelia  is  accompanied  somclimes  hy  concentric  contrac- 
iiun  of  tli(>  visual  fields  and  raHy  l)y  optio  neuritis.  Abduccns 
jiiiralysis  aii'l  nystaginu:  have  also  been  reported. 


disea^:eis  cf  the  spinal  coed. 

Myelitis  is  .iccon.,.ani<^d  sometimes  hy  optic  neuritis,  which  may 
vc.veror  jio  on  to  cmplete  l)liii.lnesp;"and  Swanzy  points  out  that 
1  the  cervical  portion  of  the  cord  is  involve.l  wo  may  have  my.lria-sis 
lin- to  irritation,  or  pavalvtic  niyosis. 

Tabes  dorsalis  is  in  a  large  proportion  of  cases  accompanied  or 
iT.T.l.,!  l)v  eve  svmntoms  which  :ire  nf  Mie  i;re.ntest  importance 
in.l  often  supplv  the 'first  positive  indication  of   the  nature  of  this 

rious  disease.  "  These  consist  of  atrophy   of  the  optic  ncr\-e,  par- 


(J4(> 


THE  EYE. 


i\\\i^\fi  and  ataxy  "f  the  ocular  iuuspIos,  pupillary  alterations,  and 
jiansis  or  paralysis  of  accoininodatiiiii. 

Assooiatt'd,  as  tabes  often  is,  with  other  ditTuso  cerebral  and  spinal 
vlisease,  the  ocular  symptoms  afford  important  assistance  in  estab- 
lishiui;  the  diaf^nosis.  Atrophy  of  the  optic  nerve  is  found  in  about 
20  per  cent,  of  the  cases,  and,  when  fully  develojied,  the  disk  is  s^iiy. 
is  often  slifthtly  cupped,  revealing  the  delicate  fibres  of  the  lamina 
<'ribrosa,  ainl.  especially  in  cases  with  a  deep  physiological  depression, 
is  dilhcult  to  distinguish  from  glaucoma  siin|)lex. 

In  the  earlier  stages  the  grayish  discoloration  of  the  disk  is  more 
noticeable  on  the  temporal  side  than  on  tlie  nasal,  which  is  normally 
nioH'  jiink  than  the  outer  half,  but  as  the  disease  ailvaiices  tht^  whole 
.surface  becomes  uniformly  gi'ay,  and  the  arteries  and  veins  are  reduced 
to  narrow  threads. 

Whatever  may  be  the  cause  of  tabes,  it  is  evident  that  the  atrophic 
process  in  tiie  optic  nerve  is  not  a  direct  extension  of  the  disease  in 
the  brain  ;ind  cord,  but  a  se|)arate  manifestation  of  the  same  process. 
The  fibres  in  the  centre  of  the  nerve  are  affected  last,  and  LeIxT  has 
shown  that  it  liegins  in  the  peri|)hery  of  the  retrobulbar  p'ortion  and 
extends  toward  tiie  axis.  The  gray  atrojihy  may  also  sometimes  be 
d(>tected  in  the  chiasm,  tiie  tractus,  and  even  as  far  as  the  primary 
()|)tic  ganglia  ( Knies). 

Some  writers  claim  that  in  the  very  early  stages  hypcra'mia  of  the 
ilisk  precedes  .atrophy  of  tin-  optic  nerve,  but  this  is  not  established, 
and  on  theoretical  grounds  it  would  seem  improbable,  as  the  i)rocess 
is  a  primary  atrophy  of  the  nervous  elements.  Both  histologic.-illv 
and  with  the  ophth.almoscope,  tabetic  atro])hy  is  easily  distinguislieil 
from  ]i(istiieuritic  wiiite  atroi)hy,  in  which  a  den.se  white  or  yellowish- 
white  disk  is  seen  utirely  obscuri  ig  the  fibres  of  the  lamin;i  cribrosa. 
Atrophy  of  the  i)]iti('  nerve,  while  sometimes  ap))e;iring  in  the  later 
stages  of  locomotor  ataxia,  may  antedate  the  aiijiearance  of  ataxia 
or  even  i)recede  the  lightning  pains,  loss  of  knee-jerk,  and  other  spinal 
.symptoms  from  two  to  twenty  years.' 

Ophth.'dmoscopic  evidence  of  atrophy  generally  precedes  distm'b- 
ance  of  vision,  but  thi' visual  disttu'bance  may  in  >ome  cases  be  much 
more  mat'  cd  than  would  Ix'  indicated  by  the  ajipeanmce  of  the  disk. 

Strange  as  it  may  .seem,  many  writers  maintain  that  the  progr(>ss 
of  the  general  disea.se  is  checked  and  there  is  an  ab.'itement  of  the 
spinal  «iympto!us  on  the  development  of  optic  atro|)hy  if  it  appears 
in  the  |)re;itaxic  stage.'  In  regard  to  this,  Knies  very  iirojierly 
rem.-uks  that  ;i  mistaken  diagnosis  may  account  for  the  improvement, 
as  the  prognosis  is  often  much  more  favorable  in  some  of  the  n<'urotic 
.•ind  selenitic  processes  which  may  be  mistaken  for  tabes. 

Authorities  ditTer  greatly  as  to  tlu'  fnvjuency  of  the  occurrence  of 
optic  atro|)liy  in  tabes,  (lowers  pl;icing  it  at   l.'J.o  per  cent.,  while 


swan/y,  in  Nnrris  ati-I  Oliver's  System  of  IHReif.es  nf  the  Eye. 
Beneiiiet,  Wieii   lucl   I're»-e.  ISHl,  Nob.  1.  2,  3.  4,  5. 


THE  EYK  IS  irs  RELATWy  TO  GEXEIIAL  inSEASEH. 


«47 


,Vr.n.r  dvos  :5:U  per  ont..  an.l  rtl.off  20  per  .-.nt.     Altlx.ugh  both 

' \;Z'::^^iu..t^'^  that  two-thinls  of  all  optic  ..rvc-  atn.phu. 
J.  t2ti..  origin ;  l.t.t  wlu-th.-r  this  1...  n.rrc.t  or  "<;J>-- ,;  f^ 
„.,  ,..nuin.-  ...y  atrophy  of  tho^.t^  llX tS  .i^^ S^i^  alt'; 

"";;';;"" '.'•X''att..ntion  to  tho  fact,  which  i.  on>itt..l  by  .onu- 
w,^;'^.:  a       to  l.cKinni,.s  vv  .nay  havo  such  ^ubjoc'tivc  phc.om- 

'as'potophobia,  J  sensation  of  sparks  an.  f-^^J'^^'  f^ 
tnt  the  patients  con.plain  ..f  a  fog  or  sn.<.ke  before  the  f'><s-     "^ 

.      ,Lts  out  th'it  the  interval  between  the  :ippearance  of  optic 

-lill  :il)le  to  set> 

TIk'  op!'"-  atropliv  oi  ^:"'f>  i>  avi...... ......■■     .    -  t4,.i,u-  .,,„i 

,„,  ,.,,,.1.  vision  'an,l  narrowin,  of    th.-  v.su:^;uul  color  helj-^and 

1 
The  contraction 


r v,.i,.„ 'a,;.i „»r.™vi:,f of  ,i„. -'-■'";;;;;';,, .t;, 

;:;;;,;;:;:::-i;i::™;rr;;:t;:l.]i;:;:.i^^»;V'^,s 
i:;,,.-::r:;;;;;,:;;H::t;^,:"i;'ir';s;;,,!v:;;;  ^■;^: 

n":,;ir:,.;;;;,::";:"':r,K'::»  S';:,.  a.  ve.^  - ..;  .»*>. 

:;:;;■  ™;ll"';;;,;«™i;;r!.u.^  "ill «,«  ,.. » .;;;;*;;;;;;;, 

;,.  nc.v    r.v  n.avke.1  in.i.ainnent  of  central  visu.n  ^^^\^  a  norma 
:.n  :Srana-l,l:  hut  usnallV  in.pairn.ent  of  the  --a^  i^;  <  an. Moj.  ;^ 
l,L\  visi..n  as  they  pr.^sress  b.-ar  a  -l.-tunt.'  n-latu  n       ''"    '  ^^'^^'^^j 
Sw.n.v  r..f..rs  to  the   fact   that    a  <<'"M'.'rary  funct  o  a    .     n^^^^ 
,„c  narr....n.  ..f  the  visual  "e;^  .->;-;■  t    --n  .;:;>; -;.  ^^^^ 

,l;;":,.;tr'7tS.':"bu;  t^:^^t..  r....^y  in  direct 


!S5!5^^" 


•rrsr 


T^S^^^S^. 


r?s^ 


^nsrr 


II 


'i\ 


(J4.S 


THE  mi:. 


|)r.)li.)rti(iM  to  till"  visual  disturbiincp  mr  to  tho  liiiiitatioii  of  tlic 
visual  ticlil.  Ill  some  instances  it  may  oven  !)(>  (Ictcctcd  Ix-forc  ojitic 
atrophy  <'tin  he  (liscovorcd  with  the  ophthalinoscopc. 

An  ('xaniiiiatioii  of  the  color  fields  is  very  important,  as  those 
cases  in  which  their  narrowiiifi;  is  much  more  niarke(l  than  the  field 
for  white  are  ajit  to  be  rapidly  profiressive :  and  Kiiies  has  ixiinted 
out  that  a  re-enteriii>;  aiijile  in  the  boundary  of  the  color  field  is  the 
forerunner  of  a  similar  riarrowiii<;  of  the  held  for  white. 

As  rare  visual  disorders,  we  may  in  the  later  stajjes  have  sym- 
metrical defects  of  the  visual  fields  or  liomonymous  hemianopsia. 

Disorders  of  the  ocular  muscles  are  of  fre(iueiit  occurrence  in  talx"-. 
and  their  iinportanci"  is  jireatly  increased  by  the  fact  that  in  a  larpe 
projiortion  of  cases  they  aiipear  in  the  early  stages,  my.lriasis,  diplopia, 
or  ptosis  often  bein<;  the  hrst  symptom  to  attract  the  attention  ot 
the  patient.  Acc<irdin<;  to  I'thoff.  Ii.ry  are  found  in  •_'()  per  ."eiit., 
and  according  to  Heifier  in  '{S  per  cent,  of  all  cases.  Thi'y  usually 
ilevelop  suddenly,  and  while  they  may  be  i)ennaiieiit,  more  freciueiitly 
disa|ipear  after  ;i  period  varyiiif!;  from  a  few  hours  to  a  year  or  more; 
but  they  are  prone  to  rehipse,  aiicl  they  are  more  ajtt  to  hi'  iiermanent 
if  occurriiifi  in  the  later  stall's  of  the  di.sease.  The  sudden  ajiix-ar- 
aiice  (if  paralvsis  of  an  ocular  muscle  in  an  apparently  h(>altliy  person, 
especially  if  it  recovers  in  a  short  time  or  subscvpieiitly  relapses, 
should  ahvavs  arouse  the  suspicion  of  tabes  (Knies). 

.\ny  one  or  more  of  the  orbital  nerves  may  be  atfected,  but  paralysis 
and  paresis  of  the  abdueeus  and  motor  oculi  are  of  most  freciuent 
occurrence. 

The  lesion  in  paralysis  of  tabetic  orifiin,  while  it  may  lx>  perinuclear 
(,.  internuclear,  is  generally  ixTijiheral  or  nuch  <r,  and  therefore  we 
never  have  associated  or  conjujiate  paralysis  '  •  t'ii's).  While  true 
nvstafimus  is  of  very  rare  occurrence  in  tabes,  we  not  infre(iuently 
iiiav  observe  ataxic  dscillations  or  what  are  sometimes  termed  nys- 
tagmic twitchiiifis,  which  may  be  (h'monstrated  by  cau.siiif;  tho  eye 
tcTfollow  ;in  object  in  motion  anil  fix  it  when  the  motion  ceases. 

Paralysis  of  the  ocular  branch  of  the  facial  nerve  is  of  rare  occur- 
rence, but  jiaresis  accompanied  by  tremor  on  etTort  to  clos(>  the  lid 
is  fre<iuently  ob-erved. 

Pupillary" alterations  arc  of  the  greatest  diagnostic  importance  in 
tabes.  Tlie  pupils  may  be  of  une<iiial  size  in  the  two  eyes,  and  are 
very  often  of  irregular  shape.  Mydriasis,  due  to  oculomotor  paralysis, 
but  not  necessai-ily  accompanied  by  cycloplegia,  is  sometimes  observed, 
though  it  is  rare!  Myosis,  on  the  other  hand,  is  very  common,  and 
may  be  looked  ui)on  as  characteristic  of  tabes  dorsalis.  The  contrac- 
tion iiiav  be  extreme  C'lnn-hole  iiupil")  or  of  only  moderate  degree: 
but  whether  normal  in  size  or  contracted,  our  attention  in  this  disea.se 
is  es])ecially  directecl  to  the  absence  of  reaction  to  light,  accommo- 
dali\i-  etTort,  cuiivfTgrnce,  ;nid  cutaiu-Diis  i; lilittiuii.  wliich  ap-jwar 
ill  the  various  stages  as  the  tabetic  changes  progress.  These  puiiil 
chan"es  are  due  to  disease  of  the  ciliospinal  centre. 


THE  EVE  IS  ITS  RELATWS  TO  GESERAL  DISEASES. 


(J4D 


Tlio  ArKvll-U..l.(Mts..n  pupil,  wliilo  it  is  als..  <.cca.«i..nally  obseryctl 
in  other  nn-v..us  .lis.-ases,  is  a  i.u.st  i.npurtaiit  sy.npt..ii.  -t  tat.os 
,l..r«ali>^  It  consists  in  the  absence  of  contraction  <.n  exposure  to 
ILrlit  of  a  pupil  wliid.  still  retains  the  power  to  contract  ui  conyer- 
..;«•.-  or  acconnn.Mlation.  Th<>  pupil  may  be-  normal  or  even  .hlate.l 
^ithoUKli  it  is  penerallv  .(uite  narrow,  and  it  shou  .1  be  born.,  in  n.in<l 
,l'Tt  later,  win  the-  .lis..as..  is  sutti.-iently  a.lvance.l.  a.ul  aft.-r 
r„.ht  stimulus  has  ceas.'.l  to  cause  contraction,  the  reflex  to  sensitive 
-tlmuli,  such  as  cutaneous  irritati..n.  is  lost,  an.l  hnally  convergence 
,ils<.  fails  to  be  accompanied  by  contraction 

Whil.-  occasionallv  .-ntin-lv  wanting,  th.^  Argyll-Robertson  pupil  is 
,„„.  of  the  most  cmstant  of  all  the  symrtoms  of  tabes,  and,  owing 
,.,  the  fact  that  it  is  often  an  initial  symi-tom.  its  value  can  scarcly 
I,.,  overestimated.  Dillman  f.mnd  it  in  7f>  per  c(-nt.  of  his  cases.  In 
:;i  (i  per  cent,  the  pupils  responded  lu^ither  to  light  nor  c.nyerg.-nce. 
V.id  th.-  iK.rinal  condition  of  both  r  »'il«  was  tomu  by  Herger  in 
„nlv  4  among  109  cases  (Knies).  The  latter  writer  has  als..  called 
.,tt;.nti<m  to  the  fact  that  in  myosis  of  si.inal  origin  mydriatics  are 
!,..<  ..ffective.  while  in  s,.inal  mydriasis  the  action  ot  myopics  is 
.r„ni„ish.-d.  In  examining  for  the  presence  of  th.-  light  r..flex.  Swanzy 
...mHs  attention  to  the  importance  of  avoiding  such  cutan.-ous  irn- 
i.tion  as  is  apt  to  result  from  touching  the  skm  of  the  face  or  luls, 
;„h1  rec.mmen.ls  that  the  t.-st  be  made  in  a  darkened  room. 

I'nalvsis  of  accommodation  is  rare.  AVhen  touiid,  it  is  g<-nerally 
in  Mssoc'iation  with  mvdriasis  and  in  the  late  stages  ..f  tlu;  disease. 

What  is  sometimes  termed  sympathetic  ptosis  but  is  really  a 
~!i-ht  drooping  of  the  upper  lids  not  due  to  paraiy.sis  of  the  third 
nrrve   is  occasionallv  observed  in  a.ssociatiou  with  myosis. 

M.other  somewhat  rare  sympathetic  syini)tom,  but  which  Borger 
,.l;,i,„s  to  have  s<.en  in  half  of  his  cases,  is  ei.iphora.  It  is  attributed 
,,,  disturb.-d  lacrymal  secn^tion  an.l  imperfect  actum  of  the  ..rbicu- 
l.uis  paliM-braruin.  B.'rg.-r  also  calls  att.mtion  to  impert<.ct  cL.sure 
uf  the  .'v.-lids.  with  tilmllarv  twitchings  of  the  orbicularis  muscle, 
:,n.l  t<.  rivluced  intra-ocular  fension.  which  h.-  attributes  t..  paralysis 
, ,1  til.,  sympathetic.     ( )th.T  writers  s.>ldom  mention  these  symi)toms. 

TROPHONEUROSES. 

.\crom.-alv  s.mietimes  causes  great  thick.-ning  of  the  bor.l.-rs  .)f 
th.^nrhitsraiid  tiiis  mav  be  incr.>as.Hl  by  .lilatat.on  ol  the  frot.tal 
.inus..s.  Th.-  lids  mav'b<>com.-  hypertroi-hi.'.!  and  brown  in  color. 
Tho  .•onjun.-tivM.  fat,"  an.l  orbital  muscles  an-  at  times  hypcr- 
irMphi.-.!,  an.l  the  .>x.M'hthalm..s  whica  occasi.mally  develops  ma> 
1m  :icc.impani.>d  by  atr.)pliv  of  the  oi)tic  n.TV.'s.  .,       , 

llvpertr-iphv  of  the  !,ituitarv  bo.ly  is  by  s..m<-  writers  cnnsi,ler<-.l 
:,<  a  .-ause.  but  Marie  looks  upon  it  as  one  ol  the  r<.suits  ..1  acr..m.-gat>-^ 
ll„w..v.-r  this  mav  be.  the  resulting  pressure  upon  the  chiasm  and 


~W. 


•T"wiTri¥- iiii~~  iii-TirM — iri i  nw-^^i  i  imrriaiffTrfi-Ti'^T  ..;'^  ^aii«.i: 


tJ50 


THE  EYE. 


optic  tract  may  lead  to  optic  neuritis  or  ciioivcd  disk,  or  to  Ijitcm- 
porai  l)(>iiiiauoi)sia,  or  narrowing  of  tiic  visual  fields,  defective  vision, 
and  sonu'tinies  even  to  complete  blindness. 

Hemifacial  h3rpertrophy  is  a  rare  affection  in  which  the  eye  neces- 
sarily hears  an  im])ortant  part.  The  orbit,  lids,  and  eyeball  are  often 
greatly  enlarged,  leading,  when  the  hall  is  hypertrophied,  to  exj)osure 
of  the  cornea  from  dithculty  in  closing  the  lids.  Knies  and  Ziehl 
have  each  reported  a  case  in"  which  the  eyeball  took  part,  proilucing 
a  high  degree  of  myopia  and,  in  tiie  case  of  the  former  observer, 
extensive  choroidal  changes. 

Progressive  facial  hemiatrophy,  which  Ix'gins  with  unilateral  irri- 
tati<in  of  the  cervical  symi)athetic  ant!  later  i)a.sses  into  paralysis, 
involving  also  a  h^sion  of  the  trigeminus,  ])roduces  pto.si.s,  myosis, 
and  enoi)hthalmos,  with  oculoi)upillary  irritation  and  paralysis. 
There  is  progressive  thiiming  of  the  skin  of  the  eyelids,  and  the  brows 
and  lashes  turn  gray  and  fall  out.  Retraction  of  the  lids  often  leads 
to  exposure  and  disease  of  the  cornea.  Kalt  observed  choroiditis 
and  myopia,  and  Ruhemann  reported  i)tosis.  divergent  .strabismus, 
cataract,  impaired  mobility  of  the  eye  and  contracted  pupil  (Kniesj. 


i 


INJUKIES  TO  THE  BKAIN  AND  SPINAL  CORD. 

Injuries  to  the  brain  produce  a  variety  of  eye  symptoms  which 
may  he  classified  as  io)  those  which  are  the  direct  effect  of  trauma- 
tism of  the  cortex,  nuclei,  tracts,  chiasm,  or  o|)tic  nerves,  and  (7/) 
those  whirl;  result  from  hemorrhage,  meningitis,  and  abscesses  of 
traumatic  origin.  I'nder  their  respective  heads  the  eye  symptoms 
wliich  follow  th<"  conditions  mentioned  in  the  latter  grouj)  (r)  have 
alreadv  receive(l  consideration. 

Well-de'ined  and  clear-cut  localizing  symptoms  may  occa.sionally 
be  observed  in  gunshot  and  punctureil  wounds.  \  wound  of  the 
cortex,  if  in  the  occi|)ital  region,  may  be  followed  by  cortical  blind- 
ness or  hemianopsia  witii  conjugate  deviation  and  nystagnuis;  hut 
fractures.  esiH'cially  fractures  of  the  ba.se,  are  aji*  soon  to  be  compli- 
cated bv  hemorrhage  and  m<'ningitis  which  obscure  the  symjjtoms. 
Not  infre(iuentlv.  however,  in  fracture  at  the  base  which  does  not 
necessarily  rcMjuire  a  blow  of  great  force,  if  in  thr-  iiroper  direction, 
one  or  both  of  the  ol)tic  foramina  are  involved,  lacerating  the  optic 
nerve,  and  we  have  innnediate  blindness  with  loss  of  i)U))illary  reaction, 
<'ven  before  iiillammatory  symptoms  have  develojjed.  This  is.  of 
eoiuse.  soon  followed  by  atrophy.  Both  Kna])]>  and  Knies  have 
reported  such  casi's,  and  the  latter  author  records  one  reported  by 
Taflier  in  which  fracture  of  the  frontal  bone  was  followed  by  nasal 
hemianopsia  evidently,  so  he  states,  due  to  involvement  of  the  anterior 
angle  <ii'  I  lie  chiaMri.  Such  traumatisms  may  also  involve  the  niotor 
nerves,  esjx'ciallv  the  facial,  proilucing  lagophthalmos  and  the  ab 
(lucens,  causing  "paralytic  convergence. 


I 


THE  EYE  IS  /!>■  RELATIOS  TO  OESEUAL  DISEASES.       (J-,1 

('uiii])i('ssioii  of  tlio  hraiii  and  (•oncu><si()ii  hotli  cause  |m|iillary 
<'liaiiji('s.  Ill  the  lornifr  we  liavc  mydriasis  witlioiit  reaction  ti)  lijjlit 
ami,  ill  rare  instances,  coiiftcstion  and  (edema  of  tiie  pajiiila.  while 
ill  tiie  latter  Hutcliinson  describes  a  decree  of  sluftftisliness  in  the 
luipillary  movements,  and  Knies  refers  to  the  not  infreiiuent  occur- 
rence of  nystajinius,  which  he  attributes  to  "cortical  inactivity  or 
interference  witii  the  conduction  of  the  innervation  impulse  which 
starts  from  the  cortex."  Concussion  of  the  brain  is  followed  by  no 
oi>lithahnoscoiiic  change,  althoujili,  as  (iowers  has  siifjpested,  .simple 
concussion  of  the  nerve  and  retina  nuiy  probably  cause  loss  of  sight 
and  slow  atrophy.  Contusions  and  lacerations  of  the  brain  antl  hernia 
cerebri  may  be  accompanied  liy  neuritis. 

Injuries  of  the  spinal  cord  rarely  cause  organic  disease  of  the  eyes. 
No  changes  in  tiie  fundus  were  found  in  17  rajiidly  fatal  cashes  observed 
l)v  .Xllbutt,  although  among  i;^  chronic  cases  he  reports  8  as  having 
exhibited  more  or  less  hypera-mia  of  the  papilla.  He  never  found 
inie  ojitic  neuritis  (Knies),  When  the  injury  is  in  the  lower  cervical 
(H  ujijier  dorsal  re};;  •;.  a  lesion  of  the  sympathetic  may  lead  to  vaso- 
motor and  trophic  -listurbances  and  inequality  or  contraction  of  the 
|iii|>ils. 

U'hile  in  rare  instances  o])tic  neuritis  and  atropliy  of  the  optic 
nerve  have  been  reported,  in  considering  them  we  sliould  bear  in 
iiiiiid  the  fact  that  sj^inal  injury  may  be  complicated  with  injury  of 
the  brain,  and  thus  account  for  the  symptoms  observed  in  the  eyes. 
\  arioiis  ocular  symjitoms  are  of  fre(|uent  occurrence  in  concussion 
nt  tiie  spine,  but  it  is  n<i,  usually  easy  to  establish  the  existence  of 
a  real  organic  lesion  in  such  cases.  This  is  especially  true  of  railway 
-pine,  or  what  by  some  writers  has  been  termed  concu.^s'on  of  the 
-^pinc:  but  even  where  this  is  the  case  it  is  difhcult  to  find  records 
nl  well-authenticated  instances  in  which  it  has  led  to  organic  disease 
(if  tlie  eyes.  The  neurotic  symptoms  are  often  very  marked,  and,  as 
we  iiiav  even  sometimes  find  hysterical  contraction  of  the  visual 
liclds.  it  is  important,  as  Swanzy  has  ])ointed  out.  that  in  our  oplithal- 
mciscopic  ex.'iminatioiis  we  carefully  avoid  interjireting  what  may  be 
a  iiliysiological  variation  in  the  color  of  the  aisk  as  indicating  an 
organic  lesion  of  the  optic  nerve. 


DISEASES  OF  THE  NERVES. 

Multiple  neuritis,  which  is  a  not  infre(|uent  effect  of  poi.sonous 
and  infectious  diseases,  may  affect  the  optic  nerve,  producing  axial 
neuritis,  central  .scotoma,  disturblinces  of  color  perception,  etc.,  such 
a-  .are  described  in  the  section  devoted  to  t«)xic  amblyopia.  It  may 
al-o  affect  the  motor  nerves,  producing  partial  or  complete  paralysis. 

Knies  calls  attention  to  tlie  fact  that  in  :iniyotrophic  paralysis  of 
I  he  arm,  when  the  nerve  roots  or  spinal  ord  .ire  involved,  if  the 
oculoimpillary  fib'-es  from  the  cin'         he  sympathetic  become  im- 


•«:.■- 


■»'-Jv,^VA     \..3(P¥!E 


().J2 


THE  EVE. 


periHcablc  %vp  may  havo  ptosis,  myosis,  and  cnoplithulnios  on  the 

'"^InHaniniation  ot  tlic  first  branch  of  the  uifii-niinus  may  lead  to 
licriios,  wliicli  is  considinMl  clscwlicro. 

In  trigeminal  neuralgia  th(>  ocular  branches  are  sonietnnes  scarcely 
involved,  but  thev  often  do  take  part,  leading  to  injection,  lacry- 
mation,  phot ophobi:-,  and  pain  in  the  eye.  Inflammation  of  the 
ocular  brancb.es  if  severe  is  (luite  constantly  reflected  to  the  other 
biaiiclio  of  the  trifieminus. 

I'aralvsis  of  the  trigeminus  is  apt  to  lead  to  neuroparalytic  kera- 
titis if  an  abnisioe  of  the  cornea  occurs  and  the  element  of  uifectiori 

is  added.  ,  ... 

\  iarjje  proportion  of  the  nervous  i.henoinena  which  appeal  as 
reflex  expressions  of  the  acc.iinmodative  and  muscul.'U-  strain,  made 
necessary  by  errors  of  refraction  and  muscle  imbalanc(>,  manifest 
themselves  in  the  sui)erior  branch  of  the  trisi-minus.  And  m  every 
case  of  obstinate  trifieminal  neuralgia  a  careful  attempt  should  l)e 
made  to  discover  and  correct  all  such  errors. 

Paralysis  of  the  ocular  branch  of  the  facial  nerve  is  followed  by 
liKoi)iithalmos.  which  mav  be  present  in  any  degree,  and.  if  marked, 
is  apt  to  b<>  the  cause  of  secondary  conjunctivitis  and  keratitis  as  the 
result  of  exposure. 

Tonic  and  clonic  spasm  of  the  orbicularis  muscU  may  be  cortical 
or  nucU  ir  in  origin,  or  a  reflex  symptom  of  peripheral  irritation. 


ij 


i  i 


s 


CHAPTER    XIV. 

(iENERAL  PREPARATION  FOR  OPERATIONS  UPON 

THE  EYE. 

By  CLARENCK  A.  VlvVSEY,  A.M.,  M.D. 

Thk  Renoral  princii)lcs  of  aseptic  and  antiseptic  surgery  shoultl  be 
(■in|)I()V('d  in  operations  on  the  eye,  as  well  a.s  in  ()i)enitions  uj)on 
ntlier  portions  of  the  body,  with  the  exception  that  the  strong  gernii- 
cidal  solutions  which  may  be  used  elsewhere  are  here,  as  a  rule, 
not  permissible. 


PREPARATION  OP  THE  PATIENT. 

If  time  permits,  it  is  important  that  the  patient's  general  health 
!)(■  place<l  in  the  best   possible  condition  jjrior  to  the  performance 
(if  any  of  the  major  ojK>rations.     Naturally,  this  does  not   ajjply 
in  those  emergency  ca.ses  demanding  immediate  attention:  but  m 
(ither  cases  the  surgeon  will    be  well   rewarded   for  attending  to 
.iiiv  of  the  details  that  will  improv<   the  physical  or  mental  con- 
dition of  the  patient.     Should  diabetes  or  albumiimria  be  present, 
tlicy  are  grave  comi)lications,  to  be  sure,  but  by  no  means  contra- 
iiidicatc   o])erative   jjrocedure,   as  was    formerly  thought  to  be  the 
'■;i.<e.     If,  however,  a  course  of    medicinal  and  dietetic  treatment 
will  improve  materiallv  the  ne])hritic  condition,  the  chances  for  ulti- 
mate success  in  anv  operation  upon  the  eye  will  thereby  be  mark- 
edly increased.      If  anv  acuto   pulmonary  disease  is  present,  it  is 
wiser  to  postpone  operation  until  after  its  subsidence;   aiK^  again,  if 
liiei-e  is  any  chronic  pulmonary  affection  it  is  not  only  necessary  to 
imi)rove  the  condition  as  much  as  possible,  esix-cially  if  the  re  is  any 
cxaciTbation,  but  it  is  also  of  the  utmost  importance  to  allay  any 
cough  tliat  might  give  rise  to  complications  during  or  following  the 
operative  procedure.    For  the  latter  purpose,  in  addition  to  the  ohler 
remedies,  heroin  hiis  been  much  employed  of  late,  and  in  doses  of 
one-sixteenth   to  one-twelfth   of  a  grain,  fre<iuenily  repeated,  has 
proved  of  value,  as  ha.s  also  the  following  spray: 

Menthol  crystalu, 

!>u!v.  camphnm!         U    gr.  xxx. 
Li,),  pctrolati,  Sj. 

M.    To  be  UBed  loc«lljr  In  »loinlier  or  nebuliJer. 

(653) 


I 


1)04 


THE  EVE. 


i 


vulur  canliiif 

:in  Dpcrsitiitii  Ix'  il 


T\w  c-(.iuliti..ii  (.f  tlic  licart  and  Lloodvi'sscls  slioiil.l  also  !.<•  (•arcfully 
iuv.'^tiuat.Ml  If  art.Ti(,-scl(Tosis  is  present,  siicli  .Inijrsas  will  reduce 
arterial  teiisu.a,  and  therein-  less.Mi  the  i)r.)i)al.ihty  ct  heiiH.rrhaKe. 
intfa-ueiilar  (.r  extra-ueiilar,  sht.uld  he  administered. 

\i,l,n.|.riat<>  r.'inedies  and  exercises  shculd  he  employed  h.r  val- 
■  ••       atYeelions:  and   if    the    patient   he   a  ■•hleeder     aii.l 

determined  uiM.ii.  all  possihle  means  for  h-sseninjt  the 
jiihiiit  V  to  excessive  hemorrhage  should  l)e  adopted.  For  this  purpose 
the  a.iministrati.m  ..f  the  calchm.  salts  and  of  gelatin  has  prove.  1 
of  vilue  The  latter  is  not  oiilv  employed  hypodermically.  but 
the  eating  of  laifie  .luaiitities  is  highly  recommendi  <l  in  the  conditK.n 

of  ha'niophilia.'  .•        >■  e 

It  is  especiallv  important  that  there  he  no  suppurative  .lisease  ot 
the  coniuuetiva'or  lacrvmal  sac  in  those  cases  requiring  the  opening 
of  till-  evel.all.  These 'conditions  should  be  treated  as  l(.ng  as  it  is 
,„.re<s4rv  to  rid  the  pali.'iit  of  them,  both  by  topical  applications 
•lud  hitranasal  m.Mlication.  and.  in  persistent  .lacryocystitis  resisting 
prolonged  treatment,  it  is  sometimes  even  advisable  to  close  the  lacry- 
iiial  pimctum  by  means  of  the  actual  ciuterv. 


bath.  II 

any  exposure 

powder,  or  a 


iU  ;  ; 


( )n  the  day  preceding  the  operation  the  i>atient  should  take  a  warm 

th,  including  a  shampoo  for  the  head  and  beard,  guarding  against 

t'^)  ilraughtsof  air.     .V  l<'aspoonful  of  comiiound  licorice 

dose  of^some  other  laxative,  to  be  followed   the   next 

morning  liy  a  saline  or  enema,  will  i)lace  the  palii'iit's 

bowels  Til  the  l-.st  condition  for  rest  and  (luiet  niter 

tiie  operation. 

Preparation  of  the  Region  of  Operation.  .Vii  hour, 
or  two  preceding  the  operation  the  skin  of  the  eye- 
liils  and  surrounding  parts  is  thoroughly  cleansed 
with  soap  and  water,  followed  by  alcohol,  and  then 
by  a  solution  of  mercuric  chloride  ( 1 :  TrfHW)).  Par- 
ticular attention  should  be  given  to  the  eyebrows 
and  ciliary  margins,  and  at  the  same  time  care  shouhl 
be  exercis(-d  not  to  irritate  the  conjunctiva  by  jht- 
mitting  the  soap  or  alcohol  to  come  in  contact  with 
it.  The  conjunctival  cul-de-sac  is  next  fn>ely  irri- 
gated, either  with  a  sterile  boric  acid  solution  fgr. 
\  to  .")j>,  sti-rile  saline  solution  (normal  strength), 
or  with  a  solution  of  mercuric  chloride  d:  .t()0()). 
The  eyela.shes  should  be  rubbed  (juite  hard,  as  it  is 
here  that  many  micro-organisms  lurk,  after  which 
the  eye  and  surrounding  parts  are  coven'd  with  a 
st<'rile  dressing  until  "the  surgeon  is  ready  to  proceed  with  the  opera- 
tion. It  is  also  advisable,  as  a<lvocated  by  Lippincott,  to  spray  the 
nares  three  or  four  times  a  day  for  a  coui)le  of  days  prec(>ding  any 


Sottic  mill  irriga 
lor  for  boric  gtii 
Mtliition. 


1  For  a  w'nm('  of  thu  lit.Talim'  and  ilirections  ».«  U)  the  iwc  of  gelatin,  coiwiill  a  paper  by  Dr.  Joseph 
Sailer,  Theruitutii-  (iazftte,  August.  IWl. 


1'i:ei'Miat[o.\  for  opkratioss  rrox  the  eye. 


tiiV) 


niicration  iipDii  the  cyclnill  vvitli  ii  soldtinn  <il'  pcrmaiijianiitc  itf 
|Mitassiuiii  (1;  ^(KK)),  ius  :mi|ilc  cxpcrifiu't'  luiw  sliown  that  the  pri)- 
(■(•iliiic  iiiatrrially  lessens  tlu>  lialiility  to  infection  of  tiie  wound  or 
Ik  intianmiatory  processes  after  operation. 

liacterioloRical  investipitions  liave  shown  that  pathogenic  inicni- 
ornanisnis  are  present  in  every  conjunctival  cul-(l('-sac  and  on  the 
lid  niarftins,  and  that  germicidal  solutions  sutficientiy  strong  to 
destroy  them  also  produce  injury  to  the  delicate  epithelial  layer  of 
the  cornea,  sometimes  resulting  in  permanent  loss  of  a  portion  of  the 
visual  acuity,  as  well  as  nivinp  rise  to  considerable  irritation  of  the 
conjunctiva  itself.  We  are,  therefore,  ohlipeil  to  content  (.urselyes 
witii  the  removal  of  as  many  bacteria  as  possible,  and  the  diminution 
of  the  vitality  of  those  remaining,  by  forcibly  flushing  the  conjmictiva. 
anil  scrubbiiij;  the  lid  marpns  with  some  of  the  .solutions  described. 

bnmediately  preceding  the  operation  the  conjunctiva  is  agiiin 
Hushed  with  the  boric  acid  or  itiercuric  chloride  solution,  the  liil 
exerted,  and  the  conjimctival  surface  wi|)ed  with  a  pledget  of  ab- 
-orbc'it  cotton  moistetied  witli  the  .same  solution.  It  is  also  well  to 
wipe  very  gently  that  portion  of  the  surface  of  the  cornea  in  which 
I  he  puncture  is  to  be  made  in  those  ojK'rations  in  which  the  eyeball 
i-  to  be  entered.  In  all  office  operations  in  which  the  surgeon  is 
re.tdy  to  proceed  at  once  the  tem]iorary  dressing  is  dispensed  with. 


PREPARATION  OF  THE  SURGEON  AND  ASSISTANTS. 

The  hands  of  the  surgeon  and  all  assisting  him  in  the  ojieration 
iiv  scrubbed  with  soaj)  and  warm  water,  the  finger-nails  receiving 
particular  attention.  After  immersing  the  hands  in  alcohol  for  a 
iiinineiit  they  are  dipped  in  a  solution  of  mercuric  chloride  {1 :  KKK)), 
.liter  which  nothing  should  be  touched  that  has  not  previously  been 
leiidet-ed  asejnic.  If  the  assistant  is  one  with  whom  the  surgeon 
i-  unaccustomed  to  work,  he  slumld  be  advised  of  the  details  of  the 
iperatioii  and  the  orde  in  which  the  instruments  will  probably  be 
required.  In  operations  upon  the  bulb,  the  a.ssistant  should  be  in- 
structed as  to  the  method  of  removing  pressure  from  the  eyeball  by 
lifting  the  speculum,  and  also  as  t^>  tlie  probable  i)roce(lurps  in  ciuse 
.if  complications.  The  nurse  should  be  |)repar(>d  to  render  any 
is-istance  re(iuin>d,  and  neither  surgeon  nor  assistants  should  have 
handled  sei)tic  cases  for  some  hovirs  before  operating.  If  several 
cases  have  to  be  operated  upon  iit  the  same  time,  and  some  of  them 
lie  septic,  these  should  be  taken  last. 


PREPARATION  OF  THE  INSTRUMENTS,  SPONGES,  SUTURES, 
LIGATURES,  AND  DRESSINGS. 

Instnunents.     .\ll  the  instruments  to  be  employed,  with  the  exeep- 
tion  of  the  cutting  instruments  with  very  fine  points  (cataract  knives 


¥'whmm^--Ttwwa.  :•».— x)««r 


f  f  'i 


IfS 


ii 


«5«i 

allll    IHMM 


I    .  ....^      l»  w  Ix'ttiT  to  t  II  t  US  iminrduitfly  alter,  a«  \m  ii 

:;"'U;;:?'.   ,..--ti;:. '"  ti:.;  an. ti.....  phu..i  m  a  ^tp...  .t.r  li.. 

for    .     mi.  ut..s  or  .-Is.'  l.oil<-'l  from  thr.r  to  tiv.-  muu.t.;s  n.  a  I  [.t 
.M.       .     i.  .     f  .-arlKmat.-  of  sodium,  tl...  iatt.-r  ,m.v.M,t.ns  tl.ov  ♦" 


Kki.  344. 


I  yttlLftOCHS.WlU,  j 

Vfttscy's  tmrtabli;  sterilizer. 

,l,nn  from  tlx-  alcoi.ol.  whicl.  is  irritatinp  to  tlu-  .-v-.     In  tl.'  op.-r- 

;;r:;;;:  •  ini.;^  1  -■  <•"  i"  t;i;.sf..rn..i  t..  ti...  ai^hoi  a,,,!  th... .. 

thl^valor  or  salin.'  solution.  ..o  instrun.ont  l.-in.  tourho.i  unt.l  th- 

''7t:i^Z.  sho.VM  tl.at  tl,.-  .l.li<-at.-  n.tti..,  i,.strun>.nts  .-am.o. 
J^Z^uX'  sa„...  manner  as  tlu-  <--;:--'"  :,;7£! 
.lestroyin,  to  a  jar,.- extent  thnr  -«>.-.  MU^^ht..^  .],':.^,;::' ■w.!;;;!!. 
for..  tir-;t  wped  Wit  1  >I(Tllc  cotton  liiolrt(I!"<l  will,  .lo.i.i  ,  ..^ 
The'e  ttins  e,l«es  and  points  having  been  can-fully  mspected  fo 
Ju^t  :.r  hill   'i.ts,  are  Ihen  wrapped  with  sterile  cotton  and   held 


}  i 


::mmsr^^smnp 


fi;i:rM:ATi<>.\  for  (H't:nATi<>ys  ri'n.s  nii:  i:yi: 


«.j7 


f,,r  a  iiioiiii'iil  in  l)uiliii>;  water,  after  wliieli  they  mav  Ix-  placed  in 
■il.Miliite  alcnluil  <.!•  wrapped  in  sterile  alisnrhent  eott  il  required 

i,,r  ii^e.     Iniiiiediately  heft.re  iisinn  tlieiii  tl-y  shoiilil  a>;ain  he  dipped 
ill  liiiiliiij;  water  fur  an  instant. 

Manv  ditleri'nt  n.etlidils  to  (ilttain  the  sjune  results  are  employed 
l,y  liillerent  ophtl'.alinie  surjjeiMis.  For  example,  some  do  not  em|»l<»y 
.lii-ohite  alcohol,  hut  phu  e  the  instruments  after  lioilinj;  in  a  :{  per 
iiiii.  .(ihitioii  of  i-arholic  acid,  or  a  1 :  KMH)  solution  of  formaldi'hyde. 
(iilins  transfer  them  at  once  from  the  sterilizer  to  sterih-  water. 
Still  oihers  sterilize  hy  means  of  formaldehyde  >ias,  employinf;  spe- 
ri:illy  devised  steriliz("rs  for  the  puri)ose.  The  one  here  illustrated 
ilU'.  ;{4.'))  was  devised  hy  Heik,  of  Baltimore,  and  is  a  very 
.•\c7ileiit  one  for  this  method.     Before  iK-pnninn  an  opiTation,  it  is 


F!(i.  315. 


Ktik'n  foriimlin  Btcrlli/ur. 


Mwavs  a  pxiil  jwocedure  to  arransje  the  iistruments  in  the  order  ni 
'Aliicii  Ihev  will  iirol.ahlv  l)e  reipiircd.  Tiiis  can  he  d..ne  when  plaeinji 
tiietn  ill  thi'  sterilizing:  tray,  and  any  one  can  then  he  picked  out  more 
■klv  should  complications  arise  diirinj:  this  operation. 

oi 


'pill 


Sponges.     Ill   nphlhalmic   operations   ordinary   sponges    may    he 

-cl  pn-pared  hv  the  usual  methods  in  vopue  anion«  >;eneral  siir- 

■..ns    hut  small"  pieces  of  sterile  gauze,  or  small  i.ledfjets  of  sterile 

Hon.  are  prefcrahle.     In  deep-seated  oiicratioiis  in  the  orhit  it  is 

'.'.vv  satisfj'a;  irv  to  have  the  gauze  wrapped  on  the  ends  of  st(>nlp 

i.ks  or  prohes,"  so  that,  in  sponging,  the  parts  may  he  more  readily 

kIiimI  and  the  assistant's  hand  will  not  ohscure  the  field  of  o|)erati()n. 

Sutures  and  Ligatures.    Catgut,  either  plain  or  chromicized,  and 

,.   .-ilk  .uv  cmplovr.l  as  sutures  an     'igatun-^^  in  ophthalmic  opera- 

•  Ills  and  the  iiietliods  of  their  jjreparation  do  not  differ  from  those 

i  use  in  general  surgery.     The  silk  may  be  either  white  or  black, 

42 


i 
I 

I 

n 


t  i 


H 


111 


if: 


(J.'iS 


r///;  rrt: 


hut  thf  latter  is  U<  l.c  i.ivf.Tic.l  if  it  is  t..  r.-main  in  positK-ii  for  soii.r 
time  as  it  is  incrr  rra.lilv  l.-cal.-.l  fur  r.-inuval.  Aftrr  \Uv  iitiir.'s  ar-' 
n-iM.iv.Ml  frni.i  the  soluli.ms  in  wliicl.  liiry  „M.aily  arr  k.-|.t  they  an- 
,,lac.'.l  ill  al.s.,liit.-  ain.hul  until  rc.|iiii.il.  «i.-'n  they  an-  nns.',l  ni 
sK'r'i'  water.     Tlie  same  prueedure  applies  tn  litjanires. 

DreBBingS.  Tiie  .IresMnjIs  f.  l.e  plaee.l  npnli  an  eye  alter  an 
,„„.ralinn  neeessarilv  .liller  aec-niin}:  in  ti.e  natnr.-  nl  tite  ..|KTatiun 
•Hul  the  exip'ii.'ies  of  Hie  ease.  In  extensive  n|«.rati.ms  aliuut  tlir 
r„ls  tii.'v  .1(1  n.it  .lilTer  fn.in  those  einployeil  in  surgery  el.sewh.'te 
viz.:  a  I'.ruteetive,  pads  of  sterile  «aiize,  alisorlwiit  cotton 


liaiiclaire.  The  ;raiize  may  have 
in  a  solution  of  niercuric  ehlorii 
ciile,  anil  (hieil 


1.1 


anil  a  roller 

sterile  l>y  heal,  or  soaked 

,1-  1:  -.'(MKI)  or  other  jierini- 

■;|erile.  and  trauze  is  to 

1„.  ..referred  in  prepaniif:  it.  as  it   r.-tains  its  i-u.-iti-.n   inueli  Letter 


The  li;inila;:e 


I  mail. 
i  I  :   IIHN) 

iiiiilil  also 


li 


1" 


thaii  if  made  of  llaiinel.     The  dressinj;  may  he  either    ry  or  wet. 
the   litter  instanee  it  is  s..ake.i   in  some  solution   hel.  re   plaemn  iii 
itiun,  iisuallv  menairie  eliLnide  :  1 :  .VMM)),  l.oric  an.l  (>rr.  x  to  .,j) 

or  sterile  normal  saline  .snlutioii,  and 
till- exeesssiiuei'zeil  out  with  the  haml. 
In  the  majority  .if  ophlhalmie  op.'i- 
ations  the  followinj:  melho.i  ot  dn-s- 
iii}:  the  eye  will  i>rove  satisfactory . 
.\  few  layers  of  sterile  fiaiize  twii  ami 
one-half  inches  in  diameter  are  moist- 
en.'il  with  a  s.iluti.ni  of  mi'icuii.' 
.,^^^^^^^^^^^      chlori.le   ll:  ")(MKI),   aii.l    placed   ov.'r 

yir^^^^^^^^Sc^l        sutiiiient   sterile  ah.-^oil.ent   cotton  t.. 

VJ-X^  L04§J        till  ill  th.'.lepressi.m  ma.le  liy  the  or- 

^  "  liital  ridfje  and  the  no.se.     These  are 

fasteii.'d  .si'curely  in  position  by  a  tew 

strips  of  isiiijrlass  plast.'r.     If  the  p.i- 

ti.'iit  is  .|uiet,  this  ts  sullicieiit;    if  in' 

is  restle.ss,  however,  or  untrustworthy 

as  to  I  ■  -sinji  his  lin<;ers  beneath  tlu' 

an   atteni|it    to   s.'.'.  it  is  saler  to  add  ihe 

^.  .      Indee.l,   in    many  cas.s.  as   after  cataract 

•i.l.rtomies,  it  is  an  excellent  iih''.  to  jilace  over  tli.' 
above  dressing  a  protective  mask  such  as  that  shown  in  Fip.  -.W 
which  was  ilevised  bv  the  late  Dr.  Frank  W.  HiiifT,  of  New  \  ork.  an.l 
is  ma.l.'  of  iiapiiT-mach.'.  Other  masks  ma.le  of  wire  or  aluniinu:n 
areempiove.1  bv  some  surjre.ais.  In  place  of  the  fisure-of-eifiht  ban.l- 
a.re  in  some  cases,  and  especiallv  in  those  who  are  contimmit!  th.'ir 
vocations,  a  m..ilih.Ml  Ijrtnrich  hand,,,,,;  which  is  knit  of  black  zephyr 
an.l  fastened  in  p.isition  bv  a  tape  at  each  end,  will  be  very  acceptabl.v 
It  is  maiie  either  sinirte  or  .l..ul.le,  accnlinp  to  wh.therit  is  n-^iuiv.- 
for  one  or  for  both  eves.  .\  prc^sur,'  hnuhutc  is  not  apjilied  .liHerently 
from  that  .lescribe.l.'  except  that  sullicieiit  cotton  is  so  plaee.l  ovc- 


RiiiK  ■ 


lilrt.-k. 


ilressin<;s,  or  lifting  it  in 
tizure-of-ei;;ht    banda;^.'. 
extractions  or  iri. 


fUEl'AUATIOS  h'olt  <H'EH.iTI»SS  ll'nS  Till:  h.YK.         (i.",!) 


(1,.'H!UIZ(>  pti.ls  tliiit.wlifii  tlif  l)Mii<laK<'  is  appliid.  linn  picxsun' upon 
il,..  cyrhall  is  niatlf.      A  rimj  ilnxstiiii.  mucIi   as  is  cniplnyfil  S(.nu- 


Kl.i.  ;U7. 


Mixliiiiil  UcbrciL-b  buiiilagu 

liiiirs  after  skin--:raftiiif;,  is  inadf  by  siim>nii(lin<r  tin"  wiu'ii'  field 

ni   nprialini;  witli  a  liiiji  of  sterile  paiize  siillieiently   lliick  to  pre- 

\riii   I  lie  (liessiiijis  from  coiiiiiin  in  contact 

uiih    it.     /',''/«■    xltiuUs    are    sometimes   em- 

pldveil    after  the  dressings    have  been  ilis- 

riiijed.  and    should  lie   firm,   lifilit,  and  so 

-li:i|ied  thit  MiHii'ient  air  can  enter  behiml 

!,„,n  tM  Kcrp  ti,  ■    ye  cool  and  dry.     (I'itr. 

:\\\.\     \    Hiiller  shield   may   he   employed 

111  lertain    I'ases   as  a  protective  dressiiif;. 

I  •(■(•Msidiially.  a-  in   tuberculous    (lis(>ase  of 

the  nrliilal  bones,  it  is  neces.^ary  to  eni|)loy 

iM,|,,|,,!-m  dressing's  about    the  eye,  but   these  do  not  differ  in   any 

I'  MKTt  from  similar  dre.-isinj;s  employed  elsewhere. 


Kyu  islmtle. 


ANAESTHESIA. 


General  Anaesthesia,  (n  the  proat  majority  nf  ophthalmic  opera- 
■i..iis  local  anasthesia  is  sullicieiit ;  l)ut  ill  a  few.  such  as  enucleation 
il  the  eyeb.all,  ojierations  upon  .severely  inflamed  eyes,  removal  of 
.ihit.al  -irowths,  jilastie  operations  upon  tht>  lids,  and  in  most  of  the 
■peratioiis  upon  children  or  very  nervous  individuals,  general  anus- 


esiaisre<iuired.     Mther  is  jm'ferable  to  chloroform,  except,  perhaps, 

patients  alTected  with  chronic  bronchial  diseases,  in  whom  it  is 

i;ilile  to  dive  rise  to  MM  attack  of  pneumonia,     liroinide  of  ethyl  is 

■Hietimes  emnloyed.  and  at  the  jm-sent  time  is  attracting  consid- 

nible   attent;  "in   among    French   surgeons,   but    by  most   ojierators 

it  is  considei   d  to   posse.ss    no  advantage   over  ether  or  chloroform. 


mo 


Tin:  i:ye. 


Nitrous  oxiilo  gas  may  be  (Miiploycil  :ulvnntaf;ooiisly  in  short  opera- 
tions in  very  nervous  patients,  as  in  tlie  ililatalion  of  strictures  of 
tiie  lacrynial  duct  or  in  tiie  ri'inoval  of  a  cjialazion. 

Local  Anaesthesia,  lor  the  purpose  of  local  ana'stjiesia  in  opera- 
tions upon  the  eye,  the  hydrochlorate  of  cocaine  is  employed  proha- 
l)lv  more  generally  than  any  other  dru}:,  although  witiiin  recent  years 
a  number  of  new  local  ana'sthetics  have  been  introduced,  each  of 
wiiicli  has  its  ailvocat<'s.  The  Iiydrochloratt!  of  cocaine  is  employed 
ordinarily  in  a  1  to  4  jier  cent,  solution,  anil  even  as  stronjz;  as  10 
percent,  by  some  surjreons,  and,  a.s  it  ])ro<luces  some  softeninj;  of  tin' 
corneal  epithelium,  the  eyelids  should  remain  closed  after  its  instilla- 
tion. For  superficial  operations,  one  instillation  usually  sutiices,  the 
operation  being  performed  five  minutes  later:  but  in  deeper  opera- 
tions, for  example,  iridectomy,  extraction  of  the  cataractous  lens, 
and  tenotomy,  three  instillations  should  be  omi)loyed  at  tive-niinute 
intervals,  and  the  o])erati(,n  begun  fifteen  miiuites  after  the  first 
instill.ition  has  been  made.  Uy  following  this  method,  the  cocaine 
has  sufiicient  time  to  reach  the  deejier  structiu-es  of  the  eye,  and 
much  less  i)ain  will  follow  th(>  seizure  of  the  iris  or  tendon  than 
otherwise.  Operations  should  be  completed  either  within  twenty 
minutes  from  the  time  of  the  last  instillation,  or  other  instillations 
made  to  |)rolong  the  effect.  For  the  removal  of  a  Meibomian  cyst, 
the  hypodermic  injection  of  a  drop  or  two  of  a  2  jut  cent,  solulioa 
in  the  immediate  neighborhood  of  the  cyst  will  render  the  operation 
far  less  painful  than  will  several  instillations. 

Hydrochlorate  of  eucainc  ".\"  and  hydrochlorate  of  eucaine  "  IV' 
are  sometimes  used  as  local  ana'sthetics,  abluuigh  the  first  is  em- 
ployed by  no  means  so  fre(|uently  as  formerly,  as  the  latter  is  less 
irritating  and  li'ss  toxic.  The  advantages  claimed  for  eucaine  "H  " 
are  that  it  is  one-fourth  as  toxic  as  cocaine,  does  not  affect  the 
heart,  d(M>s  not  produce  mydriasis,  nor  affect  the  accommodation. 
The  disadvantages  are  nuich  more  congestion  and  bleeding  during 
and  after  ojieration,  and  freipient  slougliing  of  the  tissues  when  em- 
ployed hypoderinically.  For  producing  local  anasthesia  about  the 
eve.  2  per  cent,  solutions  are  recommended. 

Tropacocaine  in  .'i  jier  cent,  solution  is  employeil  by  some  surgeons 
(Si  liweigger.  Silex),  who  claim  more  rapid  ana'sthesia  than  with  other 
ilrugs  of  this  class.     The  elTeet  also  we.ars  otT  more  rpiickly. 

Holocaine  is  one  of  the  'lewest  memliers  of  this  grou]).  and  is  usi'd 
in  from  1  to  2  per  ci-nt.  solution.  It  is  chiimed  that  it  does  not  atTect 
the  corneal  epithelium,  produce  mydriasis,  nor  impair  the  .accom- 
modation, and  that  it  produces  ana'sthesia  more  quickly  than  cocaine: 
the  ana'sthesia,  however,  does  not  last  so  long.  It  is  preferred  to 
cocaine  by  some  surgeons  (Knapji.  Derby)  in  all  o|)erations  in  which 
local  ana'sthesia  is  used.  As  it  ]io.<sesses  some  bactericidal  action 
a?id  d'"'-  U'-t  afVecf  tlie  cnftie;'.!  epithi'limil,  it  should  be  given  tlie 
preference  in  corneal  ;il'fections  in  which  local  ana'sthesia  i.s  reiiuired. 
and  in  the  removal  of  foreign  bodies. 


BJl"  uiL'L.- 


rrcr 


in'ni  \9m\\ 


PHEI'MIATIOS  FOH  nfEHAVlOSS  Ul'OS  I'llE  EYE. 


()(jl 


Siroseliciu's  Husk. 


f  „f  tl.o^c  -solutions,  as  well  as  other  alkaloidal 

nasnu.ch  as  •"-      fj'  .     ^  !  !    "  •,ello.,t  n.o.lia  fur  the  finnytl. 

~':'''^''"'''';iS     1    V  ium-i'^'    "■rili.e.l  thon-ughly  h.-ro.e  l.ein, 

;:;;;;•  ;:'r'::h;;;::;:'i;;:i.."'an;;;;:pt.  ,...,1.,;: ..  exan,,.. 

':i;!o';u..,eurie    chloride,   .-r    ^-^  ^^^^^^^ 

1      \    ,le  Sehwemit/.).     The  us<>  of  a  saturate  1 
-,auUoM  of  l.orie  aei.l  will  nut  pre^i.t  t^he  p^-owth 
„l   ,u„jri,  hut  will   prolong  s.miewhat   the  P.T10. 
,i,.r  t^  their  appearance.      For  stenhzat.on  by 
l,„iliM^r,  the  Stroscheiu  flask  is  very  convenient. 

' '  iifiliration  Anesthesia.    'This  metlu>.l  of  pr- 
Mu.inj:  local  anuvstlu>sia.  as  suggestea  l.y  he  leicl^ 

..,m.-ists  of  the    intmmtanvoux  injection  ot    tht 
following  solution: 

Ciicaina  hydtochlorat.,  K''  J- 

S-Hli  ihlori.lli.  ^[  J- 

A'liia'  ,k-MillttlB,  Sj-M- 

Uv  means  of  a  hyi-nlerniic  syringe  a  <lrop  or 
,  w„  of  the  solution  is  injecte,l  into  the  ^^in  resu  - 
„„  in  the  proauction  of  a  small  wh.'al.    A  not  u 

,.|,|itliahiuc  practice. 

POSITION  OF   PATIENT  AND   OPERATOR. 

:,J   i„  i,i,Vcton.y  ana  in  extraction  ot   I'^V     =  \'   .f^'^,,'      :,.. 
,Uvavs  seen.ea  to  the  writer  -^'-^^  ;--^;^^:;^.S}  ^^^.^  2u\^ 

::•:;l;;;•::^•7;;:i■:aSru;:;^V•'r^^ 

U„.K.  hi.  hoaa  resting  upon  one  or  two  'l^'''''  I^"-;  ';,';",, 

t::;;;:;7u;;:';;t:r;l;rst^lv:M'-,£;;t;.  ,.-.- 
:;;:^;i;;';:;;:i'Ii;'^:r",:i::=T:J;.rp,.™- 

.h.n.v.r  a.sin..l.aua  the  jar  of  transternng  the  patient  tio.n 


iiii 


662 


Tin:  KYi:. 


talilf  or  chair  to  the  1)0(1  is  tiicrcliy  avoiilod.  Sliould  :i  chair  l)c 
ciniildvcd.  till'  mil'  nroiiiiui'nili'ii  by  Kiiapp  is  very  satisfactory  (Fij;. 
;{.■)());  i)ut  tor  iiiiuoriipcratioiis  in  tiicoliicc  an  ordinary  arni-ciiair  witli 


li'  IT 


Kiifli'|''s  o]K'n»tiii(?-i'lm.r. 

a  low  iiack.  over  wiiicii  is  placed  a  sinall  pil- 
low for  the  i)ati('nt's  neck  and  head  to  rest 
uiion,  will  he  found  to  answer  the  purpose 
fairly  well. 

The  position  of  the  operator  may  he  either 
hi'hiiid  or  beside  and  somewhat  in  front  of 
the  |>ntient.  If  he  is  ainliidextrous,  he  may 
stand  behind  in  all  o]ierations:  if  not,  he 
will  be  obli<;ed  to  stand  behind  in  certain 
opei'aiions  ii]ion  the  ri<;ht  eye,  and  beside 
the  patient  in  the  same  operation  upon  the 
left  eye;  for  examjile,  in  making  corneal 
sections  in  the  extraction  of  cataract.  If 
he  will  accustom  himself  to  stand  behind 
the  patient  in  as  many  operations  as  pos- 
sible, however,  it  will  be  fi.nnd  much  more 
convi'iiient,  as  he  may  operate  upon  either 
eye  without  shiftinji  his  position. 
Knapp  has  truly  said  th.at  ambidexterity  is  not  a  .-ift  of  nature, 
but  must  be  acijuired.  This  can  be  done  only  by  freijuent  practice. 
To  most  of  us  it  is  '|nite  natural  to  manipulate  the  instruments  with 
one  hai'd  only:  the  other  must,  therefore,  be  educated.  This  can  best 
Im'  done  by  jiractice  upon  the  eye<  of  ;inimals  in  oper.atinj;  masks  (Fii:. 
;{.')1).  those  of  the  pi<r  beins:  the  best,  as  sullicient  i|uanlity  can  always 
Im"  obtained,     '{'he  methods  of  practice  ha\e  been  given  elsewhere.' 

'  Set?  the  writer's  buok,  ophtliuliiiic  0(K,'rati'iiis  hs  rrat'tiso<l  oti  .tiiiiutils'  Kyes. 


OftLTiii.'iK  iniisk  for  (inu'tising  (»n 
niiimiils"  fvt's. 


KA'  *.  .,.■ , 


I'REl'Ml.iri'tS  lOli  UI'IUIATIOSS  Vl'oS  Till:  EYE.         (J63 

ILLUMINATION. 

Ill  in,Nt..f  th.'  (iiicnitiniis  upnii  til.-  <'>■<■  it  is  iiupcrativc  tlmt  the 
,ih,n,iMati.m  1..-  ..f  tl.r  l.cst.  It  .imtt.-rs  nut  wl„-tluT  u  is  unlmary 
,|,vli-h1  nr  artiticial  li-ht  from  an  Arjianl  l)urii<'r  or  <'l(>('tric  Ixilt. 
I,  ;houM  come  Irnin  tli.'     i.l<"  of  th.>  .-y."  to  1)<>  oporatc.l   i-  ami 

-liouM  lie  th.-  hriirlii.st  p..ssil)lo,  l):.rriii>r  'lir.'ct  sunliglit.  I  hat 
„l,„i„,„l  from  a  small  spa.v  is  tl..>  m..st  satisfart,.ry.  as  anm.yinK 
,,.il,.,.liot.s  :hv  th.Mvl.v  av<.i.!.'.l.  If  nrtifi<-ial  li-ht  from  a.i  Ariia.i.l 
l,„ni.r  is  .■mplov.xl,  t'lu-  assistant  thr.Avs  it  up.ui  tlv-  .-y  hy  m.-ans 
,,,  :,  ,.„n.l.Misin- lens,  tlnis  in.Mvasi.ijr  its  hrillian.-y :  il  from  an  .-l.Ttne 
1,„1!,  the  liirht  shoul.l  1..-  ('..v.-nMl  with  a  r.'fl.rt.-r.  T  .<•  lat  .-r  is  a 
vny'cu.v.'nicnt  nu-tho.l  of  illiiminati.)n  in  ras.-s  in  which  tlio  arti- 


Electric  bulb  with  rcflfotor. 

•  ,i,l  li-rht  is  omplov.-.l.  as  it  mav  !>.•  attacho.l  to  any  outlet  from  the 
-nvrt  rurn-nt,  aii.l  with  suilicicnt  win- .-an  l)_c  carricl  to  th.-  most 
:.Mn,,li'  parts  of  the  .)i)<'ratinfl-ro.)m.     ( Fift.  .•{.■)2.) 

It  i<  aJM)  .if  KH'iit  importance  that   th.-  vision  of  the  op.-rat.ir  be 

, 1     Th.-  eye  is  a  vcrv  small  .irpm.  an.l  many  of  the  operations 

■^qiiiiT  .ielical.-  mani|iulatioii  in  small  spac.-s.  so  that   good  vision 

„,|    ill,„„i„,,iion    are    ii.,lisp.-iisal.le.     Operators    havnifi    refractive 

■iMiv    n-niiiin-;    orrecti.ni    for    .listiiict    near   visi.m   shoul.l   wear 

■i,:,t     (.nrivcti.m     whil.-    operating.       Various    niapnfyinp;    glasses 

:  ,ve   iMrii   suggested   from  time   to   time   l.y  diflerent   surgeoiis- 

i  ..10,^.  Herg.r.  an.l   ..th.-i-s   (Fig.  4.  Thaiiter  I.)-to  in.pn.ve   the 

-ion   in  .ip.-rative   w.nk.  .-veii    in   those  who   have  no  refractive 

'.■,„■    hut    th.'s.-   have    not    se.-ni.-.i    t..   the  writer  to  possess  any 

Ivaiitag.-  ov.-r  th.-  .mlinary  correcting  lenses  in  those  whose  media 

■  II'  perfectly  clear. 


'S'JsmfssM^^m.'ikT'.^ ',' 


L-^ST^VT^BKl.  ^.  ■&«.  JBti 


d; 


6G4 


'  !i 


I 


i 


11 

I! 


}i 


"111:  EYE. 


TIME  OF  PERFORMANCE. 


Operations  may  he  iicrtoniicil  at  any  lioiir  of  tlic  day  or  nijilit.  or 
at  any  season  of  tlie  year.  W  itli  iirojM'r  illumination,  just  (lescrii)cii, 
(Vises  first  seen  at  ni^iit  or  on  very  cloudy  days,  and  re(|uirinf;  iin- 
tnediate  operative  intert'erence.  need  not  he  post|)()ned.  Tiie  .season 
of  the  year  intluenees  results  in  those  o|H'rations  re(|uinnf;  more  or 
lew  proloiif^ed  conhnenieiit  in  bed  only  in  so  far  ;is  it  may  increas' 
tlie  debilitated  cnndition  nf  th<'  patient.  Obviously,  therefore,  if 
avoidable,  very  s'out  ])ersons  sjiould  not  be  operated  upon  in  ex- 
cessively hot  weather,  nor  those  alTected  with  ni'phritic  or  ])ulmoii- 
ary  disea.ses  in  extremely  cold  weather.  In  most  cases  it  is  probai)ly 
l)etler  to  operate,  if  ])ossil)le,  early  in  the  morninji.  whih'  fresli  ami 
before  other  cases  have  been  handled.  In  the  o|)eraf  ion  for  cataract, 
how(>ver,  it  is  thou<;ht  by  some  surjreoiis  to  be, better  too])erate  in  the 
afternoon,  as  the  few  hours  nf  smartiufj;  which  usually  follow  thi> 
op(>ratioii  will  be  succeedeil  by  a  nijiht's  sleep  and  rest,  so  necessary 
for  the  earlv  union  of  the  corneid  wound. 


AFTER-TREATMENT. 

It  is  manifestly  impossible  to  jjive  any  hard-and-fast  rules  con- 
cerning; till'  after-treatment  of  operative  cases  ap|)licable  to  all 
alike.  The  special  re<|uirement-<  of  the  more  important  operations 
have  been  {liveii  elsewhere  when  the  techni(|iie  of  the  o))erative 
procedures  lias  been  described.  In  general,  however,  if  there  is 
much  pain  followin};  an  operation  or  the  jiatient  is  restless.  ;iii 
anodvne  should  be  administered,  .^^leei)  and  rest  can  usually  be 
obtained,  if  pain  is  not  jireseiit,  by  the  administration  of  1.')  <Traii!< 
of  trioii.il.  If  ]i;iin  is  ,i  iiromiiient  symptom,  a  hypodermic  injection 
of  morphine  may  be  <:iveii.  The  patient  should  not  be  |'.;  rmitted  to 
lie  ill  one  |iositioii  any  longer  than  .ibsolutely  necessary,  especially 
upi>ii  the  back,  for  tear  of  hyixistatic  coiifrestion  of  the  lunjts.  If 
there  is  any  history  of  hemoirlia<;e  haviiifr  followed  a  former  opera- 
tion, the  head  of  the  p.atient  >liould  be  kejjt  hii;h  by  means  of  se\-eral 
pillows  in  adililidU  to  elevation  of  the  head  of  the  bed.  l*atieiit< 
.■iccu-^tiimed  to  the  habit  iial  use  of  considerable  ipiantities  of  s|)irit- 
uotis  lii|Uors  should  not  have  these  entirely  withilrawn,  l)ut  should 
be  served  in  moderation.  In  operations  recjuirini;  the  eyeball  to  be 
opened  111  in  e\tensi\e  operati\i'  procedures,  it  is  better  to  kec])  the 
patient  on  sdft  diet  for  the  siiccee<litii:  twenty-four  to  forty-<'i!ilit 
liours.  .\s  a  rule,  the  dressin<;s  should  be  clianijed  daily,  and  the 
eyes  e.irefully  ins|)ected  an<l  cleaiisecl  with  warm  boric  :ieid  lotion  until 
they  are  no  loiiirer  rei|uired:  and  eyes  that  have  been  bandaj;eil  for 
some  time  shoiilil  jiradu.'illy  be  accustomecl  to  the  liirht.  if  the  bowr'- 
di)  not  mo\-'.  nf  th''i!!-e!\-i'-;  in  three  "r  fiuir  days,  a  !:i\a!i\-''  <lii>ti!d 
be  administered,  and  in  all  operations  upon  the  bulb  straining  'i' 
stool  should  earefullv  be  jinan!'  d  ;u:ainst. 


.%      ISMVJl      ^.J*- 


TlBTTrWRRMf 


CHAPTER    XV. 

.p,.r  xErnXIQUR  OF  THE  PATHOLOGICAL  AND 

BACTEUlOLOtilCAL  EXAMINATIONS 

OF  THE  EYE. 

Hv  KDWARI)  A.  SHIMWAY.  B.S.,  M.D. 

TiiF  stu.ly  of  the  piitholofiv  of  the  oyc,  in  certain  sections,  has  not 
kept  pace  with  that  of  Kcnerul  i)ath(>l()Sy,  u  fact  that  is  .Uie  jx-rhaps 
to  tlie  ahnost  entire  silence  upon  this  subject  of  worlison  genera!  path- 
olo.rv  and  patiiological  teclurKpie.  In  no  i)art  of  the  l)0(iy,  how- 
ev.T  are  so  nianv  .litTerent  tissues  hitiinateiy  related  m  a  small 
-.paci-  ami  the  additional  interest  which  the  niicn.scoiiic  study  of 
thi'  varied  pathological  conditions  hrinfis  to  our  chnical  observations, 
well  rei)avs  the  etTorts  niadi'  to  master  th(>  techni.iue  that  is  required. 
\n  elaborate  outfit  is  :iot  necessary.  A  good  niicroscoi)e,  with  an  oil- 
iimiiersion  lens,  if  bacteriolojjical  examinations  are  to  be  made,  aiui 
a  microtome,  for  holding  the  knife  hi  making  sections  <it  the  embedded 


Mcilluin  lal«rati)ry  inii-ri>luiiiL- 


tissue,  are  the  first  essentials.     .\n  expensive  microtome  may  be  dis- 
.rnse.1  with.     The  Schanz.>  mo-l.'l  (Kig.  -^'^-^U  nwide  by  the  Hauscli  it 


l.,,mb  Optical  Tompanv,  is  an  excellent  instrument.  (Jood  secti.m- 
iMittitiL'  depends  more  uix.n  the  success  in  (  nb.  dding  and  upon  the 
••on.lition  of  the  knife  than  ujion  c.stly  mic<  tomes.  Thv  best  kiu\.  s 
luv  mad(    by  Walb,  in   i'eidelberg,  ami  a  lairly  heavy  one.  with  a 

(  ti«5  ) 


wmmn 


IJ(J(i 


THE  EYE. 


■  i 


ciiltiti^  odfic  fniiii  K)  to  20  ciii.  long,  sliould  he  selected.  n"i<;.  .'?.")4.) 
Aside  t'niiii  tliese  l;ir<;er  iiistniiiieiils,  we  need  a  pair  ct'  fine  t'(iicei)s 
(prel'eraljly  cuiahmIi.  iieediedidlilers,  spatulas  (one  hroad  and  <>ne 
narrow),  staining  dislies.  cover-classes,  slides,  etc.  For  many  sec- 
tions the  onlinary  slide,  1  x  ;?  inches,  is  suiiiciently  large,  Imt  for 
sections  of  the  entire  eyeliall,  slides  \\  x  .'{  inches,  or  the  (iernian  size, 
70  X  .■>")  mm.  ( 1 '.;  X  !'■;  inches),  may  he  ordered.  Convenient  sizes 
for  covor-jrla.sses  are    IS   mm.  s(|iiare:  121  x  •_'()  nnn.  for  .sections  of 


Fio.  3.' 


Ktiife  fur  microtoino 


one-half  of  the  oyel>all.  and  2S  mm.  square  for  the  entire  ball.  Larger 
ones,  2S  x  '.\2  nnn.,  are  occasionally  useful,  and  when  still  larger  forms 
are  nece>sary  isinglass  may  be  obtained  in  sheets  and  cut  to  the 
proper  siz(>. 

Obtaining  Material,  Normal  eyes  are  difficult  to  obtain,  but  may 
be  secured  occasionally  in  resections  of  the  upi)er  jaw,  and  very  sat- 
isfactory s|)i'cimens  are  furnished  when  the  eye  is  enucleated  for 
small  malignant  growths  of  the  anterior  i)art  of  the  eyeball  or  of  the 
optic  nerv(>.  Many  interesting  conditions  require  emicleation,  and 
l)athological  alterations  of  the  conjuiu'-va  m.ay  be  studie(l  by  re- 
moving small  bits  of  the  tissue  after  cocaine  ana'sthesia.  In  po.st- 
mortem  examinati(ms  the  removal  of  the  eyes  is  rarely  permitted: 
but  if  the  skull  has  been  o])ened,  the  |)osterior  halves  of  the  eyes  may 
be  secured  by  breaking  through  the  roof  of  the  orliit.  dissecting  away 
till'  fat.  iind  carefully  cutting  through  the  sclera  in  the  ('((uatorial 
diicction  with  a  sharji  jiair  of  scissors. 

.\fter  the  material  has  been  obtained,  it  slioulil  Ix^  placed  in  a 
fixir.g  fluid  as  soon  as  possible,  in  order  that  the  fine  changes,  which 
take  place  in  the  nervous  structures  of  the  eye,  may  be  |)reveiited, 
and  the  tissues  pr<'ser\('d  in  api)roxim.'itely  the  same  comlition  as  in 
life.  The  exact  time  for  the  earliest  appearance  of  post-mortem 
cha.nges  in  the  retinal  ganglion  cells  h;is  not  been  determined  for  the 
hum.'iM  e\e.  I^irch-Ilirschfeld,  IxAvever.  found  d.'cideil  changes  in 
rabbits'  e\es  iwo  hours  after  di',;lh,and  it  is  fair  to  assum(>  that  if  a 
nmch  longer  time  has  elM|),sed.  the  human  eyeliail  can  l)e  of  little 
value  for  a  study  of  the  g.'inglion  cells,  Mllhough  it  may  still  be 
us(>ful  in  ileterjnining  changes  in  other  li'ss  susce])tible  ])ortion,s. 


j:xAMiyArw.\s  or  rni:  j:yi-:. 


G(j7 


Preparation  of  the  EyebaU.    ( )n  removal  of  the  .>>(•  the  iiu't.suro- 
incnHofits.liaM.ctcrsslu.ul.llH-niuk  and  any  pcciiliaritics  iii   its 
,.M,.rnal  apiM-aran.-.-  .•aivlully  i.nt,..l.     Th."  iu.-asur.M,u.Mts  may  cm- 
)taiiuMl   hv  iiicaiis  of  an    iiistruniiMit     like   tlit 


one 


i\>\y 
vciiiciitiv    1)1'  ohtainiMl   by  means  ot   an 

~li,,Nvn  in  V\ii.  ;}.V).  wliieli  was  .lesijined  for  measimnjr  interpuin,- 
l-iiv  (lislmees  Tli<-v  sliouM  incliKle  the  antero-i)ostenor  diameter 
.i„;i  tl„.  'vei-tieal  ana'l.oii/ontal  .liam.'ters  at  tlu-  e<iuator.  The  snle 
,,l  111.'  liead  from  wliicli  th.-  .-ye  was   removed  should  also  I...  noted. 

■    ■■  on  the  nasal  side  of  the  jiosterior 


The  o|)tie  nerve  enters  the  (  yehail 


pole.s.)   that   if   the   long  axis  of  the  eornea  is  held  in  a  1.  'nzontal 


Instrument  tor  oMaiuing  meHsuanii'nlsnf  IheeyetBll. 


.lireetion.  an.l  th.<  opti.-  n.Tve  dweeted  toward  the  n.japnurv  fell  w 
,.v,.  the  problem  of  orientation  later  should  be  a  snnple  one.  It  this 
,.■„.;  is  not  reeorded.  w.>  must  rely  on  the  ai.pearanee  and  insertion  ..f 
,|„,„bli.,u.-museles.provid..d  that  they  are  still  II'-''^^'^^-  .  ^ ''''"- 
iHior  obli-iue  tendon  is  more  tl,.shy  and  is  =\'1''<-1""  f'"-^'",;  " 
U;nn  th<-  eornea  than  the  superior,     lioth  are  inserted  o  t  m- 

l„„.alsideof  the  c,>m>spondin«  reetus  musele.  /•""•;'■  '^  ^'"'^'^ 
Uis  of  the  eornea  is  h.<l.l  apiin  m  the  hon/on  al  plane  xMth  tl<> 
M.perior  reetus  up,  the  attaehments  of  the  obupies  ^.'1  '";;'»;;^  <" 
,l,;.,o,nporalsideof  the  eyeball,  and  the  side  from  whieh  it  \uis 
,,, Moved  The  position  of  any  ulceration  or  opacity  ot  the  cornea 
-huuKl  In.  sketched,  and  the  jm-sence  of  a  coloboma  or  other  i-ecu- 
li.ritv  of  the  iris  noted.  If  an  intra-ocular  tumor  is  sus];ected.  it 
,„,.,v  be  lo..ate,i  by  noticing  a  difference  in  ""■ '•■^';'7;;'V':'"f  I';.';  "; 
Lvlooking  through  the  pupil  while  the  oye  is  hel.l  be  o.e  a  b  ig  t 
li.h,  Ordinarilv,  sections  are  made  of  the  antero-p..sterior  .liam- 
,.t'.r  of  tlie  eveliall,  so  that  the  eve  should  be  divided  m  this  direction. 
I'his.  however,  should  i)e  done  after  the  fixation  and  hanlenmg,  in 
Mider  to  avoiii  distortion  of  tlie  halves.  ■     .•        • 

Fixation  and  Hardening.  Unl<>ss  some  special  exanima  i.m  is  ro- 
,,ui,vd  (see  nu'thod  for  the  retinal  ganglion  eel  s,  page  O.M  we  may 
,..,nli,„.  ours(>lves  to  the  use  of  two  solutions-formalin  and   MuUer  s 

'  "Mailer's  flui.l  consists  of:  potassium  dichromate,  2.o  gm.:  sodium 
<ulohate     1    zm.;  <listille.l   wat<>r.   1(K)   gm.     The    s.^lution    shoul. 
1...  used  in  considerable  (,uantity.  and  tlu-  bottom  of  the  jar  nAon-d 
with  cotton,  so  that   the  fluid   may   have  ready  access   to   all   por- 
lions  of  the  eveball  and  the  eye  not  injured  m  transportation.     It 


-s- 


ZtJiKlij^ 


":?sr 


I.,-  i"  \_ 


■ffaflpMMI 


(iOH 


nil:  LYE. 


I 


is  iimii'ci'ssiirv  to  iiutkc  an  npcniiii;  in  liic  ('y('i):ill.  as  tlic  tUiitI  pene- 
trates rapidly.  The  specimen  slKuiid  he  i<ept  in  the  ilark  ti>  prevent 
llie  r')nnatii)ii  of  pre<'ipitates,  ami  tlie  lluid  should  l)e  cliarifted  daily 
until  it  no  loiifier  hecumes  cloudy.  At  the  end  of  six  weeks,  at 
ordinary  room  temperature,  or  after  two  weeks  in  tiie  incubator 
(oT'  K)°  I'.)  the  eye  should  he  washed  thoroufihly  in  runninj:  water  for 
twenty-four  hours,  and  then  hardened  in  firailually  ascendiiifistrenjrths 
of  .ilcoiiol.  .Mii'.ier's  fluid  is  of  s])ecial  value  when  it  is  (h'siral)le 
to  employ  the  \Veii;ert  stain  for  the  nerve  sheaths,  and  even  when 
other  methods  for  fixation  are  used,  it  is  well,  if  the  lenjtth  of  the 
nerve  permits,  to  cut  off  a  piece  and  place  it  in  Miiller's  fluid  for  cross- 
.sections.  It  is  also  the  best  medium  for  the  examination  of  the  lens, 
as  formalin  causes  this  structure  to  shrink.  Its  disadvaiitajies, 
however,  are  that  it  disturbs  the  chi'omatiu  chMuents  of  the  cells, 
and  is  not,  therefore,  suitable  for  the  study  of  nuclear  structures  ; 
it,  moreover,  does  not  at  once  check  the  post-mortem  fjrowlh  of  or- 
>;anisins,  and  makes  the  subseipjent  staining  for  bacteria,  especially 
for  tui)ercle  bacilli,  very  dilficult. 

Formalin  is  a  40  per  i-ent.  solution  of  formaldehydt^  Ras,  and 
should  be  diluted  with  !)  jjarts  of  water  for  onlinary  use.  Stronger 
solutions  are  a|)t  to  cau.se  black  pre<-ipitates  in  the  sections,  jjarticu- 
larly  in  thi^  presence  of  blood.  The  eyeball  should  not  remain  in  the 
solution  lousier  than  forty-ei'j;ht  hours.  The  penetration  ami  fixation 
are  \ery  rajjid.  ami  the  sclera  ami  lens  soon  become  so  hard  that  they 
are  dillicult  to  cut.  Subse(|Uenl  washinj;  with  water  is  desirable,  but 
not  absolutely  necessary,  ami  the  fjlobe  is  then  liardeiie(l  with  alcohol. 
This  should  be  done  slowly,  in  order  to  avoiil  shrinkin<;  of  the  ti.ssues 
and  di'tacliment  of  the  retina  as  far  as  possible.  Hefiinninji  with  a 
.■{.'!  per  cent,  solution,  the  eye  remains  for  a  day  e.ich  in  'X^.  40,  oO,  (iO, 
70.  and  SO  pt'r  cent,  solutions.  It  is  left  in  SO  ju'r  cent.  al''ohol  for 
several  days,  and  is  then  ready  to  divide. 

.Mcohol  should  not  be  used  as  a  fixing  a^ent,  as  for  this  pui'pose 
it  must  be  of  absolute  strength,  and  the  rapid  withdrawal  of  water 
from  the  tissues,  which  accompanii's  tlu>  fixation,  produces  so  much 
shrinkinjj  that  llii'  eye  is  very  much  distorteil.  It  is  of  considerable 
value  if  the  sections  are  to  be  ev  uuined  for  tubercle  bacilli,  <ir  in  ex- 
amination of  the  retinal  ii;anj;lion  cells  by  the  Xissl  method,  but  for- 
malin is  almost  ('(jually  serviceable  in  these  cases.  The  conibin.ation 
of  .Miillei''s  fluid  and  formalin  in  the  proportion  of  10  parts  of 
Miiller's  lluid  and  1  part  of  strong  formalin,  as  sujij^ested  by 
Orth,  is  a  very  <;ood  one;  thi'  swelling  of  the  ti.ssue  c.. used  by  the  one 
offsets  the  shrinking;  produced  by  the  other. 

Cutting  the  Eyeball.  If  a  part  of  the  eyeball  is  to  be  [Jreserved  as 
a  microscopic  specimen,  it  will  usually  be  cut  in  a  horizontal  or  ver- 
tical plane,  which  passes  through  the  corne.a  and  < i\A\r  nerve.  If  an 
intra-ocular  tumor  is  present,  the  eye  should  be  so  divided  as  tosliow 
the  connection  of  the  growtii  with  the  tissue  from  which  it  has 
sprung.     Tumors  of  the  anterior  segment  of  the  eye  can   readily  be 


7..V.I.1//.V.1770.V.S  nr  THE  I.Yi:. 


609 


n:  „,os.- of  th.  <-hnroi,l  ..>..  usually  Lolm-at.-.l  ^^'r^J^^.^ 

,    ,     ,r  flu-cl.T.      If  thisi>nT;uiti..n  isnot()l)scrv.Ml   the  xctiniiit    \ 

.         .:      1  ,i„„l     Til  ■  n.ai-r.is.>..|.i<-  n»»n'ts  may.  Ii.'Utv.t,  l«-  mi 

,.onu'a  ana  imxlucos  ha.l  artcfac  s.     1  h    tr. .  '-"'K  '"  ,      ^ 

,„„vil  of  tl.'  al.-ol.ol.  hv  iinin.Tsion  of  the  eye  m  ^^^Ur  tor  at    .  a.t 

i::r:ir'';:=:;=:'=S'»S7ir;r;|^,:. 
i;:Sin;;^L-^;T!;,r^^ 

1  n  rt'i  t  ohanfics  should  Ik- reserve  I  for  nn.-roscopic  stu.h. 

111(1^1   iinpoii.im    I  luo'r."  Ti,;  .  ni-i\' li(>  (lone  ui  one 

'"';"  On,  .UW/..rf.     The  hen>H,here  is  passed  a^ain  thn.ufrji  alc.J.ol 
,n  as'en'li...  s.reu.ths  until  .d.olute  a  cohol  - -"j^  '•^^^.,    5^' 
iMunerse-l  in  p,.re  turpentine  f.r  several  -lays.  '"''      '"^  ^^H  ;^^^^ 
,ll.,n-..a  to  evaporate  shnvly.     (ioo.l,  l>r""'''\^^\V  7in   h       >  n^  V 
•husohtaine,!.     The  nietho.l,  however,  is  rarely  used  m  th.^  uu,Kr> 
iiux  oiaiuiu.  p„_,i.:^  „,,riv«e  fnniialm  in  4  per  cent. 

.  r   1       T'l,,.   r>T><.    i<   11  •irecl    in    tlie    SO  U I  ion    iimiii 


if 


Mi 


fi7() 


77//;  /;>'/•;. 


Clip  I'.r  thf  prf^rrvmi'iii  ttf  inHiT. 'm-opic 
st-'ctious  in  a  xiliitioti  iit  turiualiu. 


till'  iiK.ilcl  slinwn  ill  Fi?:.  ■'{.'>(■).  It  is  held  in  position,  fivcc  dowiuvanl, 
a^Caiiist  till' Hat  -iirl'ai'i'  of  tiic  cup  by  incaiis  of  a  jjlass  rod  which 
passes  tiiroimh  liic  rulihcr  cork.  Thi' ilisadvaiita«t's  of  liic  luctiiud 
arc  till'  iinpossiiiiiity  of  prcvciitiiij?  distiirl)iii>;  hiihl)lcs  of  air  from 
Icakinj;  in.  iiowcvcr  inucli  care  he  taken  in  tlic  mounting,  the  danger 
of  siihsi'i|iieiit  dispiaccMieiit  of  tile  contents  of  tile  eyeball,  which  an; 
not  lirinly  lixed  in  the  lliiid,  and  the  dist(.rtion  of   the  specimen  by 

the  i)ressure  of  the  jjlass  rod,  es|M'- 
cially  if  the  eyeball  is  empty.  The 
last  dilhciilty  may  Im>  avoided  by 
cementing  the  eye  to  the  Ikisc  of  the 
cu])  by  means  of  gelatin,  ((ielatin 
is  allowed  to  swell  in  water  for  several 
hours,  the  wtiter  is  |)oiired  otT.  and 
an  ei|ual  voiumeof  filycerin  is  added, 
and  the  fielatin  melted  by  heat  and 
liltered.  When  the  eye  is  to  be 
mounted,  the  {jelatin  is  melted,  ai)- 
l)lied  in  a  thin  coat  to  the  cut  surface 
of  the  eye,  and  the  l;itter  pressed 
lirnily  against  the  bottom  of  the  cup,  which  may  |iresently  be  tilled 
with  the  formalin.)  The  advaiita^res  of  the  method  are  the  ease  in 
mountinsi.  the  |>ri'servalion  of  the  natural  c(vloro  '  •  specimen,  and 
the  iiossibility  of  utiliziiif:  tin-  eye  later  for  mi.  ro  .ic  examination, 
if  necessary. 

.\  modiiication  of  Kaiserlinji's  method  may  also  be  used  with  the 
.same  eye  ciijts.  The  eyes  are  |)laced  in  i  pel' cent,  formalin  for 
twenty-four  liours,  and  are  thi'U  cut.  and  the  half  for  the  macro- 
scopic muuiit  is  wrappi'd  in  cotton  and  placed  in  solution  A.  com- 
posed of:  sodium  aceta;.',  .">  f?ni.:  |)otassium  chloride,  ().")  jj;m. ;  for- 
malin. 10  fim.:  water.  KMI  <;m.  It  remains  in  this  fluid  for  four  days, 
and  is  then  pl.iced  in  !t.')  pe>-  cent,  alcohol,  which  restores  the  original 
colors.  ,ind  ;ifli'r  twenty-four  hours  is  chanjied  to  solution  Ii,  which 
consists  of;  ])otassium  acetati'.  .'{()  };'"■!  jllyi'erin.  tlO  };m.:  water, 
KM)  <;iu.  .Vfter  three  or  four  days  the  eye  is  |)ermaiiently  mounted 
in  a  fresh  solution  of  the  same  formula. 

M.  I'n'.-<('rnitii)ii  in  (ili/Cfri)  .IcUij.  If  the  eyeball  has  boon  hard- 
eneil  in  .Miiller's  fluid,  it  should  be  washed  thoroiifchlv  in  water  for 
sever;il  days,  and  bleached  in  a  .")  p<'r  cent,  solution  of  chlonil 
hydrate  until  as  much  of  the  color  is  removed  as  ma_\-  be  possible. 
It  is  now  ])laceil  in  a  mixture  of  <;lyceriii  and  water — at  first  in 
the  propoiiiiiii  of  1 :  .S,  and  then  of  1 :  2,  for  one  day  each,  and  is 
ready  for  embedding  in  the  jilycerin  jolly.  The  latter  is  made  as 
follows  itlie  strenjitli  of  the  gelatin  is  <rreat(>r  than  that  usually 
recommended)  :  ft  iirammes  of  a  tine  ijuality  of  gelatin  {('oignet 
&  Co..  Paris,  oi'  (onto  I'ils.  .Nhigdeburg.  (iermaiiy)  are  covered  with 
■J.')()  c.c  of  water  in  an  .'igateware  vessel,  and  allowed  to  swell.  Heat 
is  carefully  applied,  and  the  mixture  constantly  stirred  to  ])revent 


^xT^sf — =-^.*-'a..tv.— .  *,.'  'J  .H-  f.}.  ig 


Mnr^kVnmr  tfw'^    w 


i:.\AMiy.iTio.\s  OF  THE  i:yh. 


(i71 


l)iiriiiii>;:  dtlicrwisc  tlic  jelly  will  liiivc  !i  hntwuisli  color.     After  the 
.'iliitiii   is  tlissolveil,  the  white  of  Ml  e^K  or  ;i  small  amount  of  pre- 


pa 


(1   vfT^r  ;ill)uiiiiii  (Merck)    is  ai 


1(1.  1,  aiiil  the    solution   is    boiled 


vi^orouslv  anil  hltereil  through  a  unod  tilter-pap<'r  while  hot.  The 
liltrate  should  have  a  very  pale  straw  color,  and  lie  perfectly  clear. 
To  it  is  added  an  equal  V(.lume  of  glycerin  (V.  I'.),  ami  10  c.c. 
of  a  10  |)er  cent.  ,soluti(m  of  carholic  acid  for  each  HKM)  c.c.  of  the 
ture,  to  prevent  the  growth  of  bacteria  and  moulds.    The  mount- 


mix 


iiii;  jar  is  a  plam  cup,  measmniK   1;   uiclies  m  ( 


li.'imeter  and   1  inch 


lee|),  with  a  flat,  well-polished   l)a.se  and   per|X'ndicular  sides.     It  is 
tilled  iiearly  to  the  top  wiiii  the  melted  jelly,  and  the  eye  is  immersed 


wil 


h  the  ciit  .surface  up.     All   liubliles  of  air  are  coaxed  out 


the 


meshes  of  the  tissue  by  means  of  a  needle,  and   those  (.n  tlie  surface 


if    the   jelly  are    rel 


oved   l)y  touching  them  with  a  platiimm   loop 


hich  has  iieeii  heated  in  a  Muiisen  burner.     The  eye  must   iheri  bf 


turned  over  carefullv,    >o   t 


hat    no   bu!)bles  of  air  are   included,  the 


f  which  mav  be  detected  bv  lioldini;  the  cup  over  a  hand 


<iil.  but  if  it 


presence  o 

mirror.     If  the  eyeball  is  empty,  this  re(niircs  .soi 

turned  with  one  iieedle,  while  a  second  one  pu.shes  in  the  sclera  and 

holds  the  cut  edjie  below  the  surface  of  the  jelly,  the  difficulty  will 

besliMit.      The  jellv  should  cover   tlie  .specim(>n,  but   should   not   fill 


the 


cup  to   the  t( 


Tl 


le  eve  l^ 


held 


itral   p 


)osition  l)v  means 


I  pin  which  projects  through  a  piece  of  w I  or  card-board  | 


dtil; 


ice( 


I 

1  the  specimen  isjilaced  under  a  iM-ll-j.aror 


over  the  top  of  the  cup.  am 

other  suitable  dish  until  the  jelly  hardens.     After  .-several    ilays  tl 

led  bv  cetnentin)!  to  it   a  white  porcelain 


open  top  of  the  cup  is  sea 

disk,  and  thecuji  m;iy  l>e  mounte(l  inaW( 

filvceriii  jelly  is  (luiie  transparent. 


iodenba.se.  ( l"ip. ;!.")".  t'  (iood 


an<l    fill's 


the 


firmh 


that 


there  is  no  daiifjer  of  .subseipient 
displacement  of  the  cy;-  contents. 
The  one  difficulty  in  temperate  cli- 
mates is  the  meltinK  of  the  jelly  in 
very  warm  weather.  This  may 
partly  be  avoided  l)y  turning  the 
specimen  cups  over  in  summer,  or, 
better  still,  by  exposinji  the  mounted 


UuHe  I'ur  luounliiig  cup. 


iieiier  Sim,  ov  e.xpo.siiif;  uu- iiniuiiM  .. 

specimens  t()  the  fumes  of  strong  formalin  placed  in  a  dish  under 
the  bell-i.ir  while  the  jelly  is  hard.ening.  Strong  formalin  added  to 
the  gelatin  in  solution  gives  it  a  whitish,  semiopaiiue  appearance, 
which  hides  the  details  of  the  eye  but  does  not  have  this  effect 
when  in  ;i  gaseous  state.  In  forty-«'ight  hours  the  jelly  is  hardened 
to  a  (lei)th  of  about  a  quarter  of  an  inch,  and  this  porti(.n  will  not 
melt  even  in  a  Hunsen  burner.  If  the  additional  precaution  i.s 
taken  to  invert  the  cui)s  in  very  warm  weather,  no  difTiculty  should 
be  experienced  in  jOTserving  the  specimen  in  good  coiulition. 

■  Wall  A  Ochs.  Philadelphia,  have  the  eups,  porcelain  disks,  and  wooden  bases  in  stock. 


I  iiii  V:'  a'ar  IV-'. 


^91 


Hi- 


Tin:  h:YE. 


The  Preparation  of  the  Microscopic  Specimen*.  Tlic  li.ilf  tor  ini- 
iToscnpic  i'\;iiiiiiialii>ri  i^lioiil.l  Ix- s.MrcliiMl  riuvt'iilly  I'nr  tlii'  |ncsciici> 
(.f  calcurcniis  oro.is.'oiis  (lriMisii>,  wliicli  arc  iini  iincniiminii  altera 
lonH-slaiiiliiin  cxiidativc  iiitlaiimiatidii  of  tin-  clinroid  ami  in  atn.pliic 
I'Vflialls.  Siicli  ilcposits  iirciir  iiinsi  frfiiucritly  ill  the  siirl'acr  ul  tlic 
ciu.rui.l,  aii.l  will  niiii  \\n-  <'.Ik.-  nf  the  inien.t..ihe  knife  unless  re- 
iiinved.  Maiiv  SDliitions  are  ii.se<l  for  .leeaicilicalinn.  Miiller  s  llui.t 
has  thi-  action,  Imt  requires  a  very  lotid  time.  Much  more  service- 
able is  a  1(1  |)er  cent,  solution  of  trichloracetic  acid,  which  decalcihes 
the  tissue  in  a  few  days,  and  does  not  injure  its  staining  .jualities. 
The  solution  should  "Im-  channel  daily,  and  the  ti.ssue  thoroughly 
washed  in  water  afterward.  Nitric  acid,  in  ;{  to  !)  per  cent, 
.solution  111  wat<'r,  or  in  70  imt  cent.  al.-oh..l,  an.l  the  following  solu- 
tion, conlainiii}!  phlorofilucin,  also  j;ivt'  W'od  results:  phloro>,ducin, 
1  pin.;  nitric  acid,  .')  pni.;  alcohol,  70  pni.;  wati'r,  .'{0  pin. 

llaviiiu  freed  the  siM-citnen  from  chalk  deposits.it  is  ready  for  eni- 
iM'ddiii";.  For  this  jiurpose  we  must  have  a  suhstance  which  will  iii- 
tiltratiMhe  tissue  thoroughly  and  will  also  be  sullicieiitly  linn  to  prevent 
aiiv  motion  of  the  parts'as  the  knif<'  is  drawn  across.  TIk  most 
satisfactory  material  for  thecntin'  eyeball  iscelloidin.  Photoxylon, 
which  has'beeii  recommended  as  of  (Mpial  value  ascelloidin,  is  still 
used  ill  (ierniany,  but  can  no  longer  be  obt.iineil  in  this  country. 
I'araflin  is  very'useful  in  cutting  small  growths,  or  when  very  thin 
.sections  are  ne"cess;iry,  as  of  the  retina,  but  it  does  not  infiltrate  tho 
sclera  and  lens  well.'  (Vlloidiii  is  soluble  in  equal  i)arts  of  alcohol 
and  ether.  It  is  usually  furnished  in  this  country  ni  the  form  of 
shavings,  in  one  ounce  (piantities  (Schering),  and  is  dissolved  most 
readily  by  covering  it  for  twenty-four  hours  with  absolute  alcohol, 
by  which"  it  is  .softened.  On  the  aiMili'ii  of  an  e(|ual  (piantity  of 
ether  the  mass  slowly  dissolves.  It  should  be  of  a  thick,  syrupy 
coiisistencv  for  embeiiding.  and  a  thinner  .solution,  made  from  the 
stock  solution  by  the  addition  of  more  alcohol  and  ether,  should  also 
be  on  haiKl.  It  .should  be  storeil  in  well-stoppereil  jars,  and  may  1m> 
kei)t  free  from  pos.sible  moisture  by  placing  it,  together  with  the 
jars  containing  the  absolute  alcohol  and  alcohoU-thcr,  in  a  large, 
tightly  covered  jar,  in  which  there  is  a  (lUaiitity  of  calcium  chlori''" 
to  kcei)  the  air  dry. 

Before  the  eve  is  emlx'ilded,  all  traces  of  water  in  the  tissue  should 
thoroughly  be  "removed.  This  is  done  by  carrying  it  again,  after 
thawing,  through  asceiuliiig  strengths  of  alcohol  until  absolute  alco- 
hol is  reache.;.  The  ab.solute  alcohol  is  kei)t  best  in  a  large  jar.  the 
bottom  of  which  is  covered  with  cupric  sulphate  cli  has  been 
thoroughlv  dried  bv  heat.  The  copper  absorbs  wati  .-cry  eagerly, 
and  keei)s  the  alcohol  pure  :  it  should  be  covered  by  several  layers 
of  filter-paper,  or  the  r.|)eciiii.u  .sh.iuM  !)<>  held  above  ii  by  iiioans  of 
wire  gauze  netting  susjiended  in  the  alcohol.  From  absolute  alcohol, 
after  twentv-four  to  forty-eight  hours,  the  eye  is  transferred  to 
e()ual  parts  of  alcohol  and  ether  for  twenty-four  hours,  then  to  thin 


£A.l.W/.V/ir/'>.No  Or-  TIIK  KYU- 


«73 


...llni.liii.   an.l    to   thick  (M.lloi.lin    for  iit   \vx<  oiu;  day  (■ad..     The 
...lluuliM   is  nosv  allnwcl   to  lianl.M.    vory   slowly  m  a  glass  .li.sli  at 
|(.:i>t    oni"   inch   tlccj),  am 
Uiwccn  the  eye  ai 

\vhi( 
ill! 


,,,  an.l   wide  ciinuKh  to  leave  coiisidcral)lf   s|)ac(' 

w.Ti.  ....•  -v' 1  tix-  '*''•'■•  -^i'  =''■■  '•"''''''•'  '"•■  '■'•""'V''  •""••:',"">'i 

I  the  dish  i.s  covered  witii  a  timihler  or  similar  vessel,  one  side  ot 
•h  iiiav  Iw  raised  slitjhtlv  aft.T  twenty-four  hours.     It   is   very 
■    hat    the  surface  shoul.l  harden   slowly.  otherwis<'  large 


iiortaiit  t 


Mil  loillini    mill      iiK     .-nil"--     .  .  , 

|,„l,l,l..s    collect    l.eiu.uth    it.     The    length    ..f    time    re-iuired  for  the 
,f  the  ether  varies,  hut  usually  it  will  take  three  or  tour 

I  occasionally,  hy  a  needle. 


ixaporalion  o 


The   celloidin   should    Im'    loo.-ient 


il:iy> 

from  the  wall  "f  the  ( 


lish,  and  when  it  is  sullicieritly  tinn  at  the  hot 


loll 


I    to   prevent    the   nee( 


lie   from   cutting  it  on  slight  pressure,  the 


1)1. H'k  mav  he  remove 


1  hy  shaking  and  placed  in  NO  percent     ilcc 


In  this  it  idisorl):^  wa 


ti  I  .1.11(1  hecoines  fin 


Tlie  Iw-st  Mock  of 


I'lloidii 


should  he  oiilv  slightly  opruiue.  an. 


I  its  surface  should  not 


Iv  iM-eled  olT  hv'lh.'  linglr-nail.     It  may  he  made   still  firmer 


Msily  I 


hv  adiling  glycerin  to  the  alcohol 


Cutting.     After  twenty 


hiur  hours  in  alcohol  the  hlock    is   rculy 


f..r  culling,  and  may  he  mounted  on  a 


firm  oliject   vliich  can  hi 


iiped    ill  the    mien 


WnO( 


I  mav  Im'  vised,  and  if  the  hlock 


itome.     Mlocks  of   pure    white  i  :.ie  or 


laple 


holder  of  'h(>   microtome  a   |)ort 
awav.  as  .shown  in 


large  to  enter  the  ohject 
the   underpart    may  he   cu 


purposes,  may  he  cut  in  convenient 
.sizes,  and  has  the  advantage  of  not 
staining  the  alcohol.  When  the 
|,i,,rk  luvded  is  too  large,  a  smaller 
pirc>  may  he  fastened  to  its  umler 
>iirlace  hv  means  of  hrass  screws  or 
a  T-sh:.,  'dhlockmaybocutasdes 
,  lihed  ahovo.  SuimtHuous  cellimliu 
slioiild   he   trimmed   away,  and   a 

<< Itlat  surface  cut  parallel  to  the 

lilaiie  in  which  the  sections  are  to 
mat 


Fig.  ;{.>.     \ulcanizetl  libre,  u.<ed  for  insulating 


Ic.     The    l.ase    of    tlii'    ci'l- 

i.liii  1)1. „k  is  dried  and  then  im- 
1  ill  alcohol-ether  for  a  half- 


llU'fsei 


III 


iiiiite  until  the  celloidin  is  soft- 
ii.,|     Moderately  thick  celloidin  l 

(Hired  on  tiie  ohj 


ih'iectdiolder.  and  the  speci 


linen 


mounted  in  it  and 


1  tirinlv  in  place  for  a  few  miiiut 

•k  intoSO  per  cent,  alcohol  to  hecoiiu 


hen  the  entire  hlock  is  put 
firm.    In  cutting,  the  .siH'ci 


should  he  clamiM'd  very  firmly  in  the  microtome,  an. 


1  should  be 


li'V.'lle, 
as  p- 


1  can 
sihie 


•fullv.     The  knif<>  sh..ul.l  l)e  l.lace.l  at   as  acute  an  angle 
Mh.'l.la.lean.l  object   kept   tlmroughlv  flushe.l  with 


an. 


./.„o/i 


s'l  per  cent,  alcoiio 

without  ])ressure   o 

tlat  .)n  the  bhi.le  hy  means  of  a 


The  knifr  .shoalJ  'h-  -irawn 
,f   the  lian.l  .h.wnwanl.     The  sectuMis  ar 


1 1  ivi-nhi. 
held 


li.rht  brush  held  in  the  l.-ft  hand,  or 


G74 


Tin:  icYi:. 


, 


allowed  to  roil  up.  ami  then  unrolled  when  the  section  is  complete. 
The  sections  to  he  stained  at  once  are  placed  in  distilled  water:  the 
remainder  are  put  in  SO  per  cent,  alcohol.  If  serial  sections  are  im- 
l)ortant,  numbered  circles  cut  out  of  thin  paper  may  l)e  slipped  be- 
tween each  section  as  it  is  cut,  or  numbered  dishes  may  be  used, 
into  each  of  which  ten  sections  are  juit.  If,  then,  certain  changes 
are  found  in  any  particular  location,  they  may  be  followed  in  the 
sections  immediately  [)recedin};  or  succeedinj;.  The  eyeball  should 
be  cut  entirely  at  one  sittini;,  if  pos,sil)le,  as  an  inexact  levelliufi;  at  a 
subseciuent  occasion  may  result  in  the  loss  of  valuable  material.  The 
sections  are  now  ready  to  stain. 

Small  pieces  of  tissue,  such  a.s  tumors,  portions  of  the  optic  nerve, 
etc.,  may  be  mounted  much  more  (piickly.  From  the  fixing  (luid 
they  are  transferred  for  twenty-four  hours  each  into  75  I'.er  cent, 
alcohol,  !)')  per  cent,  alcohol,  absolute  alcohol,  alcohol-ether,  thin  cel- 
loidiii,  thick  celloidin,  and  then  are  mounted  on  a  block  of  wood  and 
covered  with  a  layer  of  thick  celloidin.  When  this  has  hardened 
slijthtly  on  the  surface  (after  a  few  minutes)  the  blocks  are  placed  in 
SO  |M'r  cent,  alcohol  for  at  lea.st  six  hours,  ami  the  material  is  ready 
to  cut  witii  the  microtome. 

ParaflBn  Embedding.  The  ti.ssue  is  hardeui-d  in  the  same  way  as  for 
celloidin,  and  after  twenty-four  hours  in  absolute  alcohol  it  is  placed 
in  a  inixtun>  of  ab.solute  alcohol  and  chloroform  for  twenty-four 
hour.<5,  then  into  pure  chloroform  for  twenty-four  hours,  chloroform 
.saturated  with  i)arartin  (warm)  for  twenty-four  hours,  aii'i  then  melted 
])aralHii  in  a  paratfin  oven.  I'aratfin  of  two  meltinji  points  may  be 
used— the  first  meltins  at  42°,  in  which  the  tissue  remains  two 
hours,  and  the  second  at  .54°  to  5S°.  in  which  it  remains  for  tlie  same 
length  of  time.  The  oven  should  be  regulated  l)y  a  liiermosfat  to 
remain  steadily  at  a  temperatun*  slightly  above  the  higher  melting 
point.  The  chloroform  may  1)(>  replaced  by  xylol,  and  for  strips 
of  the  retina  the  process  may  be  nnich  .shortened  (see  page  OTSK 
Small  objects  remain  in  xylol  four  hours,  xylol  paraffin  six  hours, 
and  paraffin  up  to  five  hours.  The  tissue  may  then  be  mounted  on 
a  block  of  wood  and  covered  with  the  melted  i)araf{in  by  means  of  a 
warm  spatula,  and  then  thrown  into  water  to  harden  ipiickly.  or 
else  placed  in  a  shallow  glass  dish  (the  walls  of  which  have  been 
coated  with  glycerin  I.  and  covered  with  paraHin.  Small  paper 
boxes  may  also  he  made  and  used  for  this  ptiri)ose.  .\s  soon  as  the 
surface  of  the  p  .raffiii  h;is  hardened  slightly  the  entire  dish  or  box 
is  submi'rged  in  cohl  water,  in  order  that  the  paralHn  may  harden 
((uickly  and  evenly,  .\fter  the  su|M'rfluous  paratlin  has  been  cut 
away,  the  block  is  mounted  on  a  piece  of  wood  by  warming  the 
surface  of  the  paratfin,  ami  it  is  now  ready  for  cutting.  Incutthig, 
the  knife  is  not  placed  at  so  sharj)  an  angle,  ami  tin-  sections  are 
cut  dry.  They  must  be  kept  fnim  nilliiif;  uj)  liv  means  of  a  fine 
camol's-hair  brush,  .and  .should  be  spread  on  warm  water,  in  which 
they  flatten  out  smoothly.     If  ribbon  sections  are  desired,  the  block 


.M-i'i-»..^  I 


KXAMIXATWSS  OF  THE  EYE. 


675 


,f  parartiii  should  he  cut  accunitcly  (ju; 


Ivduudrilatcnil,  and  tlio  knifo  placed 


:it  n« 


■\u 


;iit  aiifilcs  to  the  inicrntoiui 


The  sections  should  he  stainei 


1  in  a 
pli 


i.C  :„;,1   th<"   paraflin  dissolved   ..ut  b.^fore   the  stai.i  is  app I.e.  . 

1    to  fasten    them  to  the  slide   so  tluit 
the  Hrst  place,  should 


Manv  methods   are  employei 

thcv"  shall  not  be  floated  away.     The  slides,  ui 


l.r  cleaned  scruiHilous 
>(,  that  the  latter  may 


;lv  with  alcohol  and  dipped  beneath  the  sect 
be  floated  on.     If  there  is  no  hm-ry,  the  smipl( 


ion. 


iiiralis  ot  ( 


ira 


,Mnentin>;U.em  fa.st  is  to  place  the  slides  on  the  top  of  tl.i 

™  Hill   IS  then  dissolved 


Hill  oven  for  twei 


itv-four  hours.    The  para 


li\-  xvio 


il.  the  xvlol  remove. 


leadv  to  stahi.     If  aqueous  stam 


I  l)v  absolute  alcohol,  and  the    sections 
)iis  stanis  arc  to  be  used,  the  slides  should 


ulacei 


-laiiiinji  IS  nece 


I  hi  SO  per  cent,  alcohol,  and  then  in  w 


ater.     If  inim 


■diate 


rv,  the  sections  ma% 


liv  means  of  hlter-i)aper  moi 


•  Ik    pressed  firmly  to  the  slide 

itened  with  absolute  alcohol,  the  liar 


iliiii  is 


lissolveil  with  xylol,  the  xylol  reniovi 


I  bv  absolute  alcohol, 


(1  the  sections  covere. 


with  a  rcrji  thin  solution 


)f  celloidin.    When 


s  thin  hiver  hardens  the  slide  is  i)laced  in  SO  per  cei 


Ihi 

ihcM  ill  wa 


it.  alcohol,  and 


tcr.     The  celloidin  does  n 


.t  interfere  with  the  subsequent 


staimn};,  am 


1  th 


(■  sec 


■tions  remain  in  position 


Staining  Methods.     Before  microscopic 


;tudv  the  sections  should 


stained.     For  tliis  pur] 


)ose  we  make  use  of  two  types  of  stains: 


1    Those  which  stain  electively  the  nu( 
Ifuselv  tlu-  c'll   protoplasm.     Of  the  former,  we  may  conhne  ou 


lei;  and,  2.  Those  which  stain 
titii 


Ives  prac 


ticallv  to  two— ha'inatoxylin  and  carm 


ind  of  the  lat- 


iisiii,  fnchsin,  and  pu 


1  i)icric  acid  are  especially  valuable.     Staining 


Imlk  larelvis  usei 


1,  and  each  section 


should  be  han.lled  sei)arately 


\ltcr  suitable  staiiiing  the  sections  are  (U 


hvdrated  in  alcohol,  cleared 


III  one  o 


the 


iMitial  oils,  or  mixture  o 
itlvin  Canada  balsam 


iiiounted  permanen 
;iiid  coiinterstaiiiinp  with  eosinniay 
1.   The  sections  are  placed  in  wa 

ilieii  into 


f  carbolic  acid  and  xylol,  aiid 
Stainins;  with  ha-niatoxylin 


be  described  briefly  as  follows 
t(>r  to  remove  the  alcohol,  an. 


n    tilten 
cell   llll'ol 


Deiafiel-l's  luematoxvlin.     .\  well-ripened  solution  is  ii( 
il  a  laver  one  half  an  inch  deep  can  ju 


d  tap-water  unti 


iflh 


11  this  th(>v  remaii 


1  three  to  five  mill 


I 

led 

4  be 

utes,  until  sulfi- 


■lelll 


Iv  stained  (the  eel 


iin  should  be  colored  liflbt   blue).     If,  on 


nnioval  to  tap-water,  the  stain  is  no 


t  sutlicientlv  dee]),  replace  in  the 


-taiiiiiifi  .solution 


It  is  better  to  overstain  than  to  understain. 


<\  a 


W^ish  thoroujihlv  in  filtered  tap-wat.>r,  to  which  a  diop  or  two 
water  mav  be  added,  if  it  is  not  suthcieiitly  alkaline  \o 
tinns  a  d.vp-blue  color.     If  the  sections  are  oyerstaine. 


Miiiioiiia  water  may 
tl 


le  se( 


iliiv  mav  be   placed  in  a  0,.'i  per  cent. 
in  70  per  cent,  alcohol  a  moment,  unt 


solution  o 


if  hvdrochlorie 


1. 
acid 


il  th(>  celloidin  loses  most  of 


.lor.     riien  wash  thoroughly  with  alkaline  tap-w.  ter. 
;{.   Distilled  water. 
\.  Thin  alcoholic  solution  of  eosin,  one  ininute 


'1." 


r-r  cen 


t    'dcohol.  to  remove  exces 


Irate.     Carefully  straighten  out 
tloat  them  on  the  surface  of 


f  eosin  and  to  dehy- 

the  sections  on    the  spatula,  and 


^^WB^"^ 


'■• 


I 


676 


TUE  EYE. 


G.  Carbol-xylol  (xyldl  3,  carbolic  acid  crystals  1),  whore  they 
should  spread  out  smoothly.  Here  all  reiiiaiuin";  traces  of  water 
are  removed,  and  tlie  sections  should  show  no  white  patches  in  the 
tissue  when    held  over  a  dark  surface. 

7.  Transfer  the  section  by  means  of  the  .spatula  to  the  slide, 
smooth  it  out,  and  press  it  firmly  to  the  slide  with  a  fine  fiiter-pajwr 
folded  in  six  to  eight  thicknes.ses.  A  drop  of  xylol  bal.sam  is  dropped 
on  and  a  cover-gla.ss  carefully  lowered  upon  it.  All  air  bubbles 
should  be  removed  by  jjentle  pressure  with  the  needle,  and  the  sec- 
tion is  permanently  mounted.  Too  much  balsam  is  preferable  to  too 
little,  as  the  spiH'imen  may  be  spoiled  later  by  the  appearance  of  air 
biil>bli's  as  the  i/al.sam  dries. 

Instead  of  carbol-xylol,  oil  of  bergamot,  origanum,  or  cajeput  may 
he  used  for  clearing,  but  the  .section  .should  be  pa.ssed  through  abso- 
lute alcohol,  and  more  skilful  handling  is  riMiuired.  as  too  long  action 
of  tlie  absolute  alcohol  softens  the  celloidin. 

\  AN  (iIKson's  .Mkiiioi).  1.  The  sections  are  stained  with  luema- 
toxylin,  as  befor(>,  and  should  bo  overstained.  No  ditTerentiation 
with  acid  is  ro<iuired. 

2.  Water. 

.S.  \'an  (Jieson's  solutiim  (concentrated  aqueous  .solutiim  of  picric 
acid,  to  which  acid  fuchsin  is  added  until  a  rod  color  of  the  desired 
<lopth  is  (il)taiiiedi,  thirty  .seconds. 

4.  Water,  for  a  moment. 

").  !•.")  por  cent,  alcohol  to  dehydrate. 
(').  .\bsolute  alcohol. 
7.   .\vlol. 

5.  Balsam. 

The  nuclei  are  stained  brownish  red,  the  other  substances  deep  red 
to  yellow.  .Xxis-cylindors  are  red,  an<l  the  nerve  sheaths  yellow. 
.Muscle  tissue  is  yellow,  while  (•oimective-ti.<sue  fibres  are  red. 

I'arallin  sections  are  staincMl  in  the  same  way,  except  that  they 
are  staine(l  on  the  slides,  and  the  staining  usually  ri'(iuiros  a  longer 
time.  Staining  dishes  with  .•irrangements  for  holding  the  .slides 
ajjart  ai'e  great  time-savers,  as  a  number  of  slides  may  be  handloil 
at  the  same  time. 

Carmine  Stains.  These  ar(>  especially  valuable  when  the  .sections 
are  to  be  staineil  for  mii  ro-organisms  or  fibrin,  or  when  the  reaction 
for  iron  is  to  be  apprie(l.  A  number  of  formulas  are  useil,  but  the 
two  following  nii'tliods  will  siitlice  : 

1.  Lithium  carmine  !2.5  gr.  of  carmine  ;ire  dissolveil  in  1(K)  c.c.  of 
a  cold  s.itiiraled  soliiiioti  of  lithium  carboiiatei.  Stain  for  ten  min- 
utes. DilTerentiate  in  acid  alcohol  il  per  cent.  sol.  of  H("l  in  7(' 
perceiit.  alcohol  I  for  fifteen  minutes,  wash  in  water,  dehydrate  in 
alcohol,  xylol,  balsam. 

2.  iiorax  carmine  I  carmine   'y  gm.  and  i)orax  2  gm.,  are  dissolved 
in  KtOc.c.  of  w.ater,  the  solution  is  boile(i,  !ind  .')  c.c.  of  ji  ().,'>  percent 
solution  of  acetic  aciil   is  addeil;   filter  after   twentv-f(>ur   hours). 


k 


-..-.^.^.VA^JL.'J.,  Iff 


EXAMiyATIO.SS  OF  THE  F.YE. 


677 


^fiin  for  fifteen  minutes,  wash  in  water,  different iute  in  arid  alcohol 
l,,t,M-n  minutes,  wash  in  water,  aicolml,  xylol,  balsam. 

Double  stains  with  earmine  may  b<'  obtame.l  by  a.KuiK  to  1 
i,.,rt  of  the  lithium  carmine  solution  2  parts  ot  a  saturate.  1  i.ienc 
;„'i,l  solution.  The  nuclei  will  be  stained  red  and  the  remauung 
iii'otoplasm  vellow.  ^,  ^ 

Special  Staining  Methods.    I.  Wkic.ert's  St.mn  for  Neuvk  Sheaths. 

1.  Fix  in  Muller's  solution,  and  harden  sul^se.iuently  m  alcohol, 

irilhiiul  wnxhimj  the  tissue.  ,     ,    ,  ,  i 

•'    Kmbed  in  eelloidin.     Eighty  per  cent,  alcohol,  sevenil  hours. 

'{'  Saturated  solution  of  nevitral  acetate  of  copper,  ililutetl  one- 
lialf.  in  the  incubator  at  ;}5°  ('.,  twenty-four  hours. 

J    Wash      l'lac(>  in  70  per  cent,  alcohol  six  to  twelve  hours.     Lut. 

-,'  Stain  in  Weigerfs  alcohol  Iwinatoxylin  (1  gm.  of  ha-matoxy- 
lin'  is  a.lded  to  10  c.c.  of  absolute  alcohol  and  UK)  c.c.  of  water,  an.l 
,1,,.  solution  boiled:  add  to  this  solution  a  saturated  solution  ot 
li,l,iuui  carbonate  h.  the  proportion  of  1:  UK)  at  tlu- tmu- o  usmgK 
Tl,(.  stahi  should  be  use.l  coM,  aiul  maybe  allowed  to  act  tweUe 
I,,  twenty-fours,  the  sections  stahiing  an  mtense  black. 
().  Wash  thoroughly  in  water.  o        *      • 

7.  DitTerentiatc  in  a  solution  composed  of:  borax,  2;  potassium 

t'l  rricvanide,  2.5;  water,  10(X  ,  .,     ,      i 

The  normal  nerve  sheaths  retain  the  black  color  while  the  degeu- 
,  rated  fibres  and  the  remainhig  tissue  become  lifl't  l'n>wn-  f  ^h'';!'*- 
iVn-ntiation  pr..cee.is  too  rai)idly,  the  solution  should  be  diluted.  Ihe 
,„,„rss  should  be  interrupted  from  time  to  time  and  the  sections 
.samined  under  the  micro.scope.  as  the  optic  nerve  hbres  are  ex- 
,r..,lin.dv  fine  in  calibre  and  are  decolorized  much  more  (juickl}  than 
,  no.,,  of'the  central  nervous  system.  Tlu-  ri-^ht  time  tor  interruptmg 
it  ,nay  be  judg<-<l  by  watching  the  ciliary  nerves,  which  often  ai  -  m- 

''''s''\vash''tlmnuigillv  in  water  until  all  traces  of  the  differentiating 
,oluti<m  are  remove.)',  .lehy.lrate  in  alcohol,  carbol-xylol    balsam 
-Phis  m.-th...l  is  rea.lilv  applie."    f  tlu-  optic  nerve  has  been  cut  far 


iiiiiugh  back  of  the  eye   to 
"\:iniinati.>n.     (i.).>.l  results 
the  pieces  if  the  sections  in 
ill  (I..")  per  cent.  s.>luti.)n  of  <• 
iliiii    staine.l    aii.l   .litTerentiat 


removal  of  a  piece  f.ir  special 
)  be  obtained  without  coppering 
n  are  placed  for  twenty-four  hours 
'  aci.l  in  the  incubator.  They  are 
„,  ,,„„  „„„.„..„.,.,.d  as  bef..re,  but  shoul.l  be  watche.l 
.nvlullv  The  fibres  will  be  staine.l  bluish  black  rather  than  .lea.l 
l,la,.k.  "This  method  is  applicable  f.  the  sectiotis  of  th.M-veball,  pr..- 
^id,■.l  that  th..  .'ve  has  been  har.lene.l  in  Miiller  s  flui.i.  SectK.ns 
lived  in  formalin  al.me  will  n..t  give  certain  results,  even  if  they  are 
uvat...!  with  the  chr.nnic  aci.l  s..lution.  an.l  if  tlu-  examinati..n  of  the 
nerve  fibn-s  is  of  importanc.-,  Miillcr's  Hui.l  shoul.l  always  be  used  for 
-  ...        '  -.t  "■■■♦■■i;i  of  theretmn, 


\iiit;.    Where  thi^  w. 


I  IK 
■^niall  strip  ma\ 


,uid  interfere  with  an  exammnt 


IV  !«•  remove 


i  as  described  in  six'aking  of  the  methods 


tu.lying  the  ganglion  cells. 


678 


THE  EYE. 


l\ 


II.  Maiuhi's  Method.  1.  Hx  siiuill  jHocp.-i  of  the  optic  noivo  in 
Miillcr"s  fluid,  eijjlit  days. 

2.  Freshly  prepared  luixturo  of  Miiiler's  fluid  and  1  jjer  cent. 
Ofiuic  acid  solution  in  ecjual  parts.    Six  to  twelve  days. 

'.i.  Wash  in  running  water.    Twenty-four  hours. 

4.  Alcohol,  celloidin.  Cut.  The  .sections  are  dehydrated  in  alco- 
hol, cleared  in  carl)ol-.\ylol,  and  mounted  in  (Canada  balsam.  The 
(Icjiencrated  nerve  tibre.<  appear  as  Hue  black  dots  arranged  in  chains; 
fat  tissue  around  the  nerve  is  also  stained  black.  .\11  else  is  li'^lit 
yellow,  often  with  a  greenish  tinge.  The  .sections  may  also  be  stained 
with  carniiiie,  \'an  (iieson's  Huiil,  etc.  If  permanent  |)reparations  are 
desired,  the  sections  should  not  i)e  covered  with  a  cover-glass,  other- 
wise the  black  color  is  apt  to  fade  quickly.  On  the  cut  surface  of 
the  nerve  there  is  always  a  deposit  of  black  dots,  but  they  do  noi 
extend  far  into  tlie  substance  of  th(^  nerve. 

III.  (Janci.iox  Cki.i.s  or  the  Retina.  Tiie  study  of  the  ganglior 
cells  of  the  retina  has  become  of  great  importance,  especially  in  con- 
nection with  various  intoxications.  Sections  made  through  tlu^  eye- 
ball, in  celloidin,  are  usually  too  thick  for  this  i)urpo  e,  and  small 
strips  of  the  retina  may  be  cut  out  with  a  sharp  jk  ir  of  scissors 
when  the  eye  is  cut  in  half.  Il  .Miiiler's  fluid  is  to  bi'  u.sed,  a  <?ut 
.should  be  made  with  a  sliarj  i'lstnrnent  through  sclera,  choroid,  and 
retina  immediately  aftur  enucleation,  the  retina  carefully  lifted  from 
the  underlying  choroid,  and  a  strip  excised.  It  may  be  placed  in  20 
per  cent,  formalin,  or  in  90  per  cent,  alcohol  for  twenty-four  hours, 
then  into  al)solute  alcohol  one  hour,  xylol  for  one  hour,  xylol  par- 
aflin  (concentrated  solution  of  paraflin  in  warm  xylol)  one  h(mr.  and, 
finally,  for  fifteen  minutes  each  in  soft  and  hard  paraflin.  The  sec- 
tions should  be  from  2  to  (>  ,«  thick. 

(I.  Stoi)>i)i(i  irilli  Tliioiiin.  1.  U)  per  cent.  a(iueous  solution  of 
thionin  ten  minutes. 

2.  Wash  rapidly  in  water. 

.'i.  Difi'erentiate  in  ;)()  ])er  cent,  alcohol  (watch  under  the  microscope). 

4.  .\b.soliite  alcohol,  xylol,  balsam. 

The  sections  may  also  be  stained  with  a  concentrated  a(iueous 
Folution  of  thionin,  and  suliseijuently  ditTerentiated  \>ith  aniline  I. 
1  gm.;  absolute  alcoiiul,  U  gm.:  cleare(|  with  xylol,  and  momited  in 
balsam.  The  NissI  bodies  in  the  protoplasm  surrounding  the  nucleus 
of  the  ganglion  cell  are  stained  dee])  blue,  thi;  nucl<'i  a  i)aler  blue. 
Coiitnist-stains  with  eosin  or  erythrosin  may  be  used,  but  are  apt  to 
blur  the  finer  details. 

h.  Stfiiniufi  trilh  Tohiidlnr-hhir  (Yloycr  iiniW.  l.ciiliossek). 

1.  I'ix  in  concentrated  corrosive  sublimate  .'solution,  twenty-four 
hours. 

2.  Il.'irden  in  alcohol. 

'A.  limbed  in  paraflin  (using  chloroform  as  a  solvent). 
4.  Cut.     Mount  with  distilled  water.     ICxtnict  |);iraflin  with  xyol 
and  iodine-alcohol  (solution  of  iodine  in  absolute  alcohol). 


-Ai.  .    .rii'aJ.,.  Jl'itl,!,'^J-. 


EXAMiyATIONS  OF  THE  EYE. 


679 
t()lui<  line-blue 


5.  Stain  with  concentrated   a<iueous  solution   of 

several  hours.  .  i     i    r 

().  Differentiate    in    aniline-alcohol.    Counterstam   with   alcoliolic 

eosin  solution  (or  erythrosin) 

7.  Rapidly  dehydrate  in  absolute  alcohol,  xylol,  balsam. 

The  .stains  are  not  usually  tK>rnianent. 

IV  Sr\iN  FOK  NKi-uiKii.iA.  The  det<'nnination  of  the  condition  of 
the  neuroRlia  may  be  of  value  in  the  *udy  of  the  optic  nerve. 
WeiRert's  method  is  a  long  an.l  rather  dittieult  one,  an.l  good  results 
may  be  obtained  by  either  of  Mallory's  methods,  especially  when  the 
neuroglia  is  patholoRically  incn'a.se<l.    The  first  method  is  as  follows: 

1.  Fix  in  formalin  (10  per  cent.)  four  days. 

2.  Concentrated  atiueous  solution  of  picric  acid,  four  to  eight  day.s. 
■]    5  per  cent,  solution  of  ammoniu.n  bichromate.     Four  to  six 

days  in  the  incubator  at  37°.    Clu  nge  the  solution  on  the  second  day. 

i.  Alcohol. 

,").  Celloidin. 

C.  Slain  bv  Weigert's  fibrin  method  v-"'"  beh>w). 

7.   DilTereiitiate  with  anilin<'  oil  and  xylol  (of  <'ach.  e(iual  parts), 
xylol,    balsam.      As   contrast-stain,   fuchsiii   may  be  added   to  the 

'  The  second  method  is  said  to  be  esjjecially  suited  for  demonstrat- 
i)Hr  the  neuroglia  in  glioma  of  the  retina.  The  tissue  is  treated  a.s  in 
ilir  first  method  until  the  celloidin  sections  are  cut.  They  are  then 
iihiced  in 

1,  (),."}    per   cent,    aciueous  solution   of   potassium    permanganate 

iwciity-five  to  thirty  minutes. 

•_'.  Wash  in  water. 

:i  1  per  cent,  aqueous  soluticm  of  oxalic  acid  fifteen  to  thirty  min- 
utes. 

\    Wash  in  two  or  three  changes  of  water. 

.-)   Stain  in  i)hosi)hotungstic  acid  ha-matoxylin  one  to  three  days. 
The   fortsuila  of    this   is:   ha>matoxylin.   0.1    gm.;   water,  SO  gm.: 
|,h„si)h(.iungsticaci.l  (Merck).  20  gm.:  jK-roxide  of  hydrogen,  0.2  gm 
Dissolve  the  ha'inatoxylin    in    a  little  water,    by  aid  ol    heat,  and 
add  it,  after  cooling,  to  the  rest  of  the  solution. 

'■).  Wash  (piickly  in  water. 

7.  Dehydrate  in  <).")  per  cent,  alcohol. 

S.  Oleum  origani  cretici. 

(I.  .\vlol  balsam.  ,  ,  .        ,.    , 

Tlu'  nuclei,  neuroglia  fibres,  and  fibrin  stain  blue,  axis-cylinders 
.•iiid  .'anHion  cells  i)ale  i)ink,  connective  tissue  deep  pink.  The  blue 
e.,l.,r  isslightlv  sensitive  to  light,  and  is  apt  to  fade  to  pmk  after 
pn.longcMl  .-xposure.  If  a  i)ermanent  isolat.-d  stain  of  the  neuroglia 
libn-s  is  desired,  transfer  the  .sections  (after  staimng  m  the  phospho- 
iun"stic  acid  luematuxvlin  and  washing  in  walei  i  to  a  oO  jicr  tit. 
alc(iiiolic  solution  of  ferric  chlori.le  for  five  to  twenty  minutes,  tnen 
wash  in  "ater,  and  dehvdrate  as  before.    The  nuclei,  neuroglia  fibres, 


^E«l- X  V: 


swi«wwi««rtl^f^^PP"i^""iii^w 


OHO 


TUB  EYE. 


and  fibrin  stand  out  sharjily  of  a  clear  l)lu('  color.  Kvcrythinf;  else 
is  docoiorizcd,  or  apjM'ars  (tf  a  pale  ycllowisli  or  firayisii  tint. 

StainiBg  for  Bacteria  in  Sections.  For  this  purpose  tiic  s(H'tions 
sliould  1)0  as  thin  as  possible,  and  the  eyeball  slioulil  not  be  cut  as  a 
whole,  but  divided  after  embedding  in  eelloidiu.  With  other  tis,sues 
l)aratfin  should  be  used  as  the  enibeddiiiji  substance.  The  use  of 
Miiller  s  fluiil  for  fixation  makes  the  search  very  difficult,  as  the  or- 
};anisnis  ilo  not  stain  well.  If.  however,  the  sections  are  placed  for 
se>-eral  hours  in  a  5  Jht  cent,  solution  of  oxalic  aciil,  satisfactory 
results  may  b      '  tained. 

Staimni; -^  :i()i)s.  i.  Mrlliiilcnc-hlue.  1.  Stain  in  LoetHer's  al- 
kaline metliylene-blue  ten  minutes  (concen; rated  alcoholic  niethylene- 
blue  solution  ;5()  j;m.;  caustic  potash  solution  (1 :  1(),(XK)),  KM)  fim.). 

2.   Wash  in  water. 

."i.   DilTerentiate  in  O.o  jier  cent,  acetic  acid  one  to  three  seconds. 

\.  Water. 

.").  !t.")  per  cent,  alcohol,  absolute  alcohol,  bergainot  oil,  ,ind  xylol 
balsam. 

The  organisms  and  cell  nuck-i  are  stained  blue.  If  the  bacteria 
retain  th'ir  color  by  the  (Jram  method,  this  may  be  employed.  It  is 
a  valuable  stain,  as  it  reveals  the  presence  of  fibrin  at  the  same 
time. 

II.  0'-niH-\Vi'i<ii'rl  Mvlliitd.  1.  The  sections  may  be  staine<l  first 
with  lithium  carmine  (.see  page  fiTCt)  for  contrast,  .\fter  washing  in 
water  the  sections  should  be  spread  out  carefully  i^n  a  well-cleaned 
sli(k',  .so  that  no  wrinkles  appear,  and  presse<l  firmly  to  the  glass  by 
hlter-i)a])er  in  layers.  The  stain  should  be  freshly  prepare<l,  and 
may  be  made  by  shaking  0..^  c.c.  of  transparent  aniline  oil,  with  ">  c.c. 
of  wat(>r  in  a  test-tul)e,  and  filtering  through  a  fine  hlter-jjaper 
moistened  with  water.  To  this  is  added  a  filtered,  concentrated  al- 
coholic solution  of  gentian  or  methyl-violet,  in  the  proportion  of 
1 :  10.  Stain  for  three  to  five  minute's,  pour  off  the  .solution,  and  dry 
the  sections  carefully  with  the  filter-])aper. 

2.  Lugol's  solution  (iodine,  1  gm. ;  potassium  iodide,  2gm.:  water 
KM)  gm.).  two  minutes.     Dry  thi>ri>iuihlti. 

'.\.  DilTerentiate  with  aniline  oil  xylol  (2  :  1)  until  no  further  color 
is  given  otT. 

4.   Remove  aniline  oil  thoroughly  with  xylol. 

.").  .\ylol  balsam. 

The  organisms  ami  the  fibrin  will  be  stained  a  dee|)  violet:  certain 
hyaline  substmices.  homy  cells,  karyokinetir  figures,  and  nmcus  are 
also  stained  by  the  method.  The  other  miclei  should  be  sfaineil  red 
by  the  carmine.  Parailin  sections  are  stained  in  the  same  way,  but 
the  <lrying  .should  be  done  very  c.arefully. 

III.  S'iiiniu;/  of  Tiihcrrlr  IhuiHur:  in  Ti.---<n<'.  1.  Stain  in  Ziohl'.s 
carbol-fuchsin  solution  for  two  hours  in  the  incubator,  or  in  cold 
solution  for  twenty-four  hours.  (Fuch-'in,  1  gm.;  absolute  alcohol, 
10  gm.;  o  [H'r  cent,  carbolic  acid  solulion,  100  gm.) 


^3^K?^^V 


hW' JlV^irl 


EXAMISATIOXS  OF  THE  EYE. 


G81 


2.  Wash  m  wattT. 

.{.   I  )  \ivx  cci  t  solution  of  nitric  acid  for  a  fo\v  seconds. 

tinii  tU'   :     '"   AMI 


Tiic 


section  is  rose  rci 


I. 


4.  Wash  tliorouphly  in  water. 
").  1)5  ])er  cent,  alcohol  until  tlie 
(•).  Water. 

7  .\(iueous  solution  of  nietliylene-blue,  one-lialf  nunutc. 

5.  Water. 

!).  Dehvilrate  in  alcohol. 

10.  ( )il  of  iKTKaniot.  Balsam.  (Carbol-xylol  should  never  he  used 
for  clearing  tissue  stained  in  an  aniline  dye.) 

The  methods  of  staining  which  have  heeii  given  include  the  most 
important  that  are  used  for  the  determination  of  pathological  changes. 
\  description  of  .special  methoils  for  histological  structure,  such  as 
Ihedolgi  methods  for  the  retina.  Khrlich's  methyleiu'-hlue  stam  tor 
living  tis.sue,  silver  and  gold  methods  for  the  cornea,  etc.,  would 
rxceed  the  limits  of  the  present  article,  and  the  .student  who  desuvs 
to  pursue  advanced  researches  on  such  lines  is  referrcil  to  sju'cial 
hooks  on  technique.' 

Bacteriological  Examinations.  Descriptions  of  the  Organisms  that 
are  Most  Frequently  Pound  in  Diseases  of  the  Conjunctiva  and  Cor- 
nea.    Bacteriological  studies  are  of  value  only  in  the  acute  stages  of 
corneal  and  conjunctival  infianunations.    The  cover-slip  examination 
may  then  be  conclusive,  by  reason  of  tlie  large  mnnlK>rs  of  the  organ- 
ism" which  are  present.     liter  the  siHM-ific  organism  tnay  l)e  crowded 
,nit  by  ordinarv  saprophytic  germs,  which  are  readily  introduced  mto 
tile  open  conjunctival  sac.     Cultivation  of  the  organism  is,  in  many 
cases,  very  important,  but  this  is  very  difficult  with  some  of  the  .special 
Inrms,  as  they  are  readily  masked  by  others  which  are  accidentally 
iirescnt.     If  possible,  where  the  discharge  is  abundant,  the  eye  .should 
he  wash  '•  out  an<l  the  jiatient  allowed  to  wait  ten  or  fifteen  nunutes. 
.\  portion  of  the  reaccunuilated  discharge  is  then  picked  up  by  means 
of  a  sterile  platinum  loop,  and  sm(>ared  on  the  surface  of  i>  carefully 
cleaned  cover-glass  or  slide.     After  drying  in  the  air,  the  smear  is 
p.issed  three  times  through  the  flame  of  a  Buiisen  burner,  and  then 
stained  with  solution  of  an  aniline  dye.     I.oeffler's  alkaline  methy- 
li'iie-blue  (page  OSO)  is  one  of   the  most  useful.     It  stains  deejily  in 
five  to  ten  minutes.     The  cover-glass  is  then  washed  in  water,  driejl, 
•  nounted  in  Canada  balsam,  an<l  examined  with  a  one-twelfth  oil- 
immersion  lens.    The  app«'arance  of  several  of  the  special  conjunctiyai 
Mn'anisins.  notablv  the  Koch-Weeks  bacillus,  and    the  dii)U)bacillus 
..rMorax-.Vxenfeld,  is  sufHcieinly  characteristic  to  allow  a  iwsitive 
liagnosis  by  means  of  the  cover-glass  examination.     A  second  smear 
-liould  be  stained  by  the  Gram-Weigert  method,  as  follows: 

'  Two  excellent  monographs  have  recently  api^are.!  In  <ierma.i  :  'Anleilungzur  raikroskopiwhen 
L-ntersii<-h.M.K.  .U-.  A.ig.-s,"  bv  ITofes«)r  It.  <lrwtV,  «...!  •■  Lie  raiknwkoplschen  Cnter«nehunp.ineln- 
-le.i  Jes  Augcs."  by  9,  aeligniann,  the  Imier  of  which  eontaiiis  the«  anJ  other  special  metbodn  In 
klail 


682 


THE  KYE. 


w 


1.  Aniline  vvutor,  gontian-violi't  solution  (.page  080),  three  to  five 
minutes. 
'1.  Lujjol's  solution,  two  minutes. 
H.  9o  |X'r  cent,  uleoliol  until  no  further  stain  is  amoved. 

4.  WatiT. 

5.  Counterstain  vith  aijueous  fuchsin  not  lonnir  thitn  ticrntu  to 
thirty  seconds.     ''      lin  of  the  organisms  retain  the  (lee|)  violet  color, 

and  are  termed  , ..,vc;  others  lose  the  stain  and  are  colored  red  by 

the  fuchsin,  ami  are  termed  luijulivc  organisms. 

If  tiie  cover-slip  examination  is  not  conclusive,  cultun»s  should  1m' 
tnade.  For  tliis  purpose  coagulated  l)lood  .serum,  glycerin  agar, 
and  weak  agar  are  especially  adapt*'d.  (Jreat  care  shoulil  be  taken 
to  prevent  contamination  by  other  organisms  which  are  present 
along  the  lid  margins,  and,  as  in  the  cover-.slip  examination,  the  eye 
should  first  be  washed  out  with  ilistilled  water  and  the  di.scharge 
allowed  to  reaccumulate.  .\  .small  portion  is  then  picked  up  by  a 
platinum  loop,  and  the  surfaces  of  sevenil  slant-tube  cultures  or 
Petri  dishes  are  inoculated.  Two  days'  growth  in  tiie  incubator 
(37°  to  ;{!t°)  will  usually  show  the  presence  of  characteristic  colonies. 

In  obtaining  material  from  the  cornea  the  eyes  should  1k>  washed 
out  with  sKM'ile  water,  a  sterilized  cocaine  solutio;i  instilled,  and 
while  the  eyelids  are  carefully  held  away  from  the  ornea  a  portion 
of  the  material  in  the  bed  of  the  ulcer  is  removed  by  means  of  a 
pointed,  sterilized  lance,  and  transferred  to  the  media.  For  the  de- 
tails of  this  work  and  those  of  animal  inoculation,  text-books  on 
bacteriological  techniiiue  shouhl  b(>  consulteil.  The  most  important 
organisms  which  are  pathogenic  for  the  human  conjunctiva  are  as 
follows: 

1.  The  Koch-Weeks  bacillus. 

'2.  The  gonococcus  of  Neisser. 

;i.  The  diplobacillus  of  .\lorax-.\xenfeld. 

4.  The  dijjlococcus  lanceol.-itus  of  l''raenkel-\Veich.selbaum. 

5.  The  Klebs-Loertier  diphtheria  bacillus. 
0.  Staphylococcus  jn'ogeMcs. 

7.   Streptococcus  ])yogenes. 

S.  The  diplococcus  of  acut<'  follicular  catarrh  (pseudogonococcus). 

The  first  three  are  unconditionally  pathogenic  for  the  conjunctiva: 
that  is,  they  are  not  present  in  the  normal  conjunctiva,  and  when  in- 
troduced produce  a  sj)ecific  and  contagious  inflammation.  The  others 
may  be  found  on  th(!  normal  conjunctiva,  and  produce  inflanmiation 
only  under  certain  conditions  of  virulence,  lowered  vitality  of  the 
individual,  or  local  lesion  of  the  conjunctiva,  such  as  chroiu'-  iiiHam- 
mation  or  injury  of  the  surface.  Besides  these  organisms  many 
others,  for  example,  bacterium  coli,  bacillus  of  rhinosderonui,  Frie(l- 
lander's  pneumobacillus,  the  o/ieua  bacillus  and  certain  of  the 
higher  fungi  (actinomyces  and  a<pergillus)  have  been  found  in  iso- 
lated ca.ses.  The  tubercle  and  le|)r;i  bacilli  are  present  in  tlie  nodu- 
lar or  ulcerative  lesions  of  the  external  coats  of  the  eve,  and  mav 


EXAiflXATIoys  or  THE  KYE. 


6«:i 


1,..  .Iptocted  in  a  histMloRical  oxainiiiation  of  Mio  ti.suo,  but  do  not 
,  .lusc-  a  conjunctival  ca*  rrli  in  the  ordinary  s«'nso  of  the  term.  1  he 
<.,-called  xerosis  bacillus  is  also  a  freijuent  occupant  of  tlie  conjunc- 
tival sac  lx»th  in  health  and  in  disease,  but  cannot  be  said  to  be 

ii.ithogenic.  ,      t-    i     •      i^       * 

1  The  Koch-Weeks  baciUus,  described  hrst  by  Koch  in  hgvpt. 
more  thoroughly  studied  by  Weeks  in  New  York,  and  later  by  Morax 
in  I'aris,  and  MuUcr  in  \ienna.  It  is  the  cause  ot  acute  contagious 
.•..njunctivitis  in  a  varying  i)roportion  of  ipidwiir  cases  ...eijendmg 
upon  the  locality.  It  is  a  very  small,  rod-shajM-d  organism,  .esem- 
l.ling  the  bacillus  of  mouse  septicaemia,  found  in  large  numbers  l)oth 
uithin  and  between  the  cells  of  the  discharge.  Stains  readily  with 
m.'thvlene-blue  or  gentian-violet;  luyntire  to  dram.  I  .siially  found 
mixed  with  the  xerosis  bacillus,  from  which  it  is  difficult  to  separate 
ill  cultures.  Culture  dillicult;  best  on  0.5  p«T  cent,  agar  (\\eeks), 
•i<  small  punctate,  transparent  colonies.  According  to  Mnller.  it  grows 
'.,n  human  s.'rum  agar;  only,  however,  in  i>resence  of  a  certain  sapro- 
nlivte.    L'nconditionallv  pathogenic  for  the  human  conjunctiva. 

■2  The  Oonococcua  (Neisser)  occurs  usually  m  tlu"  form  of  a  diplo- 
coccus  the  edges  in  contact  being  slightly  concave,  so  that  the  indi- 
viduals are  shaped  like  a  coflee-bean.  The  organisms  are  arranged 
u<uallv  in  small,  irregular  groups  oi\  and  in  the  cells.  Stams  readily 
with  inethvlene-blue;  nviiotivr  to  Clram.  Cultivation  is  «hthcult; 
l.,wt  „n  serum  covered  with  human  blood.  Produces  severe  j)urulent 
uphthalmia,  and  is  the  most  frequent  cause  of  ophthalmia  neor  - 
ti.nim.     Unconditionally  pathogenic. 

:{  DiplobacUlus  of  Morax-Axenfeld.  Large  bacillus,  measuring  on 
•m  average  2  n  long  and  1  /i  broad,  with  rounded  extreniiti  ,  occurs 
'.hieflv  in  pairs,  occasionallv  in  chains,  usually  free  in  th^  cretion 
in  larite  numlxTs.  Stains  readily  with  aniline  dyes;  ne{]alm  'f^ram. 
i:a41v  distinguished  from  Koch- Weeks  bacillus  by  its  size.  Gro\yth 
•ibimdant  in  blood  serum  in  the  form  of  small  transparent  co Onies, 
which  graduallv  sink  below  the  surface  because  of  their  hquejochon 
-./  //„.  serum.  Vnconditionally  i)athog<'nic  for  man,  pro.lucing  a  sul)- 
icute  catarrh,  which  yields  (piickly  to  solutions  of  zmc^ 

J  Diplojoccus  Lanceolatus  (Pneumococcus)  of  Praenkel-Weichselbaum. 
(  XM-urs  in  pairs,  tlu^  in.lividuals  l)(<ing  slightly  oval,  with  pomted 
,, liter  extremiti<>s;  occasionally  is  found  in  short  cliams.  hach  pair 
nmv  l)e  .surrounded  bv  a  definite  capsule,  which,  however,  is  often 
,lM-nt  on  the  conjunctiva.  Stains  readilywitli  amlme  dyes,  and  is 
nu.Hirv  to  Cram.  Grows  liest  in  glycerin-agar  (the  media  shoul.  Ih^ 
<!i.'htlv  alkaline),  as  delicate  transparent  colonies,  resembling  dew- 
droos."  Found  in  the  normal  conjunctiva,  but  may  be  the  cause  ot 
a.'ut.'  contagious  coniunctivitis,  u.sually  of  a  mild  type,  with  moderate 
,.  cretion  and  much  'fibrin.  It  i-  also  the  caiL«e  of  a  certain  propor- 
tion of  cases  of  ophthalmia  neonatorum,  and  is  the  specific  organism 
lor  a  large  percentage  of  c.^s  of  ulcus  cornea-  serpens.  Uccasu)n- 
ally  it  is  the  cau.se  of  panophthalmitis. 


B^H 


084 


TUE  EYE. 


! 


! 


li 


5.  Klebs-Loeffler  Diphtheria  Bacillus.  Tho  diphthoria  h.icilliis  is  «  x- 
cctvliiigly  variable  in  form,  soriictimos  apix-aring  a.s  straiKht  or 
slightly  curved  nnls,  with  pointed  ends;  at  other  times  sj)indle  and 
eluli  siiaj^'s  oeeur,  in  which  «""^inents  less  deeply  stained  apjx'ar.  On 
cultures  the  mori)h<)loKy  is  even  more  irregular.  It  stains  ix'st  with 
LoelHer's  methylene-hlue:  grow.s  readily  on  all  ordinary  media;  Im-sI 
u|)on  Loertler's  blood  serum  and  upon  glycerin-agar.  It  is  patho- 
genic for  animals,  and  causes  death  with  characteristic  lesions.  It  is 
the  cause  of  di|)htheritic  conjunctivitis,  but  is  found  also  in  the 
more  su|M'rticial  (crouiMuis)  form,  as  well  iis  in  simple  catarrh  and  on 
the  normal  conjunctiva.  Morphologically  and  culturally  it  may  be 
confoun<led  with  the  xrri>si.'<  Ixicillu.-i.  a  very  fre(|uent  and  harmless  oc- 
cupant of  the  conjunctiva,  both  alone  and  associated  with  other 
s|H'cilic  organisms.  In  cultures,  however,  the  xerosis  bacillus  d(H's 
not  grow  so  luxuriantly,  the  coloni«>s  are  u.sually  dryer  on  the  sur- 
face, the  individuals  do  not  show  such  bizarre  forms  oii  blood  serum, 
the  so-called  lOrnst's  granules  do  not  appear  so  .soon,  and  the  organ- 
ism is  not  pathogenic  for  animals. 

().  Staphylococcus  Pyogenes  Aureus.  The  staphylococcus  pyogenes 
is  one  of  the  most  common  pus  organisms.  It  occurs  as  a  small 
spherical  coccus,  usually  in  groups  and  extracellular.  Stains  by 
ordinary  aniline  dyes,  and  is  posilive  to  Gram.  (Irows  well  on  all  or- 
(Unary  culture-media,  and  can  Ije  difTerentiate<l  only  by  this  method. 
It  is  present  on  the  normal  conjunctiva  in  inflannnations  of  the  lid 
marjiin,  and  in  many  forms  of  ulcer  of  the  cornea  (aside  from  ulcus 
serpens);  it  maybe  a.s.sociated  with  other  more  pathogenic  forms, 
and  is  found  occasionally  in  pure  culture  in  simple  catarrhs  and  in 
pseudomembranous  conjunctivitis.  It  is  frequently  found  in  the 
pus  of  dacryocystitis  and  in  panophthalmitis,  both  by  metastasis  and 
by  direct  infection. 

7.  Streptococcus  Pyogenes.  The  streptococcus  is  likewise  a  spherical 
coccus,  usually  slightly  larger  than  the  staphylococcus,  which  occurs  in 
chains  of  varying  length  as  a  result  of  division  in  only  one  direction. 
It  stains  readily,  and  is  poyitire  to  Gram.  Grows  on  artificial  media, 
but  less  luxuriantly  than  the  staphylococcus.  It  is  found  in  the  normal 
conjunctiva  anil  frequently  in  inflammations  of  the  tear  ducts. 
It  may  be  a.s.sociated  with  other  organisms  and  increase  the  severity 
of  the  process.  It  may  be  tin'  sole  cause  of  conjunctivitis  in  one  of 
two  forms:  1.  Catarrhal  inflannnation  (Parinaud's  conjvuictivitis), 
which  is  usually  monolateral,  and  is  a.ssociated  with  lacrymal  dis- 
ease of  the  same  side;  it  is  often  comi)licate(i  by  iritis  and  swelling 
of  the  preauricular  glands.  2.  \  pseudomembranous  form,  which  is 
more  freiiuent.  Here  it  may  be  found  alone  or  with  the  diphtheria 
organism.  The  process  is  usually  very  severe  and  the  prognosis 
bad. 

8.  Diplococcus  of  Acute  Follicular  Catarrh  (Pseudogonococcus).  This 
organism  has  been  described  by  many  as  the  cause  of  acute  follicular 
catarrh  in  epidemic  form.     It  has  a  very  do.se  resemblance  to  the 


EXAAHyATIoys  OF  THE  EYE. 


685 


jri)ii( (COCCUS  on  tho  cover-slip,  l)ut  is  pontive  to  Gram  and  is  readily 
ciillimted.  Tho  diagnosis  of  gonococcus  should  not  he  made  without 
tilt'  use  of  the  (irain  method  unless  the  direct  source  of  infection  is 
known.  Other  forms  have  been  descrilK'd  whidi  were  also  negative 
to  (iram,  but  they  could  l)e  cultivate.1  witiiout  difficulty.  The  menin- 
jrococcus  (dij)Iococcus  intracelluhiris  meningitidis,  Weich.«ell)aumJ 
might  be  confounded  with  the  gonococcus,  but  its  occurrence  on  the 
conjunctiva  is  excei)tional. 

In  keratitis  a  variety  of  organisms  has  been  cultivated  from  the 
ulcers,  but  in  many  cases  the  infection  nmst  Im-  l(M)ked  upon  as  wc- 
undary.  Only  two  forms  of  keratitis  can  l)e  considered  to  be  caus«'d 
l)v  s|K'cific  micro-organisms:  1.  The  tnie  ulcus  serix'iis,  in  which  the 
piieumococcus  was  found  in  a  large  percentage  of  cases  by  I  hthofT 
■ind  Axenfeld.  2.  Keralomvcosis  asiK-rgiilinia,  a  form  of  ulcer  pro- 
duced bv  the  .\siMTgillus  fiimigatus.  This  form  is,  however,  exceed- 
ingly rare  in  .Vint-rica:  onlv  two  cases  have  b(-en  reporteil.  Other 
.iigaiiisms  found  have  In'en  staphylococci,  I'feiffer's  capsule  bacillus, 
h'lcillu-i  pvogenes  fd'tidus,  bacterium  coli.  bacillus  i)yocyaneus,  diplo- 
l.a.illus,  ozaiia  bacillus,  and  a  number  of  other  forms  which  have 
not  been  identifieil  (I'hthoff). 


(I 


NOSE  AND  TH  !<^vr. 


( (■'»■ ) 


5 


NOSE  AND  THROAT. 


CHAPTER    XVI. 

THE  HISTOLOGICAL  PATHOLOGY  OF  DISEASES  OF 
THE  NOSE  AND  THROAT. 

Hv  J.  L.  GOODAI.K,  M.I). 
Preliminary  Considerations.     A  satisfactory 


)!'  the  nose  ami  tliroat  is  a 


cl;i.«sification  of  (lis- 
l  tiic  iircsciit'  time  ditficult  to  f'>r- 


IIIU 


at«".     Ill  the  first  place  the  variety  of  traumatic  lutlucncj 


to 


wiiicii   tlicsc  orpaii 
ilctcriiiiiiatioii  o 
liistolofiii'a 


exposed 


1    frecmeiitlv   renders   doubtful   the 


if'tlieir  etioloftv,  ami,  seeoii.C  the  insufficiency  of  the 

lirectioiis     .de  gajjs  which 


lata  at  hand  leaves  in  many  ( 


can 


Ix^hridfied  only  by  reference  to  analofious  proci 


i'sses  in  other 


situations.     .Mthough  any  system 


,f  grouping  that  can  at  the  \)ro: 


A 
rli\7  "he  f<)nuulaterrnuist"nec(>.s.sarily  experience  revision  as  our 
knowledge  of  patiiological  processes  a.lvances,  yet  other  things  >)eing 
ciuil  that  one  is  preferable  which  is  most  readily  susceptibh"  ot 
w'lboration  an<l  .-xiKinsion.  In  the  following  pages  th(>  attempt  has 
|„.,.ii  made  to  l)ring  our  c.mnaratively  meagre  information  m  regard 
to  the  patliological  histologv  of  this  si-ecial  fi.-ld  into  harmony  with 
the  svstem  which  has  been  found  most  useful  m  mod.-rn  g.'iieral 
patho'logy.  We  shall  recogniz<',  therefore,  the  following  main  divi- 
sions: 

1.  I)isturbanc(>s  of  Circulation. 

•_'.  Iiiflatnmations. 

;{.   Progressive  Disturbances  of  Nutrition. 

4.   Regressive  Disturbances  of  Nutrition. 

1.  DISTUEBANOES  OF  CIRCULATION. 

In  the  upi>or  air  pa.ssages  the  conditions  comprised  under  this 
h,.a.ling  represent  a  c(.jn|)aratively  .small  groui),  and  one  also  m  regard 
to  which  we  liave  but  little  exact  histological  data.  Ue  may  dis- 
tinguish: 

a.  Ansrmi.T. 

h.  Hvpera'inia.  .  •     i      i       ■   *• 

The  two  Drecediiig  conditions  do  not  r(>quire  particular  .iescnpton. 


GOO 


yOSE  A\D  TlinOAT. 


c.  AiiKionourDsis,  ropn'sciitcd  by  urticaria  and  in-  aiifiionourntic 
(idciiia.  I'rticaiia.  aitliougii  ()l)si'rv<'d  upon  tlic  mucous  uioniliraiic 
of  tiic  toiijiuc,  does  not  a]>pcar  to  have  i)i't'n  found  upon  the  nnicous 
incinimincs  of  the  uom-  or  tiiroat.  The  descriptions  hy  certain  authors 
of  "urticaria"  of  the  piiarynx  and  larynx  denote  evidently  anjiio- 
neurotic  (cdcnia,  since  tlic  lesions  involved  not  only  tiie  supcriiciai 
mucous  membrane,  hut  the  suiinuicosa  as  well.  We  have  no  histo- 
lojrical  knowh'dife  of  thi'se  atVections  in  these  situations,  hut  they  arc 
prohal)ly  identical  with  the  corrcspoinlinj^  cutaneous  alterations. 

(/.  (Kdema  from  cardiac  or  renal  disease.  This  condition  is  to 
he  sharp'y  distinfjuisiied  from  acute  intlanmiatory  (cdenia,  and  from 
tiie  atiftioneurotic  alVection.  There  is  no  evidence  of  active  irritation 
in  tiie  tis,sues.  If  the  st.isis  is  of  lonj:  duration  the  vessel  walls  of 
the  p.irts  become  jiradually  more  penetrable,  and  a  larfje  number  of 
white  blooil  corpuscles  find  an  entrance  into  the  neijrhboring  ti.ssues, 
altiioujth  at  the  bcfiinnin"!  of  the  di.sciuse  there  was  only  a  serous 
transudate  without  any  minfilinfi  of  the  corjuLscular  elements.  This 
round-celled  inliitration  finally  ix-netrates  the  deei)er  nuiscvilar  layers 
and  may  become  gradually  assimilated,  with  the  result  of  producing 
more  or  less  marked  hyperplastic  conditions. 

c.  Hemorrluifies.  These  conditions  in  the  nose  and  t'  roat  an; 
representiMl  by  ha-mophilia  and  scurvy.  As  we  have  no  histological 
knowledge  derived  from  lesions  of  the  mucous  membranes,  the  reader 
is  referred  to  the  dermatological  accounts. 


2.  INFLAMMATIONS. 

Infln'nmations  of  the  upix-r  air  passap«'s  may  be  divided  into  the 
followmg  groups:  (I.)  Neurotic  inflammations,  (II.)  infectious  or  acute 
traumatic  inflammations.  (III.)  chronic  inflannnatioiis  with  tendency 
to  hypertrophy,  and  (I\'.)  chronic  inllammations  with  tendency  to 
atrophy. 

I.  Neurotic  Inflammations. 

Under  this  heading  are  comprised  several  forms  of  inflammation 
in  wliich  the  characteristic  phenomena  appear  to  be  brought  about 
through  the  nervous  system.  In  all  instances  it  is  evident  that  the 
priniarv  exciting  cau.-e  lies  beyond  the  nervous  system,  which  is 
merely  an  intermeiliate  agent  in  the  production  of  secondary  mani- 
festations. Our  histological  information  regarding  such  lesions  upon 
the  nnicous  memi)ranes  i<  extremely  meagre.  The  following  groups 
may  1m'  distinguished:  heri>es  zoster,  herpes  pharyngis,  erythema 
bullosum.  and  vasomotor  rhinitis 

Herpes  zoster  h.'is  liii-n  ftiund  on  the  nrurou?  menibranes  of  the 
mouth,  jialate.  and  uvula.  It  does  not  appear  to  affect  the  tonsils 
or  the  pharynx.     While  the  histological  appearances  do  not  seem  to 


'f.i,..-j^j 


I^F:.AMM^TI(>^s. 


691 


li:,vo  boon  (IcscrilxMl  in  these  situations,  tlie  roiulitions  are  iimlouht- 
cliy  similar  to  tliose  ol)taiiiinK  iiixm  tlie  sl<in,  namely,  in  the  first 
~ia>je  an  exiidatiun  of  clear  iluid  between  the  epithelium  and  the 
rite  mueosa.  whicli  in  a  few  days  becomes  turbiil  from  the  adv(>nt 
,,'.  leucocytes.  At  this  time  a  necrosis  occurs  of  the  epithelial  cells 
covering  "the  vesicles,  causing  them  to  exfoliate,  and  leaving  a  denuded 
rete  mucosa. 

Herpes  Pharyngis.  The  histological  conditions  in  this  arfection  are 
|,i()b:il)iy  essentially  sunilar  to  those  of  herpes  zoster. 

Erythema  Bullosiun.  This  condition,  a  form  of  erytliema  iinilti- 
fiirme,  has  been  (h'scribed  as  occurring  upon  the  soft  palate,  pillars 
iif  the  fauces,  and  piiaryngeal  nmcous  membrane.  Its  pathological 
.iiiatomy  in  these  situations  has  not  been  descrilied.  Imt  by  analogy 
may  besupposed  to  consi.st  in  a  sharply  circumsoibed  dilatation  (if 
,1  ir'roup  of  vessels  in  the  subnuicoiis  tissue,  attended  by  an  exudation 
of  iluid  through  their  wails. 

Vasomotor  Ehinitis.     Ovir  histoloc;ical  information  in  regard  to  this 
Mlfection  is  extremely  scanty,  nuich  that  has  been  written  having 
apparently   b(>en   inferred    from    the    macroscopic    appearances.     A 
CISC  of  the  writer's  with  jierennial  symptoms  permitted  the  excision 
,,)  ,1  portion  of  tissue  from  the  septum,  which  was  examined  micro- 
Mupicallv.     Tlie  tissue,   which  exhibited  clinically  i)allor.  swelling, 
■iiid  free  watery  discharge,  showed  under  the  microscope  a  free  des- 
inamation  of  tlie  epithelial  cells,  the  cytoplasm  f  f  which  was  swollen. 
ihe  nuclr>i  exhibited  a  diminished  athnity  for  stains.     There  was  no 
iiicrea.^e  in  the  number  of  polymidear  nein  ro|)iiiles  in  the  intercellular 
-1  Kiccs.    Thionin  showed  little  or  no  iiii  rease  in  the  number  of  secreting 
.  |iiiii<'lial  mucous  c(lls.  The  rete  mucosa  exhibited  a  moderate  ledema, 
:iiid  was  traversed  bv  moderately  di!   tr-d  bloodvessels  which  showed 
HO  thickening  or  swelling  of  their  emi.     .dial  cells.     The  glands  were 
ii.arkedlv  swollen  from  an  increase  in   the  number  both  of  mucous 
iiid  serous  cells.     Their  lumen  showed  dilatation,  with  here  and  there 
!i!iic()us  degeneration  of  the  lining  epithelium  of  the  etTerent  ducts. 
lidow  the"mucous  membrane  was  a  ditTuse  inhltration  of  lymphoid 
■  rlls.  jilasma  cells,  and  cells  showing  various  degrees  of  hyaline  degen- 
.  I  :ition.    This  infiltration  was  collected  particulariy  around  the  glands, 
ind  did  not  seem  to  be  more  int(>nse  than  in  the  ca.se  of  essentially 
Mtiniial  tissues. 

I'lie  condition  differs  from  tiiat  which  we  .should  expect  t(,  hnd 

in  acute  inflammation,  chiefly  in  what  may  be  called  a  hydropic 

ilti'ration  of  the  ejathelial  cells,  in  seroi'«  transudation,  and  the  rela- 

•ImIv  slight  increa.se  in  cellular  inh'.t     !■■•;       The  resemblance,  on 

h.  I'.ther  hand,  to  (vdenntous  hypertn.,.;,    >-  -itriking.     The  material 

i!   liaiid  is  not  suflicieii!  to  enable  us  miulate  with  certainty 

iiiiversal  ])oints  of  distinction,  but  atteiu.  .ii  may  be  directed  to  the 

■  .v.,ilen  ajipearanre  of  the  epitlit-liuiii  in  the  ab-rnce  of  nbnnrm.il 

laicous  deg(>neration.     Whether  tli<'se  characters  are  constant  mu.st 

I'  determined  by  further  investigations. 


I! 


m 


j  r 

!  I 

S  f 


692 


yOSE  ASD  THRfUT. 


II.  Infectious  or  Trai^raatic  Inflammations. 

By  tliis  term  is  dniotcd  thosi^  >iif1a!iitaati()!is  of  the  tissue  diroctly 
«l('lM'ii(lciit  upon  hactcriiil.  chcniiiMi.  oi  pliysicai  irritants.    It  should  he 
recofiiiizctl  at  tiic  outset  that  from  the  liistolojiical  stand|)oint   the 
tiuestioii  of  tlie  l)acteriai  or  iion-hactt>rial  nature  of  tiie  irritant  is  a 
see(>nihir>-  one.     Tiie  elTeets   pnxhieed    l)y  i)acterial  toxins  may  he 
ahiiost  exaotiv  (hi|)hcated  i)y  eliemical.  mechanical.  .>r  physical  agents. 
We  may  thus  have  an  acute  inliannnation  of  the  mucous  memUrane  due 
to  an  incision  or  to  a  chemical  or  thermic  cauterization,  closely  re- 
scmhlins  that  produced  hy  the  toxins  of  the  dii)htheria  bacillus  or  the 
streptococcus  pyogenes,     .\nother  instance  n;ay  he  found  in  the  histo- 
logical lesions  produced  hy  the  bacillus  of  t\iberculosis  and  by  an  asep- 
tic foreign  bo<ly.     .\t  the  jiresent  time  w(>  are  passing  from  a  system  of 
classihcation  founded  upon  jiathological  anatomy  to  one  based  upon 
etiology,  and  although  the  <'ause  of  many  atfectioiis  has  been  deter- 
mined," yet  for  a  large  class  a  dehnite  etiology  remains  to  be  estaii- 
lished.   "This  is  ii,articularly  true   in    the    case  of  disea,-- -  of  the  iiosc 
and  throat,  owing  to  their  free  and  constant  exposure  to  visitations 
from   micro-organisms.     While  we  may,   for  instance,  a.s.sume  that 
an  acute  inflammation  of  the  throat  accompanied  by  the  predom- 
inance of  a  certain  i>athogenic  bacterium  i<  due  to  this  micro-organism, 
yet  it  must   not   be  forgotten  that   we  are  dealing  with  a  territory 
wiiich  may  in  health  h;irbor  normally  a  number  of  pathogenic  bac- 
teria.    As' long  as  the  j.atural  powers  of  resistance  of  the  individu.il 
are   preserved,    the  manifestations  of   p.ithogenic   (|ualities   in   these 
organisms  is  inhibited.     When    howevei ,  thi'  vitality  of  the  parts  is 
lowered,  directlv  or  indirectly,  it  is  not  alone  one,  but  sevi'ral  species 
of  pathogenic  bacteria  which  seize  the  opportimity  for  nuiltiplicatioii 
a:id  for  the  development  of  their  toxins.     On  bacteriological  exam- 
ination we  thus  get  a  mixed  cultup'.  and  may  be  unable  to  determine 
the  particul.'ir  n'lle  jilayed  by  the  dilTcrent  species  in  the  pathological 
process.     While  observers  have  isolated  a  variety  of  bacteria  from 
acute  Iocm'  inflammations  of  the  ujiimt  air  i>a.ssages  (among  which 
may  be  ni.iitioned  streptococcus  pyogenes,  stajiliylococcus  pyogenes 
albus,  aureus,   ;ind  citreus;    diplococciis  lanceolatus,  bacillus  pneu- 
monia',   micrococcus    tetragemis.    and    streptothrix    buccalis),    and 
although  these  infections  pri'sent   more  or  less  \vell-ile(ined  clinical 
points  of  distinction,  we  have  as  yet  no  corresi)onditig  histologic.il 
evidence  of  individuality.     We  must,  ttierefore.  be  content  with  .1 
olassilication  based  n|)on  their  pathological  anatomy.     The  etiological 
diTerentialioii  of  these  conditions  forms  a  mo.st  promi.sing  field  for 
future  slud\ . 

While  both  a  primary  trauma  (i.e..  an  agent  which  susi>ends  the 
fiorm.;!!  function^  and  secondary  irritation  from  the  introduced  sub- 
stance (i.e..  toxin  or  other  foreign  body)  are  essential  to  the  pro- 
•hiction  of  the  histological  lesions,  yet  great  variation  may  exist  in 
the  relative  |ireponderance  of  tluw  two  factors.     For  instance,  an 


IXFLAMMATIOSS. 


693 


,,,„„.  phnn-npitis  n.av  ocrur  as  the  rosult  of  a  chiUinp  ..f  tl.c  h.uh. 

,1    W.1  l.v  l.a.t..rial  "...vaMon  ..f  tlu-  tissu.-s.  or  as  tlH-  r.-sult  of  a 

1  ,,„i,,l,  ,h..r,nic,  or  pl.ysi.al  woun.lin«  -f  t  ..  parts,  with  s..,|on.  ary 

;  „,,„;.,nt   of  l,a..tl.ria   upon   tl.o  injur...!   surac.-s      I>'   t  -    .rst 

in<tan.'.-  U,.-  d.ara.'t.-r  ..f  tl,.-  l.-si..ns  is  inHucn.r.l  .■hu-f  y    n  tl,.;  lur- 

,„,.i;,l  infecti.....  in  tl,.-  s.-con.!  case-  by  the  natun-  ..f  tl..-  pnn.ary 

'T)uTh.>  l)asis  of  the  pro<rainfr  .■onsi,l.Tati..ns.  inf.Tti.ms  inllannna- 

,i„„.  ,„av  iH-  .livi^-a  into,  first.  (A,  intiannnatu.ns  of  un.l.;t..r.n.n.-.l 

i;,.,.,,.i.,i;,jry;  s.Ton.l,  a^,  intiannnations    .lu.-   t.,  a  specific  nucro- 

, ',.r.„u^ni      Til."  fornu-r  class  will  hv  first  consi.l.-ri'.L 

^\   Infectious  Traumatic  Inflammaticns  of  Doubtful  Bactenology. 

ll,,  s..  co.npriso  th.>  lars.'r  nu.nlKT  ..f  acut.-  afl.'Ctions  of  th.>  nose  an. 

1   „at     Their  phenon..-na  n.ay  l.e  nianitest.-.l  by  a  .l.-g.-n.Tat...n  an.l 

.      is  of  C..11  .  bv  exu,lation  fron.  tlu-  bloo.lvess.-ls.  by  proUfera  ...n 

;.  ....11  .an.l  In-  phag.K.yt..sis.     nistol.,j:i..ally  we  n.av  .l.vi.le  tlu-.n 

•n  ,     first,  acut..  pn.lif..rativc  ..r  .-atarrlml  inflannnat.ons  ..f  tl...  n.ucsa" 
„rivn.,  l...i.l  tissu..:    s<.c..n.l,  ..xu.lative  .,r  fibnnous  inHan.n.atu.ns 
i  ,i:  suppurative  inflan.n.ati..ns.  ..itl.er  wU h  absc.-ss  t..nna  .....  ..r 

,1    ,11,1  s..  phl..K.....n.ms  inf!an.n.atiu,..    Tl...  .-ccurrence  of    heso 

,,■„,.,„  ,„„;ii,i„t  is  .l..pen<lent  b..tl.  up..n  th.-  severity  an,    the 
,,„„„Hi..a!  lo,.ali/,ati.,n  ..f  the  infection  ..r  trauma     The  -^^j^!^'^^ 
pvo,r,.,...s.  for  instance,  n.ay  pn.luce  a  pr..lif<.rativp  t.ms.li   s  or  an 
xn^ativ..  to.isiir.tis.  or  a.,  intratonsillar  absc-ss.     It  w,  1  th..refore 
|„.  n.nst  conv..nient  to  stu.lv  tl...s..  con,liti..ns  fron.  the  anat..nucal 
'  .n./ipoint.  an.l  we  shall  tl...r..f..n.  .Ustin,uish.  first,  (a)  "|Hamn-t,,ms 
„l  tl,'.  ...ucous  n.en.bra....  ami  lyn.pluml  tissues:   sec.n.l,  (b)  inflam- 

„,:.tions  of  the  submucous  tissues  an.l  deeper  structures. 

„  Inflammations  of  the  MncouB  Membrane  and  Lymphoid  Tissue. 
V.ut..  inflan.<..ations  of  the  ...ucsa-  may  be  proliferative  or  exu- 
,|ative.  according  as  the  irritatiuR  apent  is  mil.  or  s..v..re.  In  the 
t'rst  case  the  r.^s.ilt  is  an  acute  catarrhal  rhinitis.  ^A^^ynfr^^^J^ 
huynsiitis.  an.l  in  the  latt.T  it  is  a  hbrinous  uiHammatum  of  these 

'"tIu.  proliferative  or  catarrhal  inHamn.ati..ns  ..f  the  muc..sa.  are 
..,!n,..st  unknown  to  us  hist..lo«i.-aily,  ;.wmg  to  th..r  <''"'1^"[>.  'j 
nr„v,.rv  \  ..as..  .)f  acute  rhi.iitis  stu.lu^d  by  Suchannck  ..xhil>.t...l 
,  .w..lli.'.K  ,u.d  .i..l..matous  infiltration  of  the  mucous  n...n.brane, 
.-:,„.i,.,t..,l  with  dilatation  ..f  tl..-  blo.,.lvess..ls.  {n.-rea.....l_n.u..o,us  8.-- 
,.,viion.  n.ark...!  r,.un.l-c..ll.-d  intiltrati.m.  partK...la,-ly  in  the  sulv 
,.|,i,h.-lial  lav.-r,  .^scape  of  r.-.l  bh.o.l  corp-.-l.-s  fn.rn  the  yoss.-ls  an 
d:..Muan,ati.-.n  oi  the  ..pitl.elial  c.-Us.  The  .nuc.n.s  glan.  s  si  m^..l  a 
,„a,U...l  d..}r..ne.ation  an.l  ..xf..liati..n  ..f  the  .•p.th.-hum.  In  all  pr..b- 
alMlitv  th..se  alt.-rati..ns  exist  in  a..ute  ph.arynpt.s  an.l  larv-n^tis, 
llMir'iM.livi.lual  mo.lifications  <l<.pen.linp  ui...n  the  anatomical  stiuc- 

tuti'  of  the  part.  .        ,  ...  ■  „ 

\Vh..re  thi-  irritant  is  of    peculiar  int.-nsity    he  pre  innnary.  phe- 
nomena of  pn,liferati.)n  of  the  tissue  cells  are  followe.1  by  hbrinous 


■a 


(ii)4 


yOSE  AXD  THROAT. 


exudation  from  tho  bloodvessels.  It  should  be  emphasized  that  this 
foiiditiou  is  not  separated  from  the  iireeediiiR  one  of  proliferation  by 
tlefiiiile  etiological  boundaries,  but  represents  merely  the  effect  of  ,! 
stronger  toxin  ujion  the  affected  tissues.  In  the  majority  of  ciuses  this 
affection  is  diphtheritic,  but  in  a  certain  number  of  cases  the  diph- 
theria bacillus  wiis  not  found.  Our  only  histclogi'-al  accoiuit  of  non- 
diphtheritic  Hbriuous  rhinitis  is  derived  from  ..  Ciw  of  Seifert's.  who 
says : 

"On  the  external  margins  of  the  section  the  epithelium  is  intact, 
but  penetrated  by  round  cells.  Investigation  of  the  neighboring 
places  shows  an  increase  of  the  round-celle<l  infiltrati(  ,  in  the  sub- 
nuicosa  and  epitheliinn,  with  the  appearance  of  a  thin  layer  of  fibrin 
on  the  e|)ithelium.  In  other  j)laces  the  layer  of  fibrin  incrca.st's  in 
thickness  antl  is  penetrated  by  mmierous  round  cells,  but  the  epi- 
thelium anil  subnmc'isa  show  no  other  alterations  beside  thos<' 
already  mentioned.  lOven  where  thi>  fibrin  layer  is  thickest  then- 
is  no  necrosis  of  the  epithelium.  The  condition  is  therefore  exclu- 
sively an  exudation  on  the  mucous  membrane." 

Proliferative  and  exudative  inllannnations  of  the  lymphoid  tissue 
are  relatively  well  known  t-o  us  histologically  from  recent  studies  of 
the  faucial  tonsils.  As  the  structure  of  the  various  parts  of  the  ton- 
sillar ring  is  practically  identical,  we  shall  confine  ourselves  to  a 
somewhat  detailed  description  of  the  phenomena  as  they  appear  in 
the  faucial  tonsils. 

In  diffuse  proliferative  tonsillitis  the  follicles  exhibit  enlargement, 
due  to  an  increjused  number  of  their  lymphoid  cells,  particularly  on 
the  side  adjacent  to  the  nearest  crj'pt,  and  of  the  endothelial  cells 
of  the  reticulum.  The  proliferation  of  these  endothelial  eel's  gives 
rise  to  large  phagocytic  epithelioid  cells,  characterized  by  a  rela- 
tively large  amount  of  markedly  acidophilic  cytoplasm,  and  an  irregu- 
lar, lightly  staining,  eccentrically  situateil  nucleus.  They  contain  in 
their  interior  from  one  to  ten  or  fifteen  cells  or  cell  fragments,  which 
are  generally  lymphoid  cells  and  red  blood  corpuscles  in  various 
stages  of  digestion.  The  incorporated  cells  do  not  appear  to  lie 
directly  in  contact  with  the  cytoplasm  of  th(>  phagocytic  cell,  but  are 
generally  situated  in  clear  spaces  or  vacuoles.  The  lymphoid  cells 
Ix'tween  the  follicles  are  increased  in  mimber  and  closely  packed 
together.  The  endothelial  cells  of  the  reticuhnn  of  the  interfollicular 
regions  show  an  increased  proliferation,  with  formation  of  epithelioid 
cells.  Toward  the  mucous  membrane  the  lymphoid  cells  exhibit  a 
transition  into  plasma  cells,  and  are  as.sociated  with  polynudear 
nentrophiles.  The  bloodvessels  are  dilated,  filled  with  red  and  white 
blood  corpuscles,  and  show  more  or  less  marked  proliferation  and 
exfoliation  of  their  endothelial  cells.  The  ceils  of  the  mucous  meni- 
br;!!if  show  n  contu'ctive-tissu''  |r:i!iferation  arid  exfoliation.  The 
epithelium  of  the  cry])ts  is  loosened  from  a  widening  of  the  inter- 
cellular si)aces,  which  are  crowded  with  escaping  lymphoid  and  plasma 
cells.     Bacteria,  chiefly  cocci,  occur  superficially  in  the  epithelium 


i'i,.\ri.  XX, 


i 


ili 


I  1.1    1 


^i■< 


c^^^ 


/    / 


'«i 


illil 


'"■     '       l^i''-"-'-t>.    i.,..io.mi-   ...    ll„    „„  M!,.   i„,|,,„.,.,     \.,,i    (-.,.>„„    -,.„„       Th.- 

1"""~''"'"  ' '  •  '■■    "1  .il...liv   !.•,,!,!,  :  .lliiu  .,,1.1  t. „,„,,,;;  .,  !,:,,,,,1  ,„;,    .■.,!,,.,,,    ,  ,„,. 

I'l'.    i      K.,n-I\  mil:    ..-1:1,-    In  ,„  ,t..s\  1  II  ,,.-,,,  ,..,,,,        \   ], 

I, ,1,-1,  ,,--,,„  l„  ,]„,,,  „,,,  .,,,,„  ,-,,l,,  ,„.,,,„,,,^  (.,,,^„„l  ^ 

111-^  t...ll^ 


i",   \     I'l .-,,!,, ,-.  n-  i,.,i„  „.,,  ,1  ,„,iv,,,  .t.,,,,,.,1  ,>,iii  ,,.,i 

-et-n  .,  -li.,rl  .l,-!,,,,,.,.  i,.,,„  ,i,,   i. ,,,.,.],,  ,„  , 


i'l.. 


i.,,,!ii.  :.iti..ii  .,f   ii,.   ,,,.;. .111. ;, 


t.,n-ill,li-      Th.  PI..!. .11,,  :,.,l,-,.ll,-i,,,>v  .,  -u,  lluia  ..I   III,  ,.  „ 

iMth  .1  :.,.,-,-i,,i,j  i,.,„i  11,,  „-,ii.,iiii,  ,,..>,.] 


-1.  ...  I  ,-t    \\  ith    III  illy 
ti.,ii  i.l  lb.-  -11, 1, ,1111. 1- 


In.'iin     ',1,  1  liv!,-!,(   Mil,.,  iiii.i 

,,      III,  |il\  .,  ,,,■    ;.!,;,      -I     ,11     ;,,^ 


"    "1     .1     1.1 K.  -    -1    I.,   .,,,llf 

!•  I  .111.1   l,l.,|.,],l;i-,,i     1    .;;,llirr 


iiti 


!'I..\'1"I'    XXI 


1*       • 


% 


o 
o 


I  Mi 


.^ 


e> 


2^* 


-^ 
J 


. -^-^ 


«SJ* 


■^       '-^"^ 


iti» 


F'3 


...P><? 


1,,,  I  \lii' -iw  '!<  1^- 11' I..I1WTI  ..i  the  fpillu  hiiiti  Miihi.-m.  l!\  ;  •<  H  !  "^Iiu'  ihinUi', 
\\  V,  .  .,  ti..  .,.,:i  -I, I  ill  rli'  ;.i..t.-.-.i-ni  .-l"  tin  ..It'  ^  ;  ■  'I  "  iN  l;iW.  -.  .i  ■  !i  n  ult-n-lK'  i.iiik 
-I  nil 

t-i.,  IIv,i:;TH-'l.  jMu-T  Ui'ii  "1  i.l.i^m.i-  t  M-    ■  .i  ■ '  \  -!.t^-  ■   -t.titi.  ■!  \\  U  h  -   ft  1"  ■!  I"«i.h-tn 

>irl  I'iii'H-  ;-rt-rM  1  !i-  ■■.  IN  .ilf  ;ii  '■■  ;  With  niiiiMU  -i.iiin'i  -  '•!  v.i:  Mim  -^/c  u  !iu  h  slu.w 
tllf  rh.ir  I'  l-:i-r:.     Hlniil\    I'T   I'll  li-Ml 

[.J..  !|   .-m   .;'-L^'  11'  'iti'ii  "I    e;irl!i'    ;rtm.  -1  ■-:!!■!  ^Mlli    iiietlultiK    '   lilt-  .Mi'l  tit  lit  t  ,(I 

,,i,.  !ii      1-  .■ti"i    -l  .1  vv.ill  ..t   A  ,-TV!-t  t'r.Mii      .M^f  ■>;   ■  ^11-1  n,.  I  k'  1  iIm-i-      Ni'i!.  r.Mi-  l.ixfi-^ 

'■I     h    'MIV     f-i-:  .'i'      llTIl    -ll'JW    tllf  "K^t  111    -Mill  '  il    \  .11  M,..;.   -   .H     .      M..I 

11-,     :       I'll  .^■..-vlir  tri.itlulioi.Ui-ll  tr..:i.  tllf  it-li-    iIhim  > .!  t,  .n^il       p,  ■' ■.  >  !ii  ■  .'h-    iiirttiv- 

IftltrMu.     -lirl'      -ill  TlH'i'vll       wllK-h   i-    ll\-      ;     ■,!!    .1     -iLl^i-  lU-r^tlVC  '.1     .!■.:■«  '-^1     m-.t!"!). 

i-i  -.«•(  i;  t.)  h.i\'-  in>  ■-:  i.-.TiUr.l  l!iif(-  \\  \\\\'\v  ■  y<AU  t''U'  th'  r  wilh  -i-\  •  ral  -ni.i:;  it. mm  rit*. 
-'!"  tin.  '■^■.^r  '!'  1t;lii- 

t'l'.  -.  An  '  villi'  "lull  i  ;ih,t>;'i*'v  '  ithIl-i,  ;'^  iiiit' i-i-.  ^Imw  m;-  ninnt-i  ■  u  !U  ■  irpoi  «ti-'l 
icIN  .III  I  .  .-ll  !:  ■-  -iH  .It-. 


l\hLAMM.\riO.\S. 


«!»: 


liiiiii!;  tlif  cryi'ts,  Imt  Mitpari'iitly  arc  al)-i'rii  in  thf  lyiii|ihui.l  ti»^iii\ 
■|"lii'  crvjits  arc  tilli-il  witli  cxl'itlialnl  i'|)illi(lial  cells,  Iriicdcylcs.  hac- 
tciia,  aiii(ir|ihiiiis  (Irliris,  ami  in  fw-vcrc  cases  lil)riii,  wiiicli  eiiclnscs 
cells  aiKJ  liaetcria  in  a  delicate  network.  At  tunes  the  lihrin  may 
eMeiiil  from  I  lie  crypts  into  ami  I'veii  lieyonii  the  eiiithelinm.  pene- 
trating; nmst  deeply  in  tln'  intcrlcilliciilar  refiintis.  Uacteria  are  must 
ahiiridant  near  the  surface  of  the  cryjit,  );radually  diniinisliinj;  in 
niimlters  toward  the  hasi'.  The  pliat;ocytic  polyiiuclear  neiitrophiles 
contain  hacleria  in  their  interior,  and  may  exliiliit  :i  network  frajr- 
nientation  with  ili-pirsion  of  their  chromatin.  (I'l;ite  .\.\..  I'iir.  I 
and  I'late  .\.\l.,  l'i;:s.   I  and  r>.) 

The  acute  lacunar  ulcer.itive  tonsillitis  of  Moini'  and  othi-  i-^ 
known  to  us  chielly  throuirh  clinical  <le-criptions.  .\<  f.ir  as  the  w  i  .!e|- 
can  ascertain  from  the  hi-lolo^ical  accounts,  it  i- possihiy  idenlii  :il 
with  the  condiiion  dexrilied  lielow  imiler  >uppmMli\i'  ton-illiti-. 
where  .in  intr.ilollicular  ahscos  i-  di-cli.irjiinf-'  '"'"  •'  "•'Tl't- 

//.  Submucous  Inflammations.  I  nder  llii-  lieadinL.'  are  comprised 
those  diseases  in  which  the  >ul)nnicous  tissue  form-  tin'  chief  seat 
of  the  inll.immalory  processes.  On  |ialiiolo};ical  ground-  we  may 
distinjiui-h.  Iir>l,  a  slajre  of  tidema;  second,  a  jilastic  stace:  third, 
a  siippur;iti\-e  si.ifie.  The  disi  rilmlion  of  tlii-se  processes  i~  larjrely 
dependent  upon  the  structure  of  till-  tissues  involved.  Since  the 
inllanunatory  processes  extend  in  the  ilirection  of  the  least  resist.ance. 
tho-^e  ii>sues  with  a  loose  or  disten.~il)lo  sul>muco>a  exjx'ric  nee  jireater 
alterations  than  those  of  a  more  rt.nipact  nature. 

.\  sul>nnicous  (iMJem.atous  inllammation  of  the  nose  was  foimd  liy 
the  writer  in  one  instance  localized  on  the  septum  posteriorly,  and 
was  .sei-n  hisiolo<:ically  to  coi:sist  in  a  forcilile  stretching:  of  the  envel- 
opiufi  mucous  nieml)rane  and  the  underlyinj;  connective-tissue  sjtaces 
l)y  the  escape  of  the  serous  fluid  into  a  circumscrilieil  ar(>a.  Tiie 
mucous  membrane  consisted  of  from  three  to  si\  layers  of  columnar 
eiiilhelial  cells  without  evidence  of  cilia.  Here  and  there  the  mucous 
menilirane  w.is  aliment  or  represented  hy  tattered  and  loosely  lianuinj; 
columns  of  cells,  while  in  several  places  vertical  cracks  and  fissures 
Ihroujrh  tiie  nuicous  memlirane  were  ap])arent.     The  individual  cpi- 

theli.al  cells  !<eei 1  essentially  normal.     In  the  intercellular  spaces 

were  seen  numerous  ]iolynuclear  ni'utrophilic  leucocytes,  lymphoid 
and  plasma  cells.  The  body  of  the  ma.-^s  below  the  mucous  membrane 
w:is  c(»inix)sc(l  of  a  delicate  network  of  connect ive-ti.ssue  libres  with 
wide  interspaces.  In  many  places  the  fibres  seemed  forcibly  ru])- 
tured  from  their  connections,  leaving  rafrjied  and  frayed  ends  sepa- 
r;ite(l  by  a  varyiiif;  dist.ince.  Scattered  a!)out  in  this  area  were  a 
number  of  mucous  filands  of  essentially  normal  size  and  apix-arance. 
surrounded  by  a  moderate  number  of  lyinjilioid  cells  with  a  tew 
pla;  iii.-i  ceils  and  M.iNt/.illen  ill  a  manner  similar  to  th:it  which  occurs 
in  the  ordinary  hypertrophied  mucous  membrane.  There  were  muner- 
our  thin-walleil  channels  lineil  with  endothelium  containin<:  red  blood 
cor|iuscles  and  a  few  polyiiuclear  iieutrophiles  and  lymphocytes. 


TT^r 


-JJ,  ,J|JV.L'4" 


(i!)6 


SOSE  AM>  TIUt'iyT. 


r 


i 


\\ 


% 


Tlic  (i>(|ctiiatiui>  iriflaiiiiiialiun  of  the  inula  ami  lariiyx  arc  iimnahly 
•■ssciitially  iilciiiical  liistolu^i' ally  with  tl     almv 


sii|>j)iirati(His  1m-Iii\v  llic  iinicini.-'  int'iiiliraiH'  iiia*.    I>     focal  or 


Til 
ilitTuso. 

The  fofa!  suppiiralioii.t  arc  found  in  t'lc  nose  m-:  ahsciss  of  inc 
septum,  aii.i  in  the  ilimat  as  alt-ccss  of  th.   tonsil,  pharynx,  or  larynx. 

.\l)scc.-s  .  f  ihi'  na.-ai  -c|)fn!  nccnrs  ,is  acute  idiop.-ithic  peri<"hon- 
<lritls  o!'  'he  se|it;il  cartilape  ;uiil  a«  traumatic  .ihsce.ss.  In  the  first 
in.-taiui' we  have  tl'  li  with  .1  more  or  less  extensive.-  ppurative 
softeniiijr  of  the  tissues  without  e\  iilenci'  of  trauma,  or  contagion,  or 
constitutional  disease.  The  intlammation  ,itTecis  the  whole  mucous 
memhrane  in  all  it^  layers,  the  cariil.ij;e,  ainl  even  the  hone  in  the 
vicinity.  While  we  know  that  infectious  orjiaiiisms  .are  the  cause  of 
the  condition,  the  method  of  their  penetration  into  the  tissues  has 
not  Im-cu  determined.  Th(>  tr.nnnatic  ahscess  dilTeis  from  the  j)reced- 
iiift  condition  merely  in  the  tact  th;tt  a  suhmucous  or  sul)i>eriosteal 
haniatoma  has  l)e(>n  formed  as  ;i  result  of  trauma,  wit!,  second.iry 
infection  and  suppur;itioii.  The  hisfolosiical  lietails  of  the  two  con- 
ditions have  not  heeii  described,  hut  ni.iy  he  in!'  rred  from  our  knowl- 
edge of  analoijoiis  |)rocesse>;. 

Serous  Perichondritis  of  the  Septum.  In  tliis  affection  the  clinical 
manifestations  of  bilateral  occlusion  of  the  na.sal  oiM-nings  h\  two 
pale  red  tumors  yieldinir  on  incision  a  serous  fluid,  and  termin.riiiK 
by  a  cr-rtain  amount  of  -inking;  in  of  the  bridge  of  the  nose,  have 
been  siipi>o.sed  by  some  observers  to  consist  histoloj;ie.alh  ;  a  jirimaiy 
affection  of  the  triangular  cartilajje,  due  to  a  defteiieratmn  of  the 
cartilage,  with  softeiiinj;  and  fonnation  of  cavities  tilled  with  homo- 
KciH-ous  cheesy  masses,  and  iissociated  with  .serous  exudation,  pro- 
liferation, and  new  formation  of  bl(HKlves.se|s.  My  others  ii  is  believed 
to  be  similar  to  perichondritis  sero.sa,  which  freijuently  occurs  at  the 
dia|)hysis  of  the  lonp  bones  in  younn  individuals. 

In  certain  ca,ses  of  tonsillitis  abscess  formation  occurs.  The 
ab.scesses  are  situated  at  the  bejiinninp  in  the  interior  of  the  fol- 
licles, enlarge  later,  and  eventually  discharge  into  the  crypts.  The 
relative  frequency  of  the.se  abscesses  varies  greatly  in  different 
cases,  but  is  ajtparently  .as.sociated  with  a  iiu-e  "severe  clinical 
type  of  the  di.sease,  and  has  been  foui./l  p.articularly  in  asso- 
ciation with  the  streptococcus  pyof;enes.  The  presence  of  the  abscess 
in  its  early  stage  i.s  indicated  by  ;i  circimi>cribed  infiltration  of  p(»Iv- 
nudear  neutrophiles  ainoiifi  the  endothelial  cells  of  the  reticulum 
occupyitiff  the  centre  of  the  follicle.  The  bloodvessels  in  the  imme- 
diate neighborhood  coid.ain  l.irge  numlxTs  of  ixilymiclear  neutrophiles, 
of  whicii  many  are  .seen  in  t!i.  act  of  ;)assing  thriiugh  the  ve.s.sel  wall. 
The  eiidolhelial  cells  of  the  ves,sel  show  a  varying  amount  of  swelling. 
.Miorocoeei  are  foin-d  in  varying  jismhImt!^  i;;  the  regi:.n  ucfuii'ed  by 
the  polyimclear  neutrophiles,  lying  for  the  most  part  free  in  the 
intercellular  s]):ices,  although  they  not  infrecpiently  may  be  ,soeij  in 
the  inferior  both  of  the  polynuc'eai   neutrophiles  and  of  the  large 


/AT/,yJ.UV.I/7".V.V 


«y7 


(l..il»i'li:ii  pliMRorytf-s  pivviiiuslv 


Slv    .1 


I'^rril" 


ll> 


I'.K' 


ivticiiluill. 


tlx'  lollicli'  increase:^  \-Ty  cou^l 


.1.1 


Witli   the  (jri^vtli  of 
Iv  ill  >i;'i'.  ::-!  til"'  I'-iilt 


Iv  of  a  lici>jhtiiii'<l  prolil'ffi 


tioii  (if  the  ciMlclhi'lial  (I'lls  of  tli. 


'I'hosf  ill  tin-  iiniiH'diatc  ^itiiiity  o 


f  til 


lisccs- 


-ll 


ciiiiin  of  tlicir  cytoplasiii  a 


ii.l  an  in»'j»ii 


tv  ill  oiitliin'  o|   tli.'ir 


Ici.IimI,  '  I   twi-tcl.     A  markftl 


„.,rl..iiH,  wliirli  ai..«aix  .•!.  iiuat.'.l,  iii.lci.l.Ml,  -  r  twi-t.'.l 

,n.n-as.>  is  .i!m.ltaiK'..uslv  oLscrvd  in  tl..-  nu.i.l.rr  of  iiijf  [.lia-o- 

.•vi.w  in  !lu-  vieinitv,  wlii.ii  rontain  also  a  Kivat.-r  min.l«T  <.f  mcor- 

,;.„at.Ml  .-.•lis  an.l  fra«tn.nls.     The  >iro'.vtli  of  ll..'  al.s.vs>  ,s  uM.a My 

|„  ,1...  dinrtioM  of  till-  .•.■ar.'st  m'l.t.    Tlic  iM.lv....<-i.ar  n.'ulropinl.r, 

,•  tlic    il.sc-    iirsl  |M'ii.'trnt.'  in  a  nioiv  or  It -^s  coini.ict  '      luc  ni." 

!|i.,M-  roll.vti.m  of  IviMi'l'oi'l  ••'•"^  ^v'''"'''  ''"'i'*'!''^  '!"'  '•''"♦''•''  ••'"'■"' 

luiM    -111(1  •i.lvanci'i^  toward    ili.'   mucous   ni.  inl-ianc  of  tlic  .-rypt, 

inllluMc  this  and  raur  it  to  Ik'com.c  .-xfoliat..!  over  a  dclinitc  area. 

Tl„.  ahsrcss  now  disd.arji.'s   fnn-ly  int(    tl..'  m-pt,   \xiiicli   l..con.cs 

„11,..;  with  iM.lvmiclcar  ncisrophilcs.  .•.Ilula:-  dctntus,  and  l.actciia. 

1  v.in.hoid  ai..l"pl:i.-tii:<  cclK  an-  rclaliwly  K-ms  al.nndant  than  in  raMs 

uiihout   abscess  tormation.     i'ihrin  in   the  crypts  apin-ars,  on  the 

„„„.,  ,,,„„,.  „,.„,.  almndant.     Th-  nOative  -.,.-  ol  th-  ahscesM^s  vanes 

m-ea.lv  in  the  ditTennt  follicles  in  the  -atne  tonsil,  some  Ix-in^r  l-arely 

r-coiinizal.te,  while  others  are  already  (lischar}:in>:  into  the  crypts. 

( ..rasionallv  two  or  even  three  abscesses  are  found  m  a  suigle  follicle 

:,i»d  these  are  j-enerally  of  different  sizes.         .      .      ,  ,  . 

In  some  instances  ciicmntonsillar  intlainination  is  ohser\-o<l  in  a-sso- 
,i-,ti„n  with  or  M.hs.Miuent  to  intratonsillar  abscess.     In    '.    e  ca.ses 
„„.  ,..,nn.rtive-tissue  spaces  of  the     Hculuni  a.lj..um.g  the  tonsillar 
.,bs, ess  are  crowded    with     i-olynu.     ir    neiitroi.hiles.   which     •:■ 
'.xtend  in  direct  nutinnitv  toward  th.      ise  of  the  .irgar.  in  the  dire. 
,i„„  of  the  eircuiMt..nsiliar  ab.sc<-^s.     It  is  reasonable  to  sui-lH-se  th; 
the  circuint. miliar  inttammatioi,    s  the  r.-sult  of  the  di.scharpe  of  tl., 
intratonsillar  abscess  int..  the  eH    nnt  lymph  channels 

Circumscribed  abscc-so-  of  tlu-  pharynx  are  probably  essential!, 
similar  to  those  of  the  .irruintonsillar  reKion.  an.l  need  not  1m-  dis- 
cussed in  further  detail.  In  the  lar>-nx  they  occur  I'^mcular  y  in 
,he  epiglottis,  tlu-  aryepiplottic  folds,  the  vocal  c.rds.  an,l  the  i  er- 
arvt.-n..id  region.  The  histological  picture  h.;r.-  is  exc,-,.liii«l>  xari- 
Mbl...  and  .l.-iH-nd.-nt  b.,th  upon  the  localization  ot  the  l-rocess  and 
the  original  cause  of  the  inflammation.  _ 

DitTuse  suppurativ.-  inflammations  or  phlegmonous  inflammations 
„ecur  particularlv  »k-Iow  th.-  mucous  ni-  :ubraiu-s  ot  the  n.-se  an.l 
throat  as  t!ie  result  of  an  invasi..n  of  i-yop-mc  microoocei  1  he  cn- 
.liti.ms  are  analogous  to  those  of  deep  erysi,H-lat.,us  inflammations 

"  iV'tofectious  Inflammations  due  to  a  Specific  Micro-organism. 

Diphtheria.  i)ipi.iheria  nmnifivt^  it«e!f  '.•■'■  the  '.  u-ous  membranes 
„f  the  nose  an.l  throat  in  the  form  of  an  infh.mn..tion,  which  ma> 
be  catarrhal,  exudative,  or  necrotic.  Then-  is  no  reason  to  suppose 
that  the  first  condition  ditlcrs  hist..logically  from  that  occumn-  in 


698 


AOA£'  AXD  TUROAT. 


acute  iliinitis.  Tho  formation  of  tho  pscudoinpmbrano  bogins  usually 
with  necrosis  of  the  epitheliuin  aiul  with  the  deposition  of  an  exudate 
:n  and  ujvin  the  surfiu-c  of  the  latter.  This  pseudonienihrane  may 
Ik'  deposited  in  one  or  in  several  layers,  which  may  show  certain 
ditTerences  (if  age  amonji  themselves.  It  consists  eith'T  of  a  «lelicate 
fibrin  network  or  of  a  chwiy  woven  network  of  thick  ftlisteninji 
strands,  in  the  aeshes  of  which  there  may  Im-  either'many  leucocytes 
or  almost  no  cellulai  elements.  The  vijjper  layrs  of  the  j)seuilo- 
inembrane.  which  as  a  ruli'  contain  the  laifjest  number  of  bacteria, 
are  frecjuently  seen  to  have  imderfione  fn  ;;menlation  into  a  gramilar 
detritus.  The  defjcnerafed  epithelium  disappears  usually  through 
exfoliation.  ;ilthou};h  at  times  renmants  of  tlie  epithelium  may  l)e 
found.  The  mucous  membrane  itself  ex|>eriences  alterations  in  the 
form  of  hy]>era'niia,  round-celled  inliltration.  and  fropiently  tibrinous 
exudate.  If  the  necrosis  is  limited  to  the  epithelium  recovery  occurs 
withiiut  sc.'ir  form.'ition.  If  the  mucous  membrane  \<  invaded,  how- 
ever, by  the  necrosis,  a  loss  of  sul)slai4.'e  occurs  and  heals  by  granu- 
lation and  the  formation  of  cicatricial  tissue.  The  bacillus  of  diph- 
theria is  constantly  found  in  t!ie  pseudomembrane,  most  fre(|uently 
in  the  snpi'rficial  layers,  but  also  in  the  superficial  layers  of  the 
mucous  membrane. 

In  the  tonsils  a  dilTuse  necrosis  of  the  epithelium  may  occur,  affect- 
ing the  single  cells,  or  there  may  be  a  necrosis  and  ulceration  extending 
into  the  lymphoid  tissue  from  the  cry])ts.  There  may  be  a  formation 
of  membrane  s(>condary  to  the  ulceration,  and  fibrinous  membrane 
formed  directly  in  the  lymphoid  tis.sue.  In  these  ca.ses  the  reticulum 
is  ap|)arently  converted  into  hyaline  fibrin.  In  .soin;  cases  there 
may  be  an  extensive  hemorrhage  accomp.anied  by  fibrin  and  necrosis, 
altlmugh  fibrinous  exudation  without  hemorrluige  frecjuently  occurs. 
Micro-organisms  are  rarely  found  in  the  tissue  on  microscopic  exam- 
ination. 

Influenza.  Microsco])ic  examination  of  the  nasal  mucous  mem- 
brane in  cases  characterize(|  clinically  by  shnple  hyi)era'mia  shows 
but  slight  alterations,  these  consisting  cjiiefly  in  a  dilatation  of  the 
bloodvessels  and  increased  emigration  of  leucocytes  through  the  e[)i- 
thelium.  In  cases  of  greater  severity  there  appeared  an  increased 
amount  of  infiltration  in  the  .adenoid  layer,  together  with  heightened 
des(|uaination  of  the  superficial  epithelium,  exudation  of  blood  into 
the  tunica  propria  and  through  the  epithelium,  with  imico>is  degen- 
enition  of  the  superficial  epithelium.  The  cedema  has  been  observed 
te  be  rather  irregularly  distributed,  being  in  some  places  entirely 
absent,  and  in  otli'Ts  concenleil  by  a  proliferation  in  the  lymphoill 
laye-.  ,\  ch.aracteristic  feature  is  the  desipiamation  of  the  glandular 
epithi'lium.  which  may  be  exfoli.ated  over  a  contiiuious  area,  and  in 
this  condition  filling  the  lumen  of  the  glands.  The  [jrocess  api)ears 
to  be  extremely  rapid.  The  pharynx  shows  an  infiitr.ation  of  the 
mucous  membrani'  with  leucocytes,  together  with  dilatation  of  the 
cai)illaries  and  small  vein.^.     In  the  larynx  and  trachea  hypera'inia  of 


ISFLAMMATIOXS. 


699 


tlio  iniipous  mpmhrano  exists  to  a  prcator  or  loss  extent,  unevenly 
.li^trihuted,  and  at  times  so  intense  that  the  papilhe  a|);)ear  to  consist 
s.,lelv  of  dilated  bloodvessels.  This  dilatation  affeets  the  small  vems 
and  "the  veins  of  the  eapiilaries,  %vhil.>  the  arteries  themselves  are 
jieiierally  emi)tv  and  contracted.  The  mucous  membrane  is  sunul- 
taneouslv  inhltrated  with  leucocytes,  which  her(«  and  there  give  rise 
to  the  formation  of  small  Ivmphoid  swellings.  In  the  more  marked 
decrees  of  hviM'ra'inia  there'is  stasis  of  the  blood  in  the  vessels  which 
;nv  distended  with  leucocytes.  These  latter  form  small  heaps  within 
tiic  lumen  of  the  vessels,  fre<iuently  associated  with  thrombi  and 
micnwH-ganisms.  The  vessel  walls  show  proliferation  of  the  lining 
iiidothi'lium.  The  limiting  membrane  of  tiie  mucous  nwmbrane 
Mopears  thickened  ami  hvaline.  The  mucous  membrane  may  become 
tianslucent  and  siiow  mlicoiis  degeneration,  with  at  times  sup.Tficial 
areas  of  necrosis  api>earing  as  small  uiceratio.is.  the  floor  of  which 
miv  b<-  form.'d  i)v  tiie  bare  cartilage.  In  some  cases  this  necrosis 
i-;  ,'liic  to  thrombosis  in  the  vessels,  in  others  it  is  |)robably  due  to 
sla-is  and  inliltration  of  blood.  The  distribution  of  the  influenza 
|,:i<ilhis  in  tlu!  mucous  membranes  of  the  nose  and  throat  is  not 

known. 

Typhoid  Fever.  The  inanif(>stations  in  the  upiM>r  air  pai*sagcs  accom- 
panving  tvphoid  fever  may  1m-  divided  into  three  groups: 

1.'  An  active  hypera-mia,  loosening  and  desiiiiamation  of  the  epi- 
thelium, producing  erosions  which  then  form  the  entrance  point  for 
micro-organisms  which,  mingled  with  the  exfoliated  epithelium,  i)ro- 
duce  a  whitish  deposit  upon  the  mucous  membrane.  The  micr<>cocci 
find  a  favoral)le  soil  in  the  affected  tissue,  penetrate  into  the  vicinity, 
and  till  the  dilated  Ivmph  vessels  with  thrombi. 

•>  I'lcerations  occur  as  a  later  stage  of  the  precetling  manifesta- 
tions. These  mav  le:id  to  perichondritis  in  the  larynx  and  necrosis 
of  the  cartilage,  particularly  the  epiglottis  and  the  arytenoids. 

.{  Tvphoid  ulceration  which  behaves  in  the  same  manner  as  the 
cli.iracteristic  intestinal  afTection.  These  affect  the  adenoid  sub- 
<t.ince  in  the  larvnx  bv  i>reference,  and  also  the  anterior  commissure 
and  the  base  of  the  arvtenoids.  The  i.rimary  swelling  in  these  areas 
i<  diH'  to  a  penetrati.;t,  of  tvphoid  bacilli  into  the  lymph  sinuses  with 
a  pnuhiction  of  toxin.  The  direct  action  of  the  toxin  upon  the  tissue 
causes  an  inflammatorv  exudation  of  serum  ami  leucocytes  into  the 
,,Pter  portion  of  the  Iv'miihoid  areas  and  the  adjoining  tissue.  Later 
tlie  exmlation  disappears  .md  is  followed  by  an  mU'uso  des(iuamati(m 
uf  the  endothelial  cells  lining  the  reticulum  of  th.-  lyni])!!  spaces. 
I'lK'se  cells  are  oceasionallv  i)hagocytic.  Finally,  necrosis  and  slough- 
ing of  the  newly  formed  tissue  occur,  and  repair  by  granulation  tis.-iiie 
fdllows  from  the  base  of  th<>  ulcer. 

Tuberculosis.  The  histological  unit  in  this  affection  is  the  miliary 
tubercle,  a  clumi)  of  eiuthelioid  cells  produced  by  proliferation  from 
thf  emlotheiial  ami  connective-tissue  cells,  with  or  without  the  as.>*o- 
ciatioii  of  giant  cells.     It  may  appear  ui)on  the  upper  air  passages 


■& 


700 


yosK  ASD  Til  no  AT. 


1 


ill  an  acute  or  dmiiiip  form,  in  llic  first  instaufo  as  a  part  of  a  more 
or  less  Rcncrallv  distriliutcd  acvitc  miliary  tuiu'rculosis.  Tiicsc  tn- 
ixTclfs  arc  (listril)iitc.l  in  tiif  s\il)c|)itli('liai  layers  of  the  mucous  mem- 
hranc.  and  arc  practically  identical  histologically  in  every  situation. 
As  a  rule,  a  fatal  terininatlon  of  the  case  prevents  their  developing 
into  the  stage  of  caseation  or  ulceration. 

The  chronic  forms  of  tuiwrculosis  in  the  upper  resjuratory  passages 
occur  as  an  ulceration  or  as  a  tumor,  or  as  a  combination  of  Ixitli. 
These  phenomena  vary  so;>,c\vhat  according  to  the  site  of  the  process. 

In  ihe  nosr  the  lulicrcular  ulceration  presents  itself  in  the  form  of 
an  infiltration  in  the  sulu'inthclial  region  of  coiuiective-tissue  c(!lls  and 
endothelial  cells  aggregated  more  or  less  closely,  and  containing  here 
anil  there  giant  cells  and  a  few  tubercle  bacilli  extending  ii  the  direc- 
tion of  the  epith(>lial  surface.  Central  caseation  and  necr  isis  of  these 
tiiberclcs  ensue,  with  the  restilt  of  causing  an  exfoliatior.  of  the  o.  r- 
Iving  mucous  inenibrane.  thrombosis  in  the  terminal  bloodvessels, 
and  the  i)roduction  of  a  graiuilar  detritus  ujxtn  the  floor  of  the  ulcer. 

Till-  tubercular  tumor,  or  tuberculoma,  of  the  no.s(  is  extremely 
variable  histologically,  but  consi>is  essentially  of  .-in  aggregation  of 
connective  tissue  and  endothelial  cells  wiiich  ])roliferale  to  form  epi- 
thelioiil  cr-lls.  The  new-formed  tissue  is  travi'rsed  by  young  i)loo(l- 
ves.-els  and  .ontains  scattered  through  it  giant  cells  an<l  tulx'rclft 
bacilli  in  varying  numbers.  The  whole  is  covered  fre(iuently  by  more 
or  less  normJil  epithelium.  (Hands  may  or  may  not  ocr-ur.  Toward 
the  peripheral  portion  ol  thi'  tumor  obliter.-ttivt-  endarteritis  at  times 
occurs,  le.-iding  to  thrombosis  and  peripheral  necrosis  •)f  the  tissue. 
Structures  have  been  found  in  these  growths  in  the  neighborhood 
of  the  giant  cells  and  in  their  interior,  comi)osed  of  coiicentrically 
arranged,  degenerated,  elastic  fibres,  infiltrated  with  mineral  salts, 
which  are  sujiposed  to  arise  from  the  hyaline  degeneration  of  the 
bloodve-^sels. 

Tiihirftiliisif:  i)f  llir  fiihsil  .appears  in  three  forms: 

1.  Irregular  shallow  lesions  occur  in  which  the  eiiithelium  of  the 
eryj)ts  is  destroyed  without  the  i)re\ious  ftirin.atio'i  of  'ulMTcles. 
ricerati'iiis  of  this  sort  are  superiici;d  .an<l  affect  the  who!.-  of  the 
crvpt,  or  at  least  most  of  its  wall.  In  the  cenH'e  of  such  ulcerations 
we  find  no  pnidects  of  ca-<er,us  mi  tamorphosis,  neither  epithelium 
nor  gi.int  celb  The  floor  of  the  ulcer  consists  exclusively  of  inlil- 
tr:  hi  lyii'pli'  'd  ti^-  le  iii  which  the  bacilli  ;u-e  fo\ind  in  great  num- 
bers, tlw  (■  liiteiils  tif  th'  crypts  c()ii<i<l  <.|'  yellowish-white  matter 
of  thick  ciin-isteiice.  wiilm  .'  odor,  and  coni.iining  numerous  tubercle 
Itaiilli.  b,iter  tin  lubercul.ir  proce«  ext.iids  into  the  deeiier  lymph- 
oid tis-iie.  giviii'j;  rise  trei|ueii!ly  to  cer\  leal  adenitis. 

2.  Theiommoii  f'>rm.  with  tyincal  tubercles,  gi.aii!  cells,  and  ca.^eous 
(legenenition  in  its  early  stages  i^  el,.inieteiizf  d  by  the  appenrance  of 
tubercles  under  the  epiiheliuin  and  around  the  crypts  in  the  form 
of  small  light  p-.irit-;.  The  tii<t  of  such  tubercles  generally  occur  in 
the  Iv.i.  )hatic  siiuises.     When  the  process  is  more  advanced  and  some 


/.vr/-/i.v.v^  Tioxs. 


701 


tiilKTclc-*  have  undorgono  civsoous  inotamorphosis  there  is  :.n  mva- 
si.,u  ..f  th.>  coiuioctiv..  tissu.'.  An.un.l  Xho.  e|)ith(>li()i<l  cells  there  is 
.,  recicri  ..f  intense  n.und-eell.'d  inHltration.  In  tlie  follicles  it  is  not 
„„ss^ble  always  to  separate  this  layer,  since  it  so.n.-tin.es  coalescs 
with  the  inhltration  of  the  iieiKhhoiinR  tubercf,  ami  is  soinewiiat 
uLscured  by  the  similar  ap!)earance  of  the  follicles  themselves  lh<- 
hlo„dv(^sels  are  numerous  and  show  a  marked  thickening  of  their 
a.lventitia,  particularly  in  the  neighborhood  of  the  tubercles,  t  luse- 
ous  metamorphosis  begins  generally  in  the  eentre  of  the  tubercle 
in  a  giant  cell,  or  at  times  in  epithelioid  cells,  h  urther  developmeni 
„f  this  leads  hnallv  to  ulcerations  which  attack  the  walls  of  the  crypts. 
Such  ulcerations  are  deeper,  their  floor  is  jovered  with  caseous  detii- 
t  us.  and  consists  of  epithelioid  cells,  among  which  are  varying  numbers 

(if  giant  cells.  .        , .  ,    ,,     ^       -i  i    „„ 

.{    \  diffuse  tulMTcular  infiltmiv-.  occurs  in  which  the  tonsil  loses 
almost  completely  its  normal  s.ructure,  and  is  reduced  to  a  mass  o 
..ndothelial,  ei.ilhelioid,  and  giant  cells  in  a  hbrous  n-ticulum  covered 
by  mucous  membrane.    This  represents  the  tubercular  tumor  above 

""rV/Iercm'.^vi.s  of  the  adnmid  may  occur  in  a  latent  form  without 
n,acroscoi)ic  alterations,  showing  histologically  tulx'rcles  singly  ami 
in  .rn.ups  on  either  side  of  the  crypts  in  the  lymphoid  tissue,  consisting 
„f  farge  epithelioid  cells  containing  in  their  centre  one  or  nu.re  large 
m.,nt  cells  In  vimng  individuals  the  cylindrical  epithelium  j-rcdonn- 
ir\u'<  but  in  older  p.'rsons  the  pav(>ment  tyix-  usually  replaces  it  <in 
ti„'  surface,  although  't  is  often  well  pres.-rved  in  the  dcM.per; portion 
uf  th<-  crvpts  The  exrcnsion  of  the  tubercular  foci  varies  in  diflerent 
,••,<(•<  bein"  at  times  isolated  and  at  times  conflu.  ..t.  Giant  eels 
.,',•,■  numennis,  but  bacilli  are  few.  This  la'ent  tuberculosis  may  be 
!l,c  tirst  and  exclusive  point  of  localization,  although  it  i.s  more  tre- 
nncntlv  associated  with  an  infection  elsewh<-re  m  the  body. 

The'follich's  at  the  bnyf  «-/  tkf  tomjue  are  at  times  aheeted  hy 
,ul„.,,.ular  ulcerations  which  extend  from  the  floor  of  the  crypt  to 
,!„■  iM.int  of  entrance,  and  develop  over  a  great  or  less  extent  of 
the  lingual  mucous  membrane.  . 

T'lhirrulosis  ,>l  the  lan/nx  occurs  as  a  more  or  less  diffuse  inhltra- 
ti„n  aiui  ulcerati.m,  or  as  a  circumscribed  tubercular  tumor.  In  the 
lir-t  instance  we  have  to  do  with  an  infiltration  into  the  suU  .ithehal 
nvers  of  the  mucous  membrane  of  tubercles,  which  may  undergo 
ra'-lv  caseation  an.l  pnwlu.-e  ulc.Tations  of  the  ov(>rlying  mucous  mem- 
brane (,r  mav  remain  for  a  longer  period  in  a  formative  state.  Ilie 
tiivt  ..uteome"  is  particularlv  j.rone  to  occur  m  those  situiitiuns  most 
subject  to  motion  an.l  friction,  such  as  tb'  interarytenoi.l  region, 
liie'mar-'in  of  the  vocal  cords,  and  the  epiglnttis.  W  hen  an  ulcera- 
ti,,M  has  once  formed  its  margins  fr.s,uently  undergo  proliferation. 
whi.'l,  mav  .attain  a  consideralile  six.-.  Thr  infiltrations  of  longer 
tinilin"  are  xeen  more  particularlv  in  the  neighborhood  of  the 
arvtenoTl-   and   the    ventricular    bands.     In   the    arytenoid   region 


702 


SOSE  ASD  THROAT. 


lesions  of  [Hrineuritis.  ijurtidiliirly  pcriiM'uritis  of  the  recurrent  nerve, 
liave  bcH-n  found  in  tiic  ecntre  of  the  intiltrated  tissue.  Tlie  essential 
nature  of  the  alterations  consists  of  a  compression  of  the  affected 
nerves  hy  granulation  ti-sue.  In  addition  to  the  thickening  of  the 
neurolenitna,  there  is  an  invasion  of  the  tissue  by  proliferatinji  con- 
nective-tissue cells.  The  inyeline  undertjoes  fiaKmentation,  and  later 
di.sap|M'ars.  Finally,  the  axi.s-cylinder  is  completely  ilestroyed.  This 
proliferation  is  accentuated  in  liie  region  of  the  ghuids,  where  nervous 
Hlaments  are  seen  to  give  off  nerve  t<'rminals  ruiming  b-tween  the 
acini.  In  and  around  tlie  tubercular  granulations  the  nerve  altera- 
tions appear  in  th(>  form  of  genuine  nervous  tulK-rcles  formed  by 
concentric  hlaments.  without  any  apparent  lesion  either  of  the  myeline 
or  of  the  axi.s-cylinder.  These  lesions  are  essenti.dly  proliferative 
and  hyperpliustic,  and  by  their  anatomical  character  and  develop- 
ment ai)]iroach  neuromata. 

The  (uberculnr  tumor  consists  histologically  of  a  tliffuse  tubercular 
infiltration  in  the  form  of  granulation  tissue  covereil  with  stratified 
pavement  epithelium.  The  granulation  ti.ssue  consists  partially  of 
round  cells  with  darkly  staining  miclei.  partlv  "f  epithelioid  cells, 
with  a  varying  number  of  giant  cells,  the  latter  exhibiting  \isually 
caseation.  This  granulation  tissue  is  dividi>d  into  different  areiis  l)y 
coimective-ti.ssue  trabecuUe  proceeding  from  the  submucous  connec- 
tive-tissue capsule. 

The  final  stage  of  the  tubercular  lesion  is  a  sclerosis,  more  or  less 
generalized,  consisting  histologically  in  a  thickening  of  the  interstitial 
fibrous  tissue,  principally  around  the  ves.sels  and  below  the  e])ithelium. 
If  ulcerations  have  occurred  previously  the  epithelium  is  w.-mting, 
and  the  surface  is  formed  by  scar  tissue.  In  the  lymphoid  ti.s.sues 
the  follicles  are  fre(juently  atrophied  and  degenerated. 

Lupus.  The  histological  conditions  (occurring  upon  the  mucous 
membranes  in  this  affection  are  essentially  like  those  in  true  tuber- 
culosis. The  unit  is  the  Iujjus  nodule,  which  invades  tlie  mucous 
membrane  irregularly  and  at  different  depths,  and  is  sharply  distin- 
guished from  the  surrounding  tissue.  The  nodule  is  coinpo.sed  of 
gramilation  tissue  consisting  of  fibrous  trabecula'  of  varying  size 
l)enetrated  by  numerous  bloodvessels,  large,  strongly  refractile,  deeply 
staining,  nucleated  cells,  together  with  smaller  cells  ami  (>pithelioid 
and  plasma  cells.  In  the  later  stage  the  blood  and  lymph  vessels 
exhibit  a  proliferation  of  their  adventitia  in  lus.sociation  with  pro- 
liferation of  the  connective-tissue  cells. 

This  stage  is  followed  by  n>trograde  metamorphosis,  which  is  mani- 
festeil  first  by  a  diminution  in  the  vascul;irity  of  the  centre  of  the 
nodule.  The  cells  become  inflated,  gramilar.  and  fragmented.  In 
ni.iny  pl.ices  there  appear  giant  cells  resembling  those  of  tulKTculusis 
anil  syphilis.  A  portion  oi'  the  lupus  ti.ssue  exhibits  an  organization 
into  younj;  connective  tissue  which  later  cicatrizes.  While  this 
process  is  going  on  in  some  nodules,  others  arise  in  the  vicinity  and 
extend  iis  far  as  the  submucosa,  with  the  result  of  producing  an  irregu- 


i    !i 


Pl.ATi:    XXI 


^v,- 


i-*-    . 


Pi  <  .lil.TiiiiM'  P.-r  !•  Ii.  111111111^.  Sfcii'iii  llu<iiii|li  ii  Spur- 
•  >l  ilif  Sfpliil  CiirUli\c|i',  -.Ipiwinc)  rii.  II 11 1 1  '  il  ,l:i--i  ^  himI 
NfW  I  \  -|i  iitiifi  I   C'iii  1 1  lii()i'.       H.i'i  I  lalc  ix  \  1 1  n-i''  .-1 1 1. 


IXfLAMMA  TWX^. 


703 


lar  .litTuso  infiltration  ..f  all  the  layrs  ..f  th.'  imu-ous  nion.  .run.-. 
This  niuv  un.l.T«u  .•icalrizati.m  ..r  Icul  t..  a  rnn...-ctiv.'-t issue  l.yi..T- 
,,n|.hv,  \vitl.  til.-  rrsi.lt  of  i.ro.l,.,-i..fl  .M.lai-.Ml  papilla'  with  .•orn- 
.pu'uiinsrlv  laPK-  iiifrpapillary  pro!., ..Rations,  llu-  .-pitli.-huni  ...a 
rshil.it  p'rolif.Tati...i.  vacuolization,  aii.l  ...ay  Ih'  thrown  ofi  1  >  . 
|,n„.,.ss  of  suppuration  a.ul.|."s.,ua.,.at.on.  This  may  ovntuallv  h.  a 
l,v  fibrous  contrai-tion  an.l  cicatii/.ation.  leaving  a  thin  supeiiicial 

^''sypWlis.  The  histolonical  unit  of  syphilis  ai.pcars  in  the  mucous 
,„eml.ranes  as  a  sharplv  eirc-umseril.e.l  aiul  (■..iiipact  mhit.ation  in 
,1„.  papilla-  a..,l  mucosa"  of  .oun.l  cells,  which  .lo  not  pass  into  i.er- 
„.:.„;-nt  ..rpans  of  conne.-tive  tissue,  l.ut  always  un.l.-rpo  n-tropnnlc 
.n.tamorphosis.  .-ither  l,y  ab-sorption  or  snppu.ati.....  This  ii.hl  la- 
li„r  has  a  diaract.-ristic  .lir.-ctioii  an.l  metho.l  ol  projiress.  a.-c.nl  nR 
,„  which  the  infiltrati.,.,  on  one  side  c.nstantly  .-nlarp-s.  an.l  ..n  the 
„.|,.T  si.le  exhibits  retrofira.le  .netam..ri.l.o.sis.  The  onlarjiement  and 
,hr  r.-troijressi..n  tak<-  place  always  in  a  centnfupa    manner. 

riie  initial  l.'si..n  mav  occur  in  three  forms  ui-oii  the  tonsil,  namely, 
th,.  erosive,  the  ulcerat'ive.  an.l  the  anpnous.  Our  histological  infor- 
iiK.tion  regarding  these  vari.-ti.-s  is  meagre. 

S.-con<larv  lesi.ms  in  the  tonsils  an.l  neighboring  mucous  mem- 
l.ruies  are  "seen  histologicallv  t..  consist  of  an  infiltration  of  endo- 
,l,:,h,.d  an.l  plasma  c.-lls  which  are  situate.l  i>>larH';proui.s  together 
i„t.Msp.>rsed  iK^t ween  the  loo.s<-ne.l  epithelial  cells.  Many  of  h>  latter 
exhibit  a  nuclear  fragment  at  i.m.  The  pajnlla-  are  enlarged,  the  blood- 
vessels are  .lilated.  the  f..rn.er  being  infiltrate.l,  and  the  latter  en- 
velou(-d  with  a  thick  mantle  of  roun.l  cells. 

Tlu-  palatal  muscles  mav  .show  an  inv..lv.-mont,  consisting  of  an 
i„fil.rafi..n  ..f  th.-  bloo.lve'ssels  ..f  the  perimysium  corresponding  to 
,l„.ir  arrangement  ar.nm.l  the  primary  muscle  bundW,  ui.  to  luir 
l„nnching  an.l  final  t.-rmination  in  the  capillaries.  I  here  is  a  so  a 
nrnliferation  of  the  p..iimysium  its<-lf.  In  assoc.ation  with  these 
Ui„ns  giant  cells  may  ..<-cur  in  th(>  sarcolemma,  and  the-  transverse 
Miiations  of  the  muscles  may  di-ajjpear.  ,       ,     ,  w 

Tertiarv  l(>sions  .-.re  supi)..se.l  t..  arise  from  unabsorbed  exudates 
|,.|t   b.hii.d   from   the  s.-cun.lary  stage.      Wo  may  distinguish  the 
,.,n„na  an.l  the  granuloma,  th.-  latter  having  been  report.-.  1  only   rom 
!he  tissues  „f  the  nose.     The  gumma  c.nsists  in  all  situati.ms  ol  the 
-iiiw  histological  .■lements.  nain.-ly,  a  n.'.re  or  less  comi.act  aggre- 
■atiim  of  proliferating  en.loth.-lial  and  connective-tissue  cells,  epi- 
•hrli..id  cells,  an.l  giant  cells.     The  blo...lv.-ssels  in  the  v.cmity  shew 
,  !hick.-ning  ,.f  tlu-ir  a-lventitia.     H.-tn.gra.le  metam..rphosis  takes 
,!:,.■,•  bv  ca.s.-ation,  b.-ginning  in  the  giant  c.-Us  an.l  epithelioid  cells, 
xt.-ii.ling  periptierallv,  and  leading  to  .-xfoliation  of  the  overlying 
mi.'ous  membrane.  ,         , 

The  granuloma,  which  apiiears  clinically  in  the  nose  as  a  broad  or 
.,.,!unculate<l  tumor  .f  varvinj;  size,  situated  upon  the  mucous  mcm- 
■lane    of  a  friable  consistence,  but   without   tendency  to  central 


.-.JW.^yj] 


7(^i 


XOSE  ASD  Til  HO  AT. 


softoniiip,  is  sopii  histoldRically  to  consist  of  an  ondotliolial  and  con- 
nect ivc-t  issue  |)rolif<'rati(»n,  witii  piant  ceils  atu!  tliicl^eiiinn  of  tiic 
vessel  walls,  in  the  younjter  stap>  closely  resenihling  guniinata.  Later, 
tliroujtii  a  swelling  of  the  deeply-situated  tumor,  the  mucous  mem- 
brane is  forced  out  above  the  original  level,  often  IxToiniuR  [M-dun- 
culated.  Ketrograde  metamorphosis  occurs  in  the  older  portions  of 
the  jirowth,  namely,  at  its  ])eriphery,  in  the  form  of  oblitcrative 
endarteritis  with  thrombosis  and  necrosis. 

A  form  of  sy|)hilitic  lesion  occurs  at  the  biise  of  the  tongue  as  an 
atrophy  of  the  linjiual  follicles.  This  is  due  either  to  an  intorstitiiil 
iiitlammatioti.  leading  to  a  diminution  in  the  number  and  diameter 
of  the  linsiual  follicles,  or  to  scar  formation  following  tertiary  lesions 
of  the  mucous  meml)rane. 

Leprosy.  In  leprosy  of  the  upper  air  j)assages  four  stiiges  may  Ih' 
distinguished:  the  prodromal,  infiltrating,  ulcerating,  ai'd  the  cica- 
trizing. The  prodromal  stage  may  be  extremely  prolonged.  After 
marked  infection  and  swelling  of  the  mucous  membrane  the  di.sea.-e 
attacks  particularly  the  septal  cartilage,  being  freiiuently  superim- 
(loseil  upon  a  rhinitis  sicca  anterior.  For  this  reason  nasal  hemorrhage 
lias  been  fnM|ucntly  given  as  a  prodromal  sym])tom  of  lejirosy. 

The  stage  of  inhltration  consists  of  a  firm  swelling  and  reddening 
of  the  mucous  membrane  of  the  sej)tuni  lus  well  as  of  the  turbinates, 
associated  witli  a  liyixTsecretion.  at  (irst  serou-;,  later  purulent.  The 
infiltrations  m;iy  ri'inain  diffuse  or  pass  to  the  formation  of  individu^tl 
no<lules  ranging  from  the  size  of  a  pinhead  to  that  of  a  pea.  This 
infiltration  shows  a  tendiney  to  nipid  necrosis,  most  fre(|uently  in 
the  anterior  portion  of  the  cartilaginous  septum,  and  attacking  at 
times  the  bone  secondarily,  either  by  caries,  or  at  time--  by  osteo- 
porosis. There  is  an  enormous  crust  formation,  extremely  hard,  and 
a.-:si>i-iated  with  fetor. 

The  stage  of  cicatrization  follows  the  completion  of  the  ulcenitivc 
process,  and  leads  to  the  extensive  cutization  of  the  mucous  meni 
brane.  the  surf.-ice  of  which  now  resembles  dry  leather,  is  ana'inic 
and  whitish  yellow  or  brownish  red.  The  turbinates  are  greatly  re- 
duced and  sometimes  absent.  Synechia  or  atresia  fre(|uently  exist 
associated  with  local  .'ina'sthesia.  ,\t  times  exten.<ive  suprrficial 
iilcenitioMs  occur  as  the  result  of  trophoneurotic  disturbances  in 
the  regi(,n  of  the  trigeminal  nerve,  which  begin  with  the  outbreak  n) 
follicles  re.<eMibling  those  (if  herpes  and  jjcmphigus. 

Mycosis  Fungoides.  Hi.'<tologic;illy  this  process  consists  of  .in  infiltn- 
tion  of  ly|iical  round  cells  |irocccdiiig  froiTi  the  vessels  in  the  chorion 
and  subcut;uieous  tissue.  This  infiltnition  is  deposited  in  a  fine  net 
work  of  lejic'ite  fibrill.iry  comiei'tive  tissue.  The  e|)it!ieliuni  appe.'i.' 
at  \\v>\  proliferating,  growing  into  papilke,  later  flattened  over  tl>" 
nodules.  The  round-celled  infiltration  appears  aggregated  In-twe.  n 
the  coimective-ti.-isiic  si)aces  in  the  form  of  foci  of  varying  size,  lik  ■ 
a  nodule,  whicli,  however,  toward  its  |)eriphery  a,ssunies  again  ti'' 
character  of  ;in  infiltnition. 


ISFLAMMATIOXS. 


706 


Thcso  prowthfl,  rosoinbling  somewhat  lymphoid  strncturcs  in  upiM'ur- 
aiicc,  iilthoujjh  no  foliiclrs  arc  rccoKniziihic,  occur  upon  the  mucous 
nicnihrancs  of  th''  throat,  ami  may  i)ccoinc  suixThciaily  ulcerated. 
Leptothrix  Myc«ri«.  The  h'ptothrix  liuccalis,  whicli  occurs  nor- 
mally in  tiio  moi;th  :is  ii  saproiihyte.  jissmiies  at  times  pathogenic 
properties.  The  nmcous  membranes  of  the  lymphoid  tissue  of  tho 
fauces  and  of  the  larynx  and  (esophagus  when  jtreatly  depreciated 
in  vitality  as  the  result  of  |>reviuus  prostraiint;  disease,  may  become 
susci-ptilAe  to  tiie  development  cf  the  le|)t.)lhrix  buccalis,  the  threads 
of  wiiich  mav  penetrate  between  the  upixT  epithelial  layers  and  into 
the  orihce  of  "the  jjlands.  Tiie  invasion  of  tlie  tissues  by  the  mycelium 
may  l)e  followed  by  a  secondary  involvement  of  (,ther  pathojiemc 
.M<;anisms,  such  ti!<  the  pyogenic  cocci  and  the  diphtheria  bacillus. 

Structures  occur  at  times  in  the  ton.sils  having  a  certain  resem- 
l.hince  to  actinomvces.  The  structure  is  of  botryoid  shape,  v  th  a 
diameter  of  0.5  min.,  aiijM'aring  when  stained  with  alum  carmine  an(l 
tlun  by  (Irani  a.s  a  dark  b'ue  more  or  l(s<  compact  network  of 
threads  lying  in  a  tine  granular  substratum,  wnich  partakes  of  the 
carmine  .stain  with  irregular  intensity.  Toward  the  periphery  of  the 
structure  the  threads  radiate  omward  and  exhibit  nodular  thicken- 
ings, due  to  irregular  clumps  of  threads  and  c()cci.  Toward  the  centre 
tiie  threads  cross  each  oilier,  are  much  shorter,  and  resemble  sharply- 
iieiit  rods.  Tre(>-like  liraiichings  of  the  threads  are  common,  pyr- 
ticularlv  toward  the  periphery. 

Huge  regards  tlie.se  structures  as  lielonging  to  the  group  of  actino- 
myces,  which  are.  however,  not  identical  with  human  actinomyces. 
Tl'iev  belong  probalilv  to  the  groui)  of  leptothrix  buccalis  and  are 
probably  closely   relate(l  to  a  form  of  streptothri.v  ilescnbed   by 

Sbarazes.  .,        ,     , 

It  is  possible  that  the  mycosis  ot  the  tonsil  and  t>harynx  may  oe 
proiliiced  bv  the  growth  just  descrilied. 

Rhinoscleroma.  In  tbe  nose  and  l.iryx  th"  .-ifierte.!  tissues  are  swn 
histologicidh  10  consist  .i'  c-rtain  typical  .■!emen!ary  lesions.  Tiie 
-ubstai.ce  of  the  swelling  is  com|)osed  of  large  |.l;!sina  cells,  irregu- 
larly distrib  ii.'d  in  all  layers  of  the  mucous  membnine  and  m  the 
suliimicous  li,ssue.  Tliev  accompany  the  bloodvessels  in  the  new 
iu.rtioiis  of  the  growtii.  "The  plasma  cells  do  i-  i  contribute  directly 
id  the  hviiertrophv.  but  it  is  iK)ssible  thai  they  iK-c.me  cliang«>d 
partlv  into  spindle"  cells,  and  then  give  rise  to  the  formation  ol  new 
lihriliary  tissue.  Two  forms  of  retrograde  n.etamorphosis  occur  m 
the  plaMiia  rrlls.  These  may  Ik-  transformed  into  swollen,  liydropic, 
>.>-c.dled  Mikiilic7.  cells,  or  "into  hyaline  degenerated  cells  probably 
i.lentical  with  tlie  so-called  Hus.sel"'s  fuchsinopliiles,  described  under 
colloid  degeneration.  The  hydropic  cells  lie  <'lose  together,  have  a 
distinct  contour  and  springy  cytopliusm  dilated  iiit<.  largo  masses  m 
which  there  is  a  but  slighily  refractile,  faintly  staining,  h.ilf-fluuj 
iiKLss  within  a  small  facetol  n"uclens.  In  the  vicinity  of  these  typical 
degenerated  cells  transition  cells  occur  which  are  ^^een  to  l)e  derivetl 


I»^  '»)( 


'•   'Hi 


n 


'it! 


III. 


"nij 


XDst:  AM)  Tjino.ir 


llMiil  .l.'Kflionilr.l  |.la.s|lia  crlU.  li,  ll,i>  >|;,|;r  ,  ;h  ufl,  ,,  «•<-  from 
MX  I"  .'ifjlit  liacilli  ill  the  cells  near  tin-  iiuclnis,  «|,i,li  ij,.  always  .-it 
iv>;iilar.lislaiiccs.  This  stajre  a|.|.cais.  Iiowrvn  .  lu  !).■  inpi.ljy  tinislir.l. 
ami  whi'ii  llic  cfll  iiii'iul.raiir  hivaks  the  ||iii,|  ,  rii.ni-  inp'tii.T  willi 
S..II1C  of  the  liacilli,  liii.i  an  rxit  ami  till  ilic  maivsi  lyiii|.li  -pacs. 
'I'licsc  cilis.  arc  however,  iniiinalely  relal.-.|  to  the  .lii'eei  action  ,,1' 
the  liacilli.  Ill  all  iii>taiices  the  peculiar  ca|isiile  liacillii<  is  present 
The   cells  which   show  hyaline   .lejjciieralioii   occur   iisiiallv  inilaled. 

rarely  in  small  collections.      riie\-  corres| |   tu  (he   hyaliii.'  ilet'en- 

erate,!  cells  found  ill  other  chnuiic    intlammatioiis   of'  the    iinic,.iis 
i; '  mliraiic. 

Glanders.     This  :ilTecti,,n  appears  in  the  iio.se  and  larviix.  usually 
in  tlie  form  of  nodules  .md  nodes,  n.ore  rarely  as  ditTiiM    iiifiitrali.iiis 

coll-istinj:  of  elii.sely   .applessed    roliml   cells   without    jriilllt    rp||s.        IJie 

nodules  suppurate  nipidly.  and  the  component  p<ilviiuclear  leucocytes 
cxhiliit  frastmentatioii  of  their  nuclei.  In  tln'  ii('iKhliorlio<id  of'thc 
nodules  the  ti.ssiie  shows  fieciueiitly  lieniorrhajiic  inliltnition.  If  the 
nodule  lies  in  the  neichliorhood  of  il„'  surface  of  the  mucous  niem- 
hrane  there  occurs  e.irly  an  inliltnition  of  pus  corpuscles  into  the 
(■|iitlieliiim.  ;is  the  result  of  wliii-h  small  pus  foci  arise.  Later  these 
foci  coalesce  and  frivc  rise  to  the  formation  of  ulcerations.  During 
the  early  stajre  of  the  nodule  iii.iiiy  liacilli  lyinp  more  or  less  in  grouiis 
arc  found  in  it.  When  the  m.duie  supimrates.  however,  the  miml)cr 
of  liacilli  diminishes,  aixl  in  chronic  glanders  they  ,ire  not  to  be  demon- 
strated microscopically. 

Chronic  Inflammations  with  T«sndency  to  Hypertrophy,  rh ionic 
mllamiuatioiis  of  the  upjier  air  jia.-.sa^'es  may  lie  diviileil  histologically 
for  piirpos  s  ,,i-  cmveniemv  into,  first,  super*;,;  d  inflammations  df 
the  mucous  memlinine:  second,  inflami;iaii..ns  affectin<;  the  paren- 
ch>m:K  third.  infl;iimiiatioi,s  inv-'ving  also  the  periosteum  or  pi  ri- 
cn.i'  i:iti  uaml  iioiie.  Sii'  'i  dni-i  iiisare  toa  ciTtain  extent  .irl.itrarv 
shic.  ilitTereiit  .lejrrees  of  tiie  afTectioii  may  he  found  in  il.e.sanu- 
tissue  in  adjoining  p!  ices.  In  spite  of  the  apiiarcntly  distinct  picture 
presented  hy  these  jirocesses  in  the  iio.se.  pharvnx.  and  larviix,  a 
detinite  iiiorpholoffic.al  unity  i.-  nvcaled  hv  a"  histoln<iical  ".study. 
.\!tliou>;h  an  .iccoiin!  hased  upon  the  regional  distriliiitioii  of  the".e 
aheratiniis  necessarilv  involve-  the  repetition  of  histological  terms  to 
a  consideniMe  exfnt.  it  appears  hetter  adapted  t,,  present  clearly 
our  existin-r  inlnrm.'  (im  We  sh;ill  therefore  consider  the  cliaiiRi^ 
as  thiy  oecm  m  their  dilTerent  points  of  localization  in  the  iio.se. 
M;isopls;irynx.  pharynx,  and  Larynx. 

Nose.  In  supei(ici;il  inflammation  ;iii  infiltration  of  mononuclear 
neiitiop.i  ies  ;iiid  plasma  c<'Ils  occ'iis  in  the  adenoid  l.iver  and  in  the 
vicimfy  of  the  liasenieii!  meniliiime,  localized  particularly  around  the 
smalier  hi,,,  dve-sel.-.  and  iho  efferent  dm  ts  of  the  plaiids.  .Mast- 
zelleii  are  usually  present,  and  there  is  an  incre.n.se  in  the  mmiherof 
cells  siiMwiiiK  folloid  (h"<rciieration.  The  papilhe  of  the  miicmis  mem 
braiie  may  he  h-nfrthi-ned  int<i  wart -like  |.roiiiineiices,  ;ls  the  result 


ISFLAMMATIOSS. 


707 


I  tliri'c  factor^:  first,  |)r(ilifir!iti«iii  of  the  fibrous  tissiio:  sctoihI, 
prulitrraliun  ..I'  tin-  coluinnar  rdls  of  the  siirfacf  ami  of  thv  tells  of 
tlif  iliK'ts  of  tlif  >:lnnil-  1)\  s.«piu«'iitation  parallel  to  llit-ir  lotiji  axos: 

iliini.  .,  iliiataii f  ih.-  cliirf  .I'lcls  of  thr  ^lan.ls  ami  their  eoiimiuiii- 

(■:iiiii).'aciii  rhisroinliiiiatioii  of  |iliemimeiia  [.nKliices  tlie  inullxTrv 
hyliertropliii  -  of  liie  inferior  ttirhinated  iiolie.  Associated  with  lhe>e 
<  iiatijres  i-  tlie  pre>.  nee  of  a  eertaiii  amount  of  (eilema  in  the  tissni's, 
ino-t  riiarke.1  in  the  anterior  end  of  the  mid. lie  turhinale  and  in  the 
-inuses.  irivinit  rise  to  the  eireuniserilM-d  hypertrophies  known  as 
ixihijii.  The  stroma  of  these  Rrowth<  consists  of  a  more  or  less  loose 
coiinirtive  liss\ie.  the  meshes  of  whieli  contain  round  <'ells  and  alhii- 
minous  fluid.    Tliey  are  coven'd  hy  a  cylindrieal  epithelium  whieh,  in 

Fi.i  :t.'j9. 


Ilyinrlrophli'  iiilUmiiiatioii  of  ml.lill.'  mrblimU-.  IVIow  the  coliimiwr  epithelium  1«  «  luone  cwle- 
i.iuloii!.  (•..imiTtlv..  lisMie  with  «  KlUriliK  bUifKlvtwl»  iilkI  iHcrm.1  sUuiamur  ,lucls.  Below  this  if  a 
.Un»r  imiiiectivc  tis>\ie  Willi  iimcm«  k1hihI>.  l.liNKlveaKl*.  iiii.l  iiitiltratliig  ivlln.  The  bone  preaenU 
irri'Kular  lliiikeiiliids  mid  pnicusBcs  iliarailiTislic  of  hyjierpliuilk'  iwrioetltis. 


p!ac(>s  exposed  to  external  irritation,  tends  to  bocomo  altered  into 
pavement  epitliermm.  The  glands  of  the  frrowth  may  be  increased 
ii  number,  having;  in  the  majority  of  ca.ses  the  character  of  mucous 
L'linds.  At  times  there  occur  with  thorn  so-called  serous  glands.  Tlie 
■icini  of  the  elands  often  show  cystic  dilatation,  which  may  at  times 
lie  so  niaiked  as  to  form  a  cyst  "occupying  the  greater  jjortion  of  tlie 
polvp.    (Fig.  :i.'}f».) 

Two  forms  of  degeneration  are  found  in  the  chronic  inflanunatory 
•  iiresses  under  consideration,  first,  mucous  degeneration  of  ,he  epi- 
, helium  of  tiic  surface  and  of  the  ducts  of  the  glands;  second,  a  colloid 


MICROCOPY    KESOIUTION    TEST   CHART 

lANSI  and  ISO  TEST  CHART  No    2i 


1.0 


I.I 


^  lis 


11-25   IIIIII.4 


m 

2.2 
2.0 

1.8 

1.6 


M  APPLIED  IIVHGE     In 

5r^  "^ochesttfr.    New    vofi,  1*609        vSA 

"«ag  (716)    482  -  0300  -  Phone 

^=  [7\6)   298  ■   '5989  -  f o- 


708 


NOSE  ASD  TIIHOAT. 


or   hyaline  degeneration  of  the  migratory  cells  of  the  connective 
tissue. 

Where  the  inHainnuition  is  more  deeply  situated  the  infiltration 
extends  to  the  glandular  layer  and  to  the  periosteum,  frecjuently 
infiltrating  the  germinal  layer  of  the  latter.  All  the  medullary  spa<-<"s 
are  more  or  less  completely  Hlled  with  a  compact  cellular  inhitration, 
particularly  in  the  vicinity  of  the  vessels.  Clinically  this  deep  inflam- 
mation comprises  ca.ses  of  marked  degeneration  <)f  the  middle  tur- 
binate and  chronic  ethmoidal  sinusitis.  In  such  ca^es  the  inflam- 
mation has  probably  extended  from  the  periphery  into  the  ileeper 
portions  of  the  tissue  and  the  medullary  spaces. 

Ethmoiditis.  The  inflannnations  of  the  bony  ti.ssue  in  the  nose  are 
observed  in  the  ethmoidal  labyrinth  in  two  forms,  first,  a  distinct  new 
formation  of  bone;  second,  an  absorption  of  bone.  New  formation  of 
bone  is  the  result  of  proliferation  of  the  germinal  layer  of  the  turbinate. 
Large  imcleated  cells  are  .separated  from  the  infiltrated  germ  layer 
and  deposited  as  an  osteobhistic  layer  upon  the  oUl  bone.  From  this 
osteoi)lastic  layer  a  compact  intermediate  substance  or  osteoid  tissue 
is  formed  over  a  large  portion  of  the  protoplasm  of  its  cells,  which 
encloses  the  rest  of  th(>  osteoblasts  in  irregular  cavities  divided  by 
prolongations.  This  osteoid  tissue  lies  partly  diffuse,  partly  in  cir- 
cumscribed prominences  on  the  old  bone,  giving  rise  to  a  diffuse 
thickening  of  the  latter  or  to  prickle-like  bony  excrescences.  The 
new  formation  of  bone  coiLstantly  progresses  by  the  (le])osit  of  new 
layers  of  osteoblasts  on  the  osteoid  tissue.  In  the  same  v.av  there 
may  be  ob-served  a  new  formation  of  bony  substance  proceeding 
from  the  medullary  cavities  by  adhesion  of  the  cells  of  the  medulla 
to  the  old  bone  as  an  osteoblastic  zone,  which  after  the  formation  of 
an  intermediate  substanc(>  becomes  osteoid  tissue.  Here  and  there 
the  medullary  spaces  apju-ared  narrowed  by  the  new-formed  bone. 
Clinically  these  cases  are  characterizi'd  by  diminished  resistance  ami 
a  crackling  sound  when  the  tissues  are  touched  w-th  the  probe. 

The  other  alteration  in  which  absorption  or  rarefyii.g  osteitis  occurs, 
is  characterized  by  the  occurrence  of  numerous  giant  cells  or  osteo- 
clasts in  excavation.-?  of  the  bony  lacuna".  These  vary  in  luimber 
according  to  the  degree  of  absorption  which  is  takitig"  jjlace.  The 
trabecuhe  become  generally  thinner  by  the  erosion  of  the  osteoclasts, 
so  th.'it  the  medullary  spaces  continually  increase  in  size.  a:i(l  the 
bony  trabecuhe  become  thinner.  In  advanced  stages  the  erosion  of 
numerous  trabecuhe  may  result  in  the  coalescence  of  adjoining  med- 
ullary spaces,  producing  a  cavity  which  by  continued  progression 
in  the  [irocess  may  become  a  bony" cyst.  Such  a  cyst  is  usually  lined 
with  columnar  riliatfd  epithelium,  contains  no  glands  in  its  interior, 
but  a  certain  number  of  arterioles,  veins,  and  microscopic  erectile 
tissue. 

It  is  difficult  to  state  why  in  one  case  hypertrophy  of  the  bone 
predominates  and  in  another  j.bsorption.  It  is  pos.sible  that  the 
i.illannnatory  infiltration  which  penetrates  the  substance  of  the  tur- 


INFLAMMATIONS. 


709 


binates  may  load  in  some  places  to  a  stasis  from  coinpression  of  the 
veins.  On  the  other  hand,  a  congostion  c.f  the  periosteum  excited 
by  the  infiltration  may  produce  hypernutrition  by  which  the  hyper- 
plastic growth  arises.  •  •       .  t.. 

In  a  few  instances  polypi  have  been  founil  containing  bone.  In 
ino^t  of  them  it  was  found  that  a  single  bony  tube  extended  through 
the  whole  polyp,  although  in  some  cases  there  was  a  branchmg, 
b.-ginning  at  the  point  of  attachment  of  the  pedicle  These  tubules 
.jimved  a  well-developed  medulla.  The  condition,  therefore,  was  an 
actual  hyperplastic  structure  due  to  a  proliferation  of  the  penosteum 
of  the  turbinate  in  association  with  rarefying  osteitis. 

Neither  rarefying  osteitis  nor  hyperplastic  bony  alteration  is  essen- 
tial to  the  formation  of  polyps.  The  ix)lyp  is  an  crdematous  hyper- 
tiophv  of  the  mucous  membrane  in  which,  just  as  in  the  case  ot  hrm 
hypertrophy,  the  process  may  l)e  limited  to  the  superficial  layers  or 
eitend  to  the  depths.  It  is  wholly  immaterial  whether  this  inflam- 
matory hypertrophy  is  excited  by  a  diffuse  catarrhal  involvement  of 
the  whole  nasal  mucous  membrane  or  of  only  a  portion  of  it,  or  by 

''"in'nasa'r polypi  the  existence  of  nerves  has  been  demonstrated, 
although  in  general  these  structures  are  poor  in  ner\-e  fibres.  Ihey 
•ire  characterized  by  several  peculiarities,  extending  over  long  dis- 
tances without  giving  off  lateral  branches,  the  nuclei  showing  a  narrow 
and  elongated,  somewhat  irregular  shape,  lying  extremely  close  to 
the  ner%-es,  so  as  to  give  the  impression  of  for  mg  a  swelling  ot  the 
nerves  themselves.  From  the  course  of  the  nerve  fibres  ind  the 
iH-culiar  arrangement  of  the  nuclei,  it  is  apparent  that  we  have  to  do 
with  newly  formed  ner\-e  fibres.  Granular  cells  and  individual  ter- 
n.inal  corpuscles  were  not  observed.  The  fibres  terminate  in  the 
ti.<suc  of  the  polyp  itself,  and  do  not  extend  into  the  epithelium. 

Hyperplastic  Perichondritis  and  Periostitis  of  the  Septum.     The  anat- 
omy of  sinirs  and  deviations  of  the  septum  does  not  come  within  the 
iire^ent  consideration.     Certain  histological  lesions  are,  however  com- 
Inon  to  all  the  varieties,  chief  among  which  may  be  mentioned  hyper- 
ui'i^tic  perichondritis  and  periostitis.     Examination  of  a  septal  spur 
or  of  a  healed  fracture  of  the  septum  shows  in  many  cases  at  the 
,,oint  of  convexity  a  heightened  proliferation  of  the  cells  of  the  peri- 
(•liondrium  or  periosteum.     In  the  case  of  cartilage,  the  linear  nuclei 
of  tiie  germinal  layers  increa.se  in  thickness,  becoming  triangular  or 
-tcllate     Simultaneoasly  the  protopliism  of  the  cell  is  observed  to 
retract  from  the  cell  wall  and  become  gathered  around  the  nucleus, 
with  the  result  of  creating  an  elongated  or  oval  deficiency  in  the  cell. 
The  acidophilic  fibrous  tissue  in  the  vicinity  becomes  at  the  same 
time  more  homogeneous  and  translucent,  and  assumes  a  distinct  tinge 
with  t)asic  dyes.    These  phenomena  occur  irregularly  at  the  margin 
of  the  cartilage,  with  the  result  of  producing  prolongations  and  excres- 
<'(>nc('s  of  the  intermediate  chondroid  tissue.     As  the  latter  becomes 
older  the  cells  resemble  more  and  more  those  of  true  hyaline  cartilage. 


» 


If 


h'l);: 


n  '.- 


i  i 


no 


NOSK  AXD  THRO  AT. 


In  tho  case  of  bone  analogous  alterations  are  found  to  occur,  the 
details  of  which  have  been  previously  described  in  t'  •  account  of 
hyperplastic  periostitis  of  the  ethmoid.  At  the  line  i  racture  the 
fragments  are  separated  by  fibrous  tissue  traversed  ..y  bloodvessels 
of  varying  size.  In  this  situation  the  proliferation  of"  the  perichon- 
dreal  and  periosteal  layers  ))ro(iuces  a  diffuse  deposit  of  the  inter- 
mediate substance.  The  writer  has  obsened  the  formation  of  a 
sesamoid  fragment  of  cartilage  at  the  apex  of  convexitv  of  a  trau- 
matic deviation  of  the  se])tum  situated  in  the  fibrous  tissue  between 
the  mucous  membrane  and  the  line  of  apposition  of  the  fragments. 
The  mucous  membranes  covering  the  convexity  of  the  devia-tion  con- 
sists of  stratified  pavement  epithelium,  behnv  which  is  a  nmco.sa 
showing  more  or  less  tendency  to  pa])illary  hypertrophv,  except  at 
the  apex  of  the  convexity.  In  this  region  a  thinning  of  the  mucous 
membrane  frecjuently  occurs,  and  there  is  no  evidence  of  glands 

Hypertrophy  Id  the  Nasopharynx  and  Pharynx.  Chronic  inflanuna- 
tions  of  these  two  regions  may  be  advantageously  considered  to- 
gether. We  I!  make  a  secondary  division  into  chronic  inflannna- 
tions  of  the  lyii.,,hoid  tissue  and  of  the  mucous  membranes.  Although 
these  two  structures  are  usually  affected  simultaneously  or  in  ii.s.so- 
ciation.  an  indeix-ndent  involvement  of  each  may  occur. 

The  lymphoid  .structures  comprise  the  jjharyngeal  tonsil,  the  col- 
lections of  lymphoid  tissue  in  the  vicinity  of  the  Eustadiian  tubes, 
the  faucial  tonsils,  and  the  lymphoid  tissue  on  the  posterior  pharyn- 
geal wall.  Chronic  inflanunation  of  these  lymj)hoitl  structures  j^re- 
sents  histologically  essentially  identical  pictures.  In  all  we  have  to 
do  with  a  unit  of  structure,  the  lymphoid  follicle,  covered  with  nmcous 
membrane  of  varying  character,  which  in  places  where  the  follicles 
are  aggregated  in  large  numbers  .sends  down  invaginations  between 
them.  The  i)henomena  represent  a  heightening  merely  of  the  normal 
processes,  in  that  the  endothelial  cells  of  the  reticulum  are  seen  to 
proliferate  more  actively,  giving  rise  to  epithelioid  cell<  with  phago- 
cytic jjroperties.  The  follicles  exhibit  an  enlargement,  as  the  result 
both  of  a.n  increased  number  of  their  lymjjhoid  cells  and  the  endo- 
thelial cells  of  the  reticulum.  The  nmcous  membrane  of  the  crypts 
ai)pears  looser  and  with  larger  interspaces  than  normal.  Lvmphoid 
and  plasma  cells  are  found  here  in  unusual  abundance  making  their 
way  into  the  crypts.  The  rypts  are  filled  with  amorphous  detritas, 
exfoliated  epithelial  cells,  leucocytes,  and  bacteria. 

In  comparing  the  i)ictures  presented  by  chronic  lymphoid  hyper- 
trophy with  tho.se  seen  in  acute  inflammation,  it  is  to  be  noted  that 
in  the  former  condition  the  alterations  consist  pre-eminently  of  endo- 
thelial proliferation  with  but  relatively  slight  increa.se  in  tlie  number 
of  lymphoid  cells,  while  in  the  latter  instance  the  reverse  is  the  case, 
and  although  we  see  here  increased  endothelial  proliferation,  the 
enormously  increased  number  of  lymphoid  cells  in  the  follicles  and 
adj'iining  lymj)h  sinuses  and  crypts  gives  the  cfiaractcristic  feature 
of  the  picture. 


lyFLA  MMA  TIOXS. 


711 


Tho  histological  chans.-s  which  have  just    .......  doscnbo.l  as  <.ccur- 

ring  ■u^  tho  faucia!  f.nsils  arc  repeated  without  essential  points  of 
.liffereiice  in  the  i)harvngeal  and  in  the  lingual  tonsil. 

Th<>  chn.nic  inHan.n.ations  of  the  pharyng.'al  mucous  meinl.rano 
hav  not  been  studied  histologically  with  the  same  degree  of  care  iis 
analogous  changes  affecting  the  larynx,  and  our  histological  infor- 
mation is  so  meagre  that  it  seems  better  to  refer  the  rea.ler  o  ho 
account  of  chronic  .liffuso  hypertrophic  laryngitis,  he  histological 
.lescription  of  which  may  be  assumed  to  apply  to  the  processes  in 
the  jiharynx. 


FIO.  360. 


»ei«ratlng  the  muscles  of  the  part  from  the  overlyi.ig  tissue. 

Chronic  Inflammation  of   the   Pharyngeal  Recess  or  Bursa.      It   is 

nrobable  that  independent  inflammatory  disease  of  tho  bursa  phar- 
V  K"  extremely  rare.  Tho  so-called  T.^rnwaUlfs  disease,  a  name 
wl'Sdl  wJs^Ipphetl  to  chronic  catarrhal  inflamniatioii  of  the  structure 
in  .luestion.  hiu.  been  shown  not  to  occur,  at  lea.'.t  the  "so  of  this 
tern',  has  been  greatly  restricted  Catarrhal  processes  f  /he  narn^ 
pharvnx  involve  either  tho  whole  mucous  membrane  of  the  vault 
l,r  omain  clefts  in  the  mucous  membrane,  by  preference  the  central 
cleft  of  the  adenoid,  which  is  also  the  deepest  as  a  rule.    The  fos^o; 


712 


yoSE  AXD  THJiOAT. 


of  Itosenniuollor  may  rptain  socrotion  to  a  marked  degroo,  particu- 
larly when  they  are  divided  by  folds.  Cases  occur  of  atrophic  catarrh 
localized  exclusively  in  the  vault  of  the  pharynx. 

Chronic  Laryngitis.      Under  the  influence  of  recurrent  attacks  of 
acute  catarrh,  the  mucous  membrane  of  the  iarvux  is  j)rone  to  take 
on  hypertrophi  •  changes,  which  vary  markedly  according  to  the 
pomts  of  localuation.     The  small-celled  infiltration  dejwsited  by  the 
acute  mflammatiuTi.  as  the  result  either  of  unhygienic  su.    .undings 
or  abnormal  con.litions  of  the  i-atient,  does  not  attain  complete 
absorj)ti()n.  but  becomes  a,ssociated  with  the  jmjliferation  of  con- 
nective tissue.     Each  attack  increases  the  formation  of  new  tissue 
Ihe  histological  manifestations  are  essentially  similar  in  all  the  forms 
the  si)ecial  features  of  each  of  these  being  ^ven  by  its  localization! 
Although  the  process  of  chionic  inflammatory  hypertrophy  may 
affect  the  larynx  diffusely,  it  is  apt  to  attain  its  gre.-.ifst  development 
m  one  or  more  circumscribed  regions.     From  the  u.iatomical  stand- 
point we  may  therefore  distinguish: 
Chronic  diffuse  hypertrophic  laryngitis. 

Hypertroijhy  of  the  tissue  lining  the  ventricles  (so-called  prolapse 
ot  Mie  ventricles). 

Pachydermia  of  the  vocal  cords. 
Polyp  of  the  cords. 
Vocal  nodules. 
Subcordal  hyperfrnphy. 

Chronic  DilRxse  Hypertrophic  Laryngitis.  The  inflammatory  altera- 
tions are  situated  chiefly  in  the  connective  tissue  beneath  the  epi- 
thehiim.  reaching  their  highest  development  in  the  vicinity  of  the 
l)loodyessels  and  the  efferent  ducts  of  the  glands.  They  niay  also 
give  rise  to  a  thickening  of  the  i)erichondrium  and  cartilage  The 
epithelium  may  un.lergo  metaplasia  into  a  stratified  pavement  epi- 
thelium, which  in  advanced  Citses  may  consist  of  from  fourteen  to 
twenty  epithelial  layers.  The  epithelium  is  everywhere  infiltrate.l 
with  leucocyte^,  most  abundantly  in  those  places  "where  the  under- 
lying vissue  exhibits  (\s])ecial  infiltration. 

The  membrana  proi)ria  may  become  thickened  and  distinctly 
fibrillary.  Heiow  the  stratified  cylindrical  epithelium  the  papilhe  of 
th..  nuicosa  exhibit  pr<.liferaii„n.  branching,  and  multiform  circum- 
scribed prominences.  The  connective  tissue  „f  the  papilhe  is  soft 
poor  in  fibres  a-d  exhibits  a  marked  diffuse  infihration  with 
leucocytes.  The  submucosa  shows  alterations  which  vary  in 
different  places  „,  intensity.  It  appears  hard,  compact,  markedly 
fibrillary,  containing  only  a  few  .spindle  cel.'s.  The  round-celled  infil- 
tration appears  at  times  diffuse,  at  others  circum.scribed  in  the  form 
ot  nodules  most  conspicuously  around  the  efferent  ducts  of  the  elands 
Some  of  the  cil.  exhibit  hyaline  degeneration.  The  blo„,lvcs,sels  are 
in  general  larg.-  and  thin  walled,  well  filled  with  bloo.l,  exnopt  where 
Tl..-  mucous  menibran  .  has  un.le.-gone  fibrous  changes.  The  mucous 
glands  may  exhibit  hyperplasia.    The  epithelial  cells  may  exhibit  a 


jyFLAMMA  TIOSS. 


713 


liiilh  degree  of  mucous  degeneration.  The  perichondrium  m  the 
rcLrions  corresponding  to  the  most  markeil  alterations  of  tlie  mucous 
nu'uihrane  may  be  infiltrated  with  leucocytes  ami  show  a  hypertrophy 
of  the  cartilage.  .  . 

Hypertrophy  of  the  Ventriculw  Begion.  This  comhtion  consists 
histologically  of  marked  hyperplasia  of  the  connectiye  tissue  of  the 
yeiitriclo  of"  the  larynx,  which  extends  also  to  the  upper  aspect  of 
the  vocal  cord,  and  "is  frequently  associated  with  pachydernna  of  the 
vocal  cords.  The  histological  details  may  be  inferred  from  the  pre- 
ceding description  of  chronic  diffuse  hyiM'rtrophy. 

Pachydermia  of  the  Vocal  Cord»     Pachydermia  of  the  vocal  cords 
consists  histologically  of  an  inflammatory  hypertrophy  of  the  con- 
nective tissue  of  the  mucost),  affecting  subsequently  the  epithelium. 
This  is  particularly  evident  in  those  places  where  the  process  is  able 
to  develop  undisturbed  by  external  influence  .    Histologically  the 
.■pithelium  is  seen  to  be  thickened  and  horny  in  its  upper  layers,  which 
are  formed  by  flat  cells  with  indistinct  nucleus  or  without  a  nucleus. 
\inorig  them"  there  occur  layers  of  cells  in  which  keratohyaline  may 
1).-  encountered.     The  lowe'st  layers  of  the  epithelium,  w^uch  are 
situate<l  upon  the  connective  tissue,  are  composed  of  cylindrical  cells. 
Between  these  and  those  which  bear  keratohyaline  are  layers  of 
jM.lvgonal    cells  with  prickle  processes  and  deeply-staimng  nuclei 
which  correspond  to  the  rete  Malpighii  of  the  external  skin.    These 
horny  alterations  occur  not  only  in  the  vocal  cords  anil  those  portions 
of  tlie  larynx  which  normally  bear  pavement  epithelium,  but  also 
in  other  regions  covered  with  columnar  epithelium,  as  for  instance, 
ill  the  ventricular  bands  or  ventricles.    These  latter  situations  may 
exhil)it  a  transition  from  the  columnar  to  the  pavement  epithelium. 
( )ii  the  free  surface  of  the  vocal  cords  there  occur  in  pachydermia, 
in  addition  to  the  normal  folds,  actual  papilla>,  which  may  penetrate 
hijllier  into  the  thickened  epithelium  than  the  level  of  the  normal 
folds.    These  are  particularly     ell  developed  in  the  region  of  the 
vocal  processes.     While  the  con..,'ctive  tissue  thus  sends  j)apilla»  into 
ilie  epithelium,  the  epitheliu  n  in  turn  penetrates  the  connective 
tissue  with  interiiapillary  j^roiongations  which  may  be  divided  into 
several  summits. 

Tlie  subei)ithelial  layers  of  the  connective  tissue  exhibit  an  increase 
in  till-  number  of  round  cells,  particularly  in  the  neighborhood  of  the 
irlaiids.  The  cells  may  penetrate  the  cylindrical  epithelium  of  the 
Fatter  and  fill  the  lumen  of  the  efferent  ducts.  Keratohyaline  is  apt 
lo  occur  together  w^'h  the  formation  of  papilla,  thus  giving  the  tissue 
ail  epidernioid  character. 

The  origin  of  the  depressions  at  the  summit  of  the  pachydermal 
swellings  on  the  vocal  process  is  not  wholly  clear.  In  ca.ses  which 
have  been  investigated  histologically  the  dejiression  in  the  centre  of 
the  swelling  is  .seen  to  correspond  exactly  to  the  point  of  the  hyaline 
.artilaginous  process.  This  'after  is  surrounded  by  h\-pertrophied 
connective  tissue,  which  arc  aid  the  point  of  the  cartilage  i;'  prolonged 


714 


XOSE  AA'D  THROAT. 


upward  into  papilla'  i-ovorcd  with  a  thick  iayor  of  pavoinpnt  opi- 
tiu'liuin  forming  tin-  margin  of  the  growth  in  (lucstion.  Virchow 
iM'licvcs  that  the  ilcprcssion  occurs  from  the  ch)scr  approximation 
of  the  mucous  membrane  to  the  point  of  the  cartilage  in  the  centre 
of  the  growth,  rather  than  at  the  ])eriphery.  Fraenkel  exi)laiiis 
it  by  the  mutual  pressure  exerted  by  the  vocal  processes  during 
phonation. 

Ulcerative  processes  are  apt  to  occur  in  pachydermia,  most  cases 
being  of  long  duration.  They  begin  in  all  cases  from  the  surface, 
and  perhaps  occur  by  the  nibbing  of  the  ai)posed  portions  of  tiie 
mucous  membranes  on  each  other.  Perichondritis  may  Ik  jserved 
in  association,  but  its  relation  to  the  ulcerative  process  '  clear. 


Fio.  361. 


Vocal  cord,  normal. 


It  is  possible  that  some  of  the  cases  reported  owe  the  origin  of  these 
proci'sses  to  tubercular  or  sy])hilitic  or  typhoid  infections. 

Polyp  of  the  Oords.  Hy  this  term  is  denoteil  a  circumscribed  hypei- 
tropiiy  of  the  mucoas  membrane  of  the  vocal  cord  a.ssociated  with 
a'denia.  The  hypertrophy  afiects  all  the  superHcial  lavers  of  tiic 
cord,  and  is  therefore  distinguished  from  fibroma,  wliichis  a  totalh' 
different  structure  and  consi.sts  of  connective  tissue  covered  with 
mucous  membrane.  In  the  l)olyp,  on  the  other  hand,  tli(>  individuiil 
constituents  (nan)ely,  connective  tissue,  elastic  tissue,  glands,  vessels. 
and  epithelium)  bear  the  same  relation.ship  to  each  otli«T  as  iv  tli'' 
mucous  membrane  of  the  vocal  cord,  and  no  one  constituent  i)r(- 
dominates  over  the  others. 

The  polyp  exhibits  a  loose  large-meshed  connective  tissue.  Sonir 
of  the  meshes  are  so  large  as  to  give  the  appearance  of  cysts,  bu: 


ISFLA  MMA  TIOXS. 


715 


itr  not  tnic  rvsts,  (^incp  their  walls  consist  of  connective-tismc  fibres 
ui'out  endothelial  lining.  Th.'se  eyst-like  dilatations  may  (.eeur  at 
ti ,  t)ase  of  the  growth,  and  also  immediately  under  the  epithelium. 
N.xt  to  the  connective  tissue  the  elastic  tissue  takes  up  a  large  i«>r- 
tion  of  the  laryngeal  iM.lyj),  in  some  instances  b'ing  even  more  abun- 
,liiit  tlian  the  white  fibrous  tissue.  (Mands  are  usually  piesent.  1  He 
,.|,itlielium  varies  in  thickness  from  two  to  many  layers,  even  at  tunes 
hriiig  so  thick  as  to  deserve  the  name  of  pachydermia.  It  consists 
nl  stratified  pavement  .'pithelium  which  may  at  times  be  horny  ami 
,„av  contain  epithelial  iH-arls.  K|)ithelial  pockets  are  sometimes 
tnund  in  the  form  of  round  or  oval  cavities  under  the  epithelium. 
In  most  cases  the  basement  membrane  marks  the  liii'  iH'tween  the 
rpitheiium  and  the  connective-tissue  portion  of  the  tumor. 

The  degenerative  processes  in  the  tissue  of  the  laryngeal  polyps 
arc  somewhat  complicated.  V.-  the  result  probably  of  stasis  of  the 
l.lood  and  Ivmph  there  arises  a  homogeneous  infiltration  with  pig- 
ment and  thrombosis,  leading  finally  to  the  f..rmation  of  peculiar 
liomogeneous,  oi)a(iue,  hyaline,  yellowish,  or  brown  masses  penetrated 
l.v  small  irregular  cavities.  ,        ,,  . 

Vocal  Nodules.  Some  confusion  exists  with  regard  to  the  nature 
nl  the  so-called  vocal  nodules.    Three  hypotheses  have  been  brought 

forward:  .         .    ,  .        ,  ., 

1  ,\  |)hysical,  namelv,  mechanical  friction  of  the  margins  ot  the 
ci.nls  at  points  determined  by  the  conditions  which  cause  swelling 

in  the  vocal  cords.  ,     i    • 

2  A  physiological,  the  vibrating  nodes  of  the  vocal  cords,  bring 
points  of  the  most  vio!.-nt  action,  are  predisposed  to  the  formation 

iif  the  nodules.                                                    ,  .        ,     .  i      i 

3  \n  anatomical  '  "^  v<  ?al  nodules  stand  m  relation  to  a  gland 
situaU'd  at  the  p(.  ••  of  the  free  portion  immediately  under 
ilic  margin  of  th'   •    . 

The  present  coiisit.  '  >o  is  limited  to  those  cases  dependent  upon 
a  hvpertrophv  of  the  ei-itheliuni.  The  swellings  exhibit  stratifiec. 
|.;ivement  I'pit helium  ranging  in  thickness  from  100  to  400 /^  due 
If,  a  considerable  increa.se  in  the  lavers  of  polyhedral  and  cylindrical 
rclls.  At  the  level  of  the  polvhedral  layer  the  protoplasmic  sub- 
stance is  well  marked,  the  nuclei  are  large,  and  stain  well  with  carmine. 
Til"  cells  are  intimatelv  connected  with  each  other  by  a  protoplasnnc 
-iihstance  and  prickle' cells,  without  the  interi)osition  of  leucocytes. 
Tiie  mucosa  is  composed  of  fusiform  cells  with  bipolar  prolongations, 
.vhich  one  mav  follow  over  an  extent  of  60  //.    The  deeper  layiTs 

.f  the  section  show  a  few  strands  of  elastic  fibre.     There  is  no  actua 
i.apillary  layer  present.     The  fibro-ela.stic  mucosa  is  thickened  and 

listinctiy  less  vascular  than  normal.     In  some  cases  a  process  of 
'  Icfjcneration  and  cyst  formation  occurs. 
Hypertrophic  Subglottic  Inflammation.     Chronic  inflammatory  hyper- 

tn.])hv  occurs  at  times  in  the  subglottic  regions  of  the  larynx  and 

111  the' trachea  in  the  absence  of  tuberculosis  and  rhinoscleroma,  prob- 


716 


SOSE  ASD  THROAT. 


iilily  Jw  tho  rosult  of  recurrent  unite  infliuniiiations  which  do  not 
attain  complete  al)sori)tion.  The  inutoinical  basis  of  the  affeciiim 
is  similar  to  that  described  in  chronic  diffuse  liyiK-rtrophic  laryn- 
gitis,  consistinj;  of  an  increase  in  the  mucous  and  submucous  con- 
nective tissui',  with  a  tendency  to  nieta|)lasia  of  the  epitlieiium  into 
stratified  epithelium,  and  loading  in  severe  c.-ises  to  stenosis  of  tiie 
larynx. 

Ghronic  Inflammations  with  Tendency  to  Atrophy.  V^'^e  may 
rec(ij;iiize  two  essentially  distinct  forms  of  the  atrophic  process  in  the 
nose  and  throat,  first,  a  genuine  fetid  atrophic  rhinitis,  njusopharyu- 
gitis,  and  laryngitis;  second,  a  localized  dry  anterior  rhinitis. 


Fl'j.  362. 


Atrophic  inflammation  of  the  middle  tnrblnato.  Below  t lie  stratified  pavement  epithelium  Is  a 
(■"Uiparalivcly  denae  network  of  connecltTi-iissiie  fibres,  showing  toundcelled  iiiHIIralion  with 
watteri.ll  hlooitvessels.    Below  this  are  Irregular  sinuses  in  a  compact  mass  of  conncelire  tiwue. 


By  diffu.«e  atrophic  inflammation  is  denoted  a  chronic  inHammatoi y 
atTection  characterizfMl  clinically  by  a  more  or  less  general  progri>ssivi> 
atrophy  of  the  mucous  membrane  and  underlying  structures,  tin' 
formation  of  a  tenacious,  at  time  etid  secretion,  and  exhibiting  mi 
tendency  to  spuiitanetius  recover}-.  Our  histological  information  is 
derived  from  a  study  of  the  lesions  occurring  in  the  nose. 

In  difTu.«e  fetid  atro])hic  rhinitis  we  find  histologically  a  nictapla.<i:i 
of  the  ej.'itheliiim  associated  with  c. ^rnificati.in,  dogenerative  chanir-- 
in  the  glands  and  in  the  wandering  cells,  together  with  bony  absorp- 
tion. 


ISFLAMMATtONS. 


717 


IxiunininK  those  iiltoratici.s  inoro  ia  detail,  we  t  nil  in  the  hrst 
i,..tance  the  lu.r.nal  c.hi.nnar  ciliated  epitheUunj  t.;  he  more  ..r  less 
universaliv  replaced  hv  stratihwl  pav-nu-nt  epithelium,  with  a  Wu- 
•v  ;.,-hurnv  chaiip.  in  the  up,H'r  layers      H.low    he  mucous 
,H,,nl,rane  there  is  an  iutiltrati.m  of  n.un.l  ce  Is.  particularly  in  the 
!        'i      zone.   exten-liiiK   more   or   less   .leeply    int.,    the   region  <^ 
,  ,rla,uls.  particularlv  in  the  intertubular  tissue      In  the  vunuty 
„r  this  infiltration  are  found  numerous  fibrillary  nuc fate    connective- 
t    '  strands,  running  us.-dly  paralU>l  to  the  surface   a.ul  vary    K 
i„  „„,„1„T  acconling  to  tlu"  durati..ii  an.l  stage  of  tlu-  attectu.n.    lon- 
ui      exists  betWHM.  the  stat.-ments  of  diff.-rent  observers  as  to  certain 
.„irestati..«s    in    the    mucous    membrane    and    infiltrating    ce 
V  degenerati.m  of  the.se  n  lis  has  been  observe.l  and  is  by  son  e 
,:.'anled  as  tlu'  essential  feature  of  the  process.    .It  np,H-ars  nmv 
vusonablv  certain  that  while  M  dro|.«  "lay  occur  in  the  glandular 
„„.liu,n  an.l  sometimes  in  .he  free  epitheha    evils  a«  far  as    ».<■ 
,  ,iti,.,.  of  the  etTen>nt  duct  on  th-  surface,  nevertheless  ^•""'f'-  f  ^ra- 
„s  may  ..ccur  in  all   nasal  affections  without  .ussociated  fe  <.r  .^ 
;„,,phv  '  It  is  possible  that  another  process  of  .legenerat ion  whuh 
......u'rshere.  nanlely,  hyaline  metainorphosis  of  tl>;P»-^'"«;",J;.S 

have  le.l  to  erroneous  conclusions  by  earlier  observm.  Thm  h>  aline 
lj:en.-rated  cells,  the  so-called  Russell's  fuchsmophiles.  are  found  not 
'.nh-  in  the  subepithelial  layer,  but  also  in  the  dee,K-r  layers  of  the 
mucosa,  in  the  erectile  tissue,  and  in  the  medul  a. 

The  Erectile  tissue  shows  a  gradual  weakening  of  its  muse  la 
.„..,. ratus   and  in  advanced  stages  distinct  shnnkmg.     h.  I  raenkel 
h'.s  .l..scril)ed  an  endarteritis  obliterans,  but  his  findings  have  not 

'"  Th.-',^li;Xum  in  the  affected  portions  shows  marked  prolif^^ratbn^ 
with  hire  arul  there  an  increase  in  thickness      Large  P-'y""';';;^  ^'^^ 
Mr  found  in  varying  numbers,  the  f-<'«ll^<»;^f  •'''.^''f;; '-^'"^^1" 
,:,llv  dinctlv  on  the  margin  of  the  bone  an.l  the  lacuna>.     In  their 
vi,.i,litv  there  is  evi.lonce  .,f  bony  absorptmn.  with  the  resi.lt  that 
,hr  bonv  partitions  supporting  the  a.ljacent  medullary  s,  aces  gradu- 
,llv.lisappc.ir.     Sniall  pieces   .,f  bone  are  split   off  and  absorbc.1 
!hVr..  tllus  tak.^s  place' gra.lually  a  loss  of  the  bony  fra"«'^vo^  <^ 
,!,..    turbinate.1    bones.     Howship's  lacuna-    are   f';""'|;";  V?,  "f 
-Imridanc.     At  times  no  ost.-obhustic  layr  is  found.    These  altera- 
:Z  ie  possibly  instrumental  in  altering  the  nutnl^ion  and  cim.h^ 
,nn  in  the  bone."  Bv  some  observers  they  are  regarde.  as  c.nstituting 
.,in,l.!"ndent  primary  pr.,c..ss.  which  lea.ls  through  aterations  in 
h.  arfries  to  .  ^condary  changes  in  the  «y^'-hing_  structures 
Th..  attempt  w.vs  ma.le  .some  years  ago  t'    ..p  ain  the  ^  "sat^on  o 
t,„phic  -hinitis  by  the  presence  of  a  specif.c  ''a'-tfrmm      Scm ral 
...anism.-^  were  isolated  an.l  claimed  by  the  .hscoven-rs  as  the  specific 
...„ts.     It  is  sufficient  at  the  present  tinie  to  statr  that  no  confir- 
"ation  of  these  claims  h..s  been  establiNhed.     Its  ongm  from  chronic 
imisitis  with  empyema  seems  probable  in  some  instances. 


■M 


718 


XOUE  AM)  TUROAT. 


EhlniUs  Sicca  Anteilor.  My  this  ffriii  we  iindiTstiirKl  mi  nfToctiun 
iif  tlif  imicoiis  iiicmlxanc  of  tin-  cartiliijtirious  .xi'iitiim  iirfsciitiiij;  .1 
pii'turi-  of  dry  nifiirrh  Ic-uliiiK  to  cpitlitlial  iiictaplasiji,  and  frc(|uciii!y 
to  Imctcrial  infcrtioii.     Tlif  mucous  mnnhranc  in  tlic  atVcctcd  rcjtion 

•  •xliil)its  or r  more  laytTs  of  a  pcniliar  siihstaiicc  situated  ahovc 

and  upon  fhr  supcrticia!  cell  layer,  wliieli  sliows  in  it.>  linetoriai  reae- 
tion  a  reseniManee  to  keratoliyaline.  In  and  Im-Iow  the  inueous  ti.ein- 
l.rane  are  numerous^  iiyahne  dep-nerated  |)iii.snia  ceils,  iiiiustzciicM, 
and  a  few  eosinophilic  cells,  A  l.arKe  amount  of  |)iginent,  prohaiily 
luemato)tenous  (staininR  reddish  hrown  with  carlH)l  fuchsin),  is  dis- 
trihuted  in  the  mucous  membrane,  partly  in  and  partly  external  to 
the  cells. 

This  condition  is  the  luost  important  etiolojiical  factor  in  habitual 
i.se-bh'ed  and  in  perforating  ulcer,  probably  also  for  perichondritis 
of  the  sei)tuin. 


2.  PROGRESSIVE  DISTURBANCES  Or  NUTRITIOM. 

Under  this  heading  are  comprised  alterations  characterized  by 
jtrogressive  non-intlammatory  increase  in  tissue  volume.  We  distiii- 
«uish  new-prowths  with  mafignant  tendency  and  new-jirowths  of  a 
iM-nigii  character,  the  first  growing  into  the  tissues  of  the  vicinity, 
torcing  them  to  one  side  and  actually  replacing  tln'tn,  while  the  latter 
remain  relatively  well  ditterentiated  in  their  growth  from  the  vicinity. 

Malignant  Tumors,  of  these  we  may  distinguish  two  chief  fpes. 
according  as  they  rise  from  the  ectoderm  (or  entcxlerin),  (,r  "froni 
the  mesoderm,  the  former  being  represented  by  carcinoma,  the  second 
by  sarcoma. 

Carcinoma.  These  growths  a.I-e  through  proliferation  of  the  super- 
hcial  epithehum,  or  the  glandular  epithelium  which  grows  into  the 
neighboring  connective  tissue  an<l  produces  here  w  simultaneoas  pro- 
liferation. For  these  rea.son.s  carcinoma  Inis  two  const'tuents,  namely, 
cancer  cells  and  a  va.scular  stroma.  The  cancer  cells  appear 'mor[)lio- 
logically  as  large  cells  po.ssessing  Ijirge  round  or  oval  vascular  nuclei 
with  large  refractile  micleoli.  They  preserve  to  a  certain  extent  die 
arrangement  and  form  of  the  mother  cells.  The  stroma  varies  in 
cotisistence  and  thus  infl-ences  the  den.sity  of  the  tumor. 

Carcinomata  are  divided  intoepitheliomat.'  an<l  adenoearcinomata, 
the  first  arising  from  sfpiamous  cylindric;.|,  or  tubular  epithelium, 
and  the  second  arising  from  the  hning  epithelium  of  the  various 
glands.  In  the  case  of  the  epitheliomata.  but  little  confusion  can 
arise  as  to  the  (|uestion  of  their  malignancy.  In  adenocarcinoma, 
on  the  other  hi-id.  there  is  frequently  a  striking  resemblance  to  a 
genuine  adenoma.  We  find  all  degrees  of  transition  from  localiz«M 
hypertrophies,  in  which  all  the  constituents  of  the  mucous  niembraiir 
are  involved,  to  papilloniata  and  .adenomata,  and  finally  to  rarcinn- 
mata.     The  only  sharp  line  of  demarcation  between  the  benign  ami 


PROURESSIVE  DUiTUBBANCE.     >#'  NLTBITWS. 


71i) 


m:iliKii!iiil  >jr<)\vth.-i  ill  this  list  is  in  th<"  tcmlcm-y  of  tli«'  latter  iiionc 
1,1  invade  tiif  tissues  of  a  ilitTrrciit  Idastodcnnic  orij{in. 

llotli  ci.itlu'lionia  and  adt-nosarconia  occur  in  all  parts  of  the  upper 
:iir  passap's.  In  the  nose  carcinoma  is  comparatively  rare  and 
iiMialiy  of  the  Rlandular  ty|K>.  In  tSe  pharynx  and  larynx  epitheli- 
iiiiia  is  more  fre<|ui'nt. 

Sarcoma.     Tlies<'  tumors  consist  to  a  greater  or  less  extent  of  iinma- 
iiiie  fonns  of   connective  tissue  produced  through  proliferation  of 
crlls  of  mesodermal  nature.     The  cells  are  usually  numeroun,  and 
.  \l:il)il  ftreat  variation  in  iiuinl«'r,  size,  and  shaix-.     The  jjround  sul^ 
>i:Mice  may  ranp'  from  one  hut  slightly  develo|>ed  and  apjiarently 
iiMiorphous,  to  one  that  is  moiv  abundant  and  compact  and  more  or 
|,»  lii)rillary,  approaching  in  its  apiK-arance  th<'  mature  connective 
tissues.     Many  sarcomata  exhibit  an  alteration  of  a  ])ortion  of  their 
lioues  into  a  mature  coime<'tive  tissue,  such  as  Inine  or  cartilage, 
riie  development    of    hloodve.s.sels  is  at    times   extremely  marked, 
:is  in  angiosarcoma.     Retrograde    metamorj;Vi    -s   occur    in   sarco- 
mata under  the  form  of  fatty  degeneration,  ''iseation.  li(|uefaction, 
and  ulceration.     Histologically,   the  followiuM    .arieties  are  distin- 
uuislii'd:    First,  round-celled  sarcoma,  where  the  growth  is  made  up 
of  round  cells  with  a  small  amount  of  internuHliate  >uhstance.     The 
-ize  of  the  cells  varies,  giving  small  round-celled  sarcoma  and  large 
r.iund-celled  sarcoma.     S<>cond,  spindle-celled  sarcoma,  consisting  of 
.joiigated  cells,  large  or  small,  with  a  ver\'  slight  development  of 
iiiteimediate  substance.     Third,  endothelial  sarcoma,  arising  through 
|iroliferation  of  the  endothelial  cells,  i)articularly  of  the  \yiu]>h  vessels. 
I'ourth,  angiosarcoma,  which  includt's  the  forms  whieh  are  jKirtii'u- 
larly  well  supi)lied  with  l)loodves.sels.     Sarcomatous  tissue  surrounds 
the  vessel  walls,  which  may  exhibit  irregular  dilatations,  giving  a  hya- 
line degeneration  which  may  result  in  complete  closure  of  the  lumen. 
Iiv;i'iiie  cylinders  and  knob-like  protuberances  are  thus  jjroduced, 
t' liming  the  so-called  cylindroma.     Melanotic  sarcoma  is  a  fonn  in 
uhicli  a  portion  of  thecells  contains  a  brownish  or  black  i)igment. 
Tlie  form  of  the  cells  is  immaterial.     These  growths  exhib'^  marked 
malignancy. 

Sarcoma  may  exhibit  a  combination  with  the  mature  ti.     .    of  the 
iiesiHleriii.  giving  osKnisarcoma  and  chondrosarcoma. 
Sarcoma  may  o'-cur  in  all  regions  of  the  upper  air  jjassages.     They 
le  found  with  i)articular  frequency  in  the  nose,  while  in  the  larynx 
liey  are  of  extremely  rare  occurrence. 

Benign  Tumors.  Of  these  we  distinguish  genuine  tumors  and 
'Minnrs  arising  from  sta.si.s. 

Tiue  tumors  may  aris«-  from  the  ectoderm,  i)ro<lucing  i)apilloma 
ml  adenoma,  or  from  the  mesoderm,  giving  fibroma,  lipoma,  myxoma, 
■  lioiidroma.  osteoma,  and  angioma. 

Papilloma.  This  variety  of  tumor  is  characterized  by  the  presence 
-i  riumerons  fii)rous  branches  covered  by  epithelium.  In  the  nose 
'his  epitli  lium  becomes  atypical  and  approximates  the  squamou  . 


720 


yOSE  ASD  TIIBOM'. 


type  in  those  situations  whoro  it  is  cxposcMl  to  extornal  irritation  or 
rul)binj;  of  its  surfaces.  Kvcrywhoro  the  marked  feature  of  the  growth 
Is  the  proliferation  of  tlie  epitheUutn.  The  stroma  is  scanty  ami 
abuiiiiantly  suppHed  witli  i)loo(lves.sels.  In  si)ite  of  its  simihirity  to 
cancer,  on  account  nf  its  tendency  to  active  atypical  i)roliferation, 
the  non-malii^nant  character  is  shown  by  Hie  fact  that  the  epithelial 
covering  of  the  tumor  is  sharply  Ihnited  Ik'Iow  and  does  not  at  any 
place  penetrate  the  underlying  tissue.  The  growth  is  always  to  be 
distinguished  from  papillary  hypertrophy,  in  which  all  the  elements 
of  the  mucous  membrane  jjarticipate. 

Adenoma  By  this  term  is  denoted  a  tumor  which  imitates  the 
physiological  glandular  tissue  in  a  certain  degree,  but  does  not  exhibit 
its  function  Although  the  adenoma  resembles  the  normal  structure 
of  the  gland  it  differs  always  to  a  greater  or  less  extent,  partly  in  the 
size  and  jjartly  in  the  arrangement  of  the  epithelium.  Their  line 
of  demarcation  from  sim])le  glandular  hy|)erplasia  is  by  no  means 
sharp,  nor,  on  the  other  han ',  are  they  definitely  sejjarable  from 
adenocarcinoma.  The  chief  points  of  distinction  in  the  latter  case 
consist  in  the  regular  arrangement  of  the  epithelium  and  the  sharj) 
.separation  of  the  adenoma  from  its  surroundings.  Pure  adenoma  in 
the  no.'se  is  rare.  It  Is  more  freiiuent  in  the  palate,  where  it  is  often 
associated  with  a  dilatation  of  the  lymphatics.  It  is  rare  in  the 
larynx. 

Fibroma.  This  growth  consists  of  fibrillary  vascular  connective 
tissue  of  a  more  or  less  compact  structure.  In  the  septum  it  occurs 
at  the  junction  of  the  cohnnnar  and  triangular  cartilage,  and  shows 
an  epithelial  covering  with  the  characteristics  of  the  external  skin, 
overlying  firm,  fibrous,  closely-ajjpressed  bundles  which  contain 
numerous  spindle-celled  elements,  but  few  round  cells  and  blood- 
vessels. 

In  the  nasopharv'nx  we  see  all  gradations,  from  the  pure  fibromata, 
consisting  alniost  entirely  of  dense  white  fibrous  tissue,  to  those  of 
a  looser  structure  with  more  numerous  cells  and  bloodvessels,  which 
a|)pr()ach  in  typi'  the  fibrosarcoma.  In  the  larynx  the  true  fibroma 
is  rare,  and  is  found  chiefiy  on  the  vocal  cords. 

Lipoma.  Thes(>  have  Ix'cn  observed  upon  the  mucous  membranes 
nf  the  nose,  the  tonsils,  and  the  larynx.  They  consist  in  their  centre 
of  fat  tissue  surrounded  by  a  more  or  less  abundant  connectivi' 
tissue  in  the  ])eripheral  portions,  and  .iie  "ov-red  by  the  mucous 
membrane  of  the  ])art.  They  are  apt  to  be  a.'*.sociated  with  other 
growths,  particularly  fibromata  and  myxomata.  The  fat  tissue  in 
these  growths  is  distinguished  from  normal  fat  tissue  in  the  greater 
size  of  ts  cells  and  lobules.  It  may  be  as.sociate(l  with  greater  devel- 
opment of  fibrous  tissue,  ])roducing  a  (ibrolipoma. 

Myxoma.  True  myxoma  has  not  been  reported  from  the  nose.  It 
rarely  occurs  in  the  larynx,  consisting  of  a  homogeneous  ground  sub- 
stance wiiti  delicate  fibrilhe  containing  mucin  hi  the  meshes,  together 
with  stellate  antustomosing  cells. 


PI. AT!;    XXI II. 


FiU-Mli'l'Ill 


mn.   ill   mill    lirnm  lii.i'i  ccll-^  nii'  >lii'\\ 
5r     ].  .11. ii    ,.'■     \Vi  mill  ~  ,|.-..  1I1WI1 


»'  i. 


rKooJiKusiyj-:  DiarrniiAycEs  of  yvTRirios. 


-fix 


Chondroma.  These  jjrowtlis  consist  of  eartiii.-'e,  n.ost  eoiniuoiily 
hyaline  cartiiii^ie,  altli»iu>;li  yellow  elastic,  and  h.,,  icartilajie  may 
occur.  In  the  nose  they  are  extremely  rare,  and  arc  either  supposed 
in  .some  cases  to  i)ej;ii;  as  |HMlunculated  outgrowths  which,  by  disa])- 
pearance  of  tlieir  pedicle,  become  free,  or  in  other  cases  to  arise  from 
islands  of  cartilajic  which  persist  from  fcetal  life.  In  the  larynx  tfiey 
may  occur  as  eccliondromata  of  the  same  form  as  tiie  parent  tissue, 
or  as  chondidinata,  in  which  the  type  of  cartilafje  is  diiTcrent.  These 
^r')Wths  are  prone  to  retrograde  metamorphosis  in  the  form  jf  mucous 
dcfteneration.  They  may  also  exhibit  ••:ilcification  or  actual  ossifi- 
cation. 

Osteoma.  These  growths  in  the  nose  are  sui)])os('d  to  arise  in  one 
of  the  accessory  sinuses,  and  are  composed  in  their  outer  layers  of 
compact  osseous  ti.ssue,  .-ilthough  the  interior  may  be  made  up  of 
spoufiy  tissue.  Tliey  are  apt  to  be  broken  ott'  from  their  point  of 
attachment  either  by  traumatism  or  by  atrojjhy  from  jm'ssure, 
jM'rliaps  resultinp  from  the  occlusion  of  the  nutrieni,  bloodvessels. 

Angioma.  The.se  p;rowths  are  found  chiefly  in  the  nose  and  larynx. 
We  disti^'duish  simple  and  cavernous  angiomata.  The  simple  angioma 
consists  of  numerous  capillaries  and  veins  which  exhibit  circumscribed 
dilatations  in  th;-  form  of  globular,  fusiform,  or  cylindrical  enlarge- 
ments. These  are  closely  related  to  tiie  so-called  bleeding  polyp,  a 
form  of  tumor  whicii  is  characterized  by  an  excessive,  simultaneous, 
sudden  growth,  and  is  es.>;entially  benign,  although  apt  to  recur.  The 
hy|)othesis  of  Siebenmanii,  that  it  is  due  to  rhinitis  sicca  anterior, 
is  at  present  plausible,  but  not  demonstrated  \\\\\\  certainty.  The 
«'pithelial  covering  consists  partially  of  stratified  cylindrical  i  |)itholiuin, 
the  lower  layers  of  which  are  composed  of  large  polygonal  nucleated 
cells,  from  whicli  the  upi)er  layers  are  sharjjly  s('|)arated,  being  Hat- 
tened  and  distinctly  horny.  The  pavement  epithelium  is  not  sym- 
metrically distributed  over  the  surface  of  tin-  new-growth,  but  sends 
downward  slender  jjajiill.ary  prolongations.  The  main  [lortions  of  the 
growth  consist  of  a  loose  connective  tissue  formed  at  its  bii.se  of 
delicate  fibrilhc.  Toward  the  |)eriphery  the  round  cells  are  more 
abundant.  In  the  middle  infiltrated  portion  are  numerous  dilated 
blood  and  Uiuph  vessels,  giving  rise  almost  to  a  cavernous  ajjpear- 
ance. 

Angioma  cavernosmn  resembles  the  above  growth,  but  shows  par- 
ticularly a  new  formaiion  of  the  vessels,  which  undergo  secondarj' 
<lilatation.  They  are  situated  exclusively  oti  the  lower  turbinate  or 
septum,  and  consist  histologically  of  a  covering  of  stratified  ciliated 
epithelium  overlying  the  cavernous  blood  spaces,  separated  from  each 
other  by  trabecuhe.  These  sinuses  are  round  or  oval,  and  lined  with 
smooth  endothelial  cells.  In  the  deeper  portions  they  become  larger 
and  more  irregular,  and  the  septa  exhibit  a  greater  thinning,  and 
(irially  nipluriiig  of  their  walls,  leading  to  a  rontiuenee  of  the  adjacent 
sinuses.  Both  venous  and  arterial  bloodves.sp|s  show  a  thickening 
of  their  walls. 

46 


nV^XESSES^TS^BSS 


u 


r22 


yoSE  A.W  THROAT. 


A  lliird  fortn  in*  tlioso  vascul;ir  fjrowtlis  is  the  fihroaiiftioiiia  which 
exhibits  a  smooth  surface  l)eariiij;  stratified  ciliated  epitiieliuiii  over- 
lying a  body  of  Hrin  fibrillary  connective-tissue  strands,  and  con- 
iaining  numerous  irreftuiar  sinus(v  resultiiif;  from  dilatations  of  the 
veins  or  arteries,  which,  fro  :i  erosion  of  the  tralx'cuhe,  may  become 
conHuent.  There  is  everywhere  a  round-celled  infiltration,  particu- 
larly in  the  vessels. 

Retention  Tumors.  Betention  Tumors  of  the  Epithelium ;  Cysts.  In 
the  nose,  cysts  of  varyinji  size  occur,  most  fre(|uently  in  polypi  and 
in  the  antrum,  resulting  from  the  occlusion  of  the  etVerent  glandular 
duct,  with  resulting  dilatation  of  the  gland.  ;Mich  cysts  are  lined 
with  e[)itheliuin  and  contain  mucus.  In  the  septum  a  cystic  enlarge- 
ment is  occasionally  found  as  the  hnal  result  of  a  ha-matonia,  which 
in  place  of  suppurating  becomes  encapsulati'd,  and  is  found  to  contain 
a  fluid  which  is  either  clear  and  transparent,  or  fine,  graimlar,  and 
viscid,  or  ai  times  shows  the  reaction  for  colloid. 

In  the  na.so|)harynx  a  form  of  cyst  occurs  which  is  supjjosed  to 
arise  as  the  result  of  inflanmiatory  |)roces.ses  atTecting  the  pharyngeal 
tonsil,  leading  to  adhesion  of  tiie  surface  of  the  median  folds  and 
converting  the  median  furrow  into  a  canal  open  at  both  ends.  When 
the  mouth  of  this  canal  becomes  closed  a  retention  cyst  may  be 
formed  of  varyiiig  dimeiLsions.  ii  is  possible  for  this  to  occur  in 
other  parts  of  the  pharynx  where  the  folds  of  the  pharyngeal  tonsil 
lie  in  close  api)osition.  Lami)hear  repc  .s  a  case  in  which  the  mass 
on  microscopic  ex.amination  was  found  to  ])ossess  a  wall,  the  outer 
and  inner  surface  of  which  wa.s  covered  with  stratified  pavement 
epiiiieliuni.  The  inner  surface  w;>.s  smooth,  e.\ce])t  at  its  attachment 
to  the  pharynx,  where  th'>re  were  a  few  crypts.  The  mucous  mem- 
brane was  rich  in  lymph  corpuscles,  but  there  were  vorv  few  lvnu)h 
follicles. 

In  the  tonsils  cj'stic  growths  may  arise  from  the  occlusion  vi  a 
lacuna  following  inflanun.ition  or  tor.sillototiiy.  The  walls  of  such 
cysts  are  formed  of  fliittened  e|)ithelium,  and  the  contents  con.<ist  of 
fat  droi)s,  plates  of  choie.sterin,  exfoliated  epithelium,  and  leucocytes. 

In  the  larynx  cysts  have  been  observed  in  the  various  ligaments 
;is  the  result  of  glandular  occlusion.  In  |)olyps  of  the  vocal  cords 
th.'M'  m;iy  occur  genuine  cysts,  or  p.seudocysts  due  to  (edematous 
infiltnition  in  a  circumscribed  area.  In  the  latter  instance  there  is 
no  'ining  epithelium,  the  walls  of  the  cyst  being  formed  by  the  hyper- 
trophied  connective  tissue.  Cysts  of  t-mbryonal  origin  als)  occur 
in  the  larynx,  due  either  to  the  ocdu.sion  and  dilat.Mtio.i  of  the  thyro- 
lingu.'d  duct  or  to  a  jiersiste-it  branchial  cleft,  which  may  give  rise 
to  superfici.'d  fistuhe,  which  are  later  transformed  into  cysts  by  closure 
of  the  oixnings  at  the  extremi.ies. 

Retention  Tumors  of  the  Mucosa.  Of  these  we  distinguish  dilata- 
tion? of  the  bloodvessels  and  of  the  lymphatics. 

Hetention  tumors  of  the  bloodvessels  from  stasis  occur  most  fre- 
quently at  the  base  of  the  (ongue  as  lingual  varix.     We  have  no  exact 


HEURLSSIVE  DISTURDASCKS  OF  SiTIilTlOX 


723 


liistoloRical  kiu.wlodKe  of  tl'is  (-oiHlition,  but  it  is  probably  analogous 
to  similar  lesions  upon  the  skin.  ,         ,        •        .      i 

Tumors  of  the  Ivmi.hatics  from  stasis,  or  lymplianRiomata.  have 
l,een  rei)()rte(l  fr.)m"  tli<'  pharynx  and  larynx.  In  a  ea.s(>  ot  lym|)han- 
.ri„mu  of  the  epiglottie  lipiment  the  tumor  was  seen  to  consist  of  a 
wi.le-meshed,  loose,  vascular,  connective  tissue  contanung  many  cavi- 
ties vurviuR  in  size  up  t<.  1  mm.,  j.ossessing  a  thir  lininp  ot  eiido- 
tlieliunraml  Hlle.l  with  a  homoseneous  mass  contain  n>l  a  few  round 
,rlls.  In  manv  places  in  the  connective  ti.s.su.-  th.'se  sanu^  masses 
,„Tur.  The  tumor-like  formation  is  in  geueral  sharply  (litTerentiatwl 
Iroin  the  surrouiu'iiiK  tissue. 


4. 


REGRESSIVE  DISTURBANCES  OF  NXJTRITION. 


These  alterations  in  the  uj.per  air  pa.ssapes  consist  I  oepenorat.ye 
Mu.l  of  atrophic  changes.  The  most  important  u.  this  .^j.ecia  held 
,,,.  the  mucous  and  horny  .le-cnerations  of  the  epithelium,  lloen  s 
,„u.scular  degeneration,  and  hyaline  degeneration  of  plasma  celN.  Of 
the  atrophic  changes  the  most  nmspicuous  are  those  occurring  in 
th.'  Ivmphoid  tissue  of  the  nasopharynx  and  the  i)harynx. 

Mucous  Degeneration.     Mucous  degeneration  of  the  epithe  lum 

nceurs  in  the  nose  both  in  the  superficial  epithelium  and  in  the  ducts 

,,f  the  glands      It  is  most  commonly  found  in  association  witii  hyi)er- 

tn.phic  inflammations.     Th.>  suiierhcial  epithelium  may  iKCon.e  to- 

tailv  or  partiallv  degenerated.     In  the  first  instance  al    d..-  cylindrical 

,.pit"helium  is  transforme<l  cell  for  cell  hito  an  .'pithelium  n.nsi-tmg 

„|-  .roblet  cells  filled  with  mucus.     Partial  mucous  .legeneration  may 

oecTir  either  bv  simple  increase  of  the  normal  goblet  cells,  occurring 

hetween  th<.  cvlindrical  c.'lls.  or  by  the  <'e">7-"'''\';f/''y'\!'™f, 

,.,.!ls  in  the  recesses  of  the  epithelium.  .,r  u,  the  imd.st  of  "tier    is, 

normal  cvlindrical  epithelium.     The  epithelium  (^  the  efTe rent  ducts 

„f  the  glaiKls  mav  undergo  a  similar  change.     This  condition  ma> 

NO  occur  in  oza-na,  and  also  in  apparently  normal  cases      Si:.ce  it 

..difficult  to  demonstrate  the  efferent  ducts  in  thes<- structures  they 

niay  easily  produce  tlie  iinpn>ssion  of  purely  epithelial   formations. 

' '  Homy'iegeneition  or  KeratosiB.  By  this  term  is  denoted  a  chronic 
degenerative  process  of  cornification  affecting  the  walls  ot  the  a.una^ 
„fthelvmphoi.l  tissue  in  the  pharynx,  nasopharynx,  and  baseot 
tlic  tonl'ue.  in  association  with  a   mycelial  organism.     (I  late   AAl., 

' 'tI.c  structures  which  appear  clinically  as  white  excrescences  pro- 
tr.iding  from  the  orifices  of  the  cryi-ts  are  seen  histologically  to 
ronsi<1  of  sacs  or  cvlinders.  the  walls  of  which  are  relative!)  ver> 
ihick  at:d  consist  p:irtiallv  of  stratified  layers  of  lu.n-nucieated  horny 
,.,.ithelium,  an.l  i.artlv  of  a  homogeneous  horny  substance,  such  as 
. '  peculiar  to  the  human  hair.     The  central  lumen  of  the  excrescence 


724 


mjhj::  asv  Tint  oat. 


..r  prickl.'  IS  iiariow  .-uid  filled  with  .Ictritus  and  hartcria  In  Z.-iikcr 
siMrinirns  stained  with  lueniaiuin  and  •■.,sin  the  hornv  .•iMthcliuin 
stains  hiij,r|,t  rcl.  Th.>  peculiar  h<)ni..jr(.ne(.us  lu.rnv  substance  ..n 
he  other  nan.l,  appears  a  clear  light  blue,  iiere  and  therewith  a  fine 
hKht  y<-ll()w  piKnH>ntati(.n.  whil.-  in  the  most  peripheral  layers  red 
Cngat..,  structures  in.licate  that  there  still  remain  portions  of  flat 
.'lonjiated  cells  or  cell  m,cl.-i  in  that  part  of  the  prickle  which 
pr..trudes  Irom  tin-  crypt.  Th..  ..xternal  surface  appears  somewhat 
shredde,!,  and  is  h(.r.>  and  there  invaded  with  bundles  of  leitofhrix 
tiireads.  ' 

The  epithelium  of  the  surface  appear-   normal  both  in  reRard  to 
IS  tola    thickiKss  and  the  appearance  .     its  cellular  elements.     On 
the  other  hand,  all  the  crypts  thn.uKhout  the  wliol..  length  of  their 
lumen  ("xhibif  an  enormous  thickening  of  th.'ir  epithelial  cells      h, 
th.>  epithelium  of  the  crypts  the  cells  of  all  the  layei^,  particularly 
the  middle,  appear  elongate.l,  and  th.-  superficial'lavers  somewhat 
t  attened.      The  cells  which  are  in  contact  with  the  hornv  plug  appear 
thicker,  are  stained  mon-  deeply,  and  show  a  peculiar  granulation 
of  their  protoplasm.     Small,  strongly  refractile  granules,  apparently 
Identical  with  the  pigment  granules  <.f  the  homogonoous  blue-staining 
layer,  are  .seen  arranged  chiefly  in  regular  rows. 
Keratohyaline  and  eleidin  are  apparently  absent 
Keratosis  appears  fre,,ueiitly  in  a  mild  form,  in  otherwi.se  normal 
Oiisils  here  and  there  in  the  crypts.     In    the    first    fd-tal   months 
horny  epithelial  cylinders  and  epithelial  pearls  are  found  in  the  ton- 
sillar crypts  and  also  m   the   pharyngeal    solitary  follicles  and  the 
ymphoid  tissue  of  the  nasopharyn.x.     The  so-called  tonsillar  concre- 
tmns  are  to  be  reg;irded  chiefly  a.s  decom,K,.se,l  pro.lucts  „f  the  cor- 
mhcation  m  which  lime  salts  have  been  .leposited 

The  leptothr.x  threads  which  occur  in  this  con.lition  are  morpho- 
h.gically  Identical  with  th.-  leptothrix  buccalis,  and  are  probably 
here  merely  saprophytic.  This  organism  occurs  with  particular  abun- 
dance ^yherever  epith.-lial  structures  px,,erience  the  lo.ss  of  vitality 
being  abundant  at  times  in  cancerous  ulcerations,  leucomatous  fi's^ 
sures,  and  hyperkeratosis  of  the  lingual  i)apilhe 

A  Form  of  Degeneration  of  Striated  Muscle  Occurring  in  the  Uvula 
(Hoens   Degeneration).      Histological  examination  of    relaxe.l  uvuhr 
sh.nv.s  peculiar  degenerative  changes  in  the  striate.1  muscles  asso- 
ciate,! with  marked  nuclear  proliferation,  and  leading  to  a  nearly  «r 
quite  total  disappearance  of  the  contractile  substance  of  the  affected 
nmscular  hbr...     In  the  beginning  of  the  process  a  peculiar  bleb-like 
or  yesicle-hke  homogeneous  deposit  takes  place  at  the  r.oripheries  of 
he  muscle  fibres,  appearing  as  a  narrow  bright  margin  or  line  of 
homogeneous  nature,  at  tunes  raising  the  .sarcolemma  here  and  there 
into  smal  Webs  or  b  istei^'      rransverse  striation  becomes  less  mark«! 
and  lonptudma!  .str.d.on  beromo..  replace,!  by  wavy  undulating  lines 
•o  respoiuling  to  the  ,n,!,vi,lual  fibrilhr,  which  have  now  Lorn.: 
twLste,!  upon  this,  prosenting  an  appearance  not  unlike  tho  strand^ 


REORESSlVi:  Pl.STVRHAycES  OF  MTllirwy. 


725 


,,f  i  rope  Tliis  upiM'iiraticc  is  most  noticciihlc  at  tlic  free  ends  of 
,1,,' fibres  and  becomes  eviden*  only  after  tlie  marpnal  elia.iKc  begins 
,„  i.uMiifest  its.-lf.  The  final  staf;e  of  the  peeuliar  .legen.Tativ.-  process 
i<  n  died  when  a  veritable  cylindrical  i)hig  or  mass  composed  o 
lun,  blebs  containing  small  and  large  misshaped  nuclei  mtermmged 
with  pigmentary  detritus  is  f..rm..d.  Through  the  mi.ldle  of  this 
there  runs  longitudinally  a  mere  shadow,  deiu.ting  the  former  site 

.if  a  muscular  fibre.  •       .  .  i , 

Proliferation  and  polvnu.rphism  of  the  nuclei  are  proimnent  ph.- 
„„„„.na  in  this  p.-culiar  metamorphosis  Alterations  are  also  apj.ar- 
.„t  in  the  m.  lei,  consisting  of  a  Hattening  at  th(>  ends,  with  a  hollow 
,1  the  central  porti»)n  on  either  side,  giving  them  an  appearance 
'.(..embling  empty  cotton  spools.  Other  nuclei  appear  eh.nguted  with 
marginal  crenalions  or  serrations.  Tlie  majority  of  the  nuclei  show 
n.nmletelv  suric.unding  them  a  halo  of  a  clear  homog<-neoiis  material 
which  does  not  stain.  With  the  gradual  disai)l)earance  of  th.-  mus- 
cular fibre  this  material  augments  in  amount  and  becomes  arranged 
invsruhirlv  in  the  centre  of  the  bleb  in  small  clumps. 

i;videnVes  of  the  regeneration  of  the  muscle  fibres  have  not  iM-eii 

' '' Hy^e  or  CoUoid  Degeneration.     In  both  normal  and  i.athologically 
Mtered  mucous  membranes,  ,.articularly  in  hypertrophic  rhinitis,  there 
.„...ur  at  times  homogeneous  gh.bules,  most  numermis  m  th-'se  situa- 
tions which  exhibit  the  round-celled   nfiltrat.ons.     These  sl-''"';-  '«; 
M.pposed  to  arise  from  pla.sma  c<;lls  by  a  ^\^^^^^}';:^^^^}''^ 
n.'.'mblesthvroid  colloid  in  Its  staining  reaction.    U '"<?-^->^V  .  *"  t'l; . 
I„   specimens  stained   with   luvmatoxylin   and   acid   fuchsn.   tlu 
Mucleus  api^ears  dark  blue  and  atrophied.     The  degenerati.m  begins 
with  a  slight  swelling  of  the  cytoolasm.  which   becomes  dark  and 
l.roken.     Thes,-  fragments  increa.se  in  size    become  mounded    nM..-e 
n.fractile,  and  stain  more  deeply  with  acid  fuchsm.    The  cell,  now 
,„u,.h  enlarged,  has  the  form  of  a  sphere,  aiu   many  of  the  fra|j"«;>'Jj 
coalesce  t<.  form  larger  ones.     The  atrophied  nucleus  is  usuallv  still 
visible      Finally  there  arise  completely  homogeneous  oval  structurcN 
.taining  .lark  c'herry  red  with  acid  fuchsin      The  advance,   stages  o 
d.-,.n..rati..n  are  more  commonly  h.un.l  than  the  early  stages.     In 
,!;  b,.ginning  their  structure  is  pn.bably  plastic,  so  that  through 
,.l„s,.  apposition  of  th.'  small  granules  an.l  th.nr  coalescence  larger 
,MMnul.'s  are  forme.l.     It   has  b.-en  a.ssume.l   that   the  pn-sence  of 
hvaline  an.l  cUoi.l  , '.."generation  in  th-  iiy,,ertrop  u.;.l  •";!^-""'^.  "";'?;- 
I, nine  is  not  acci.lental,  but  stan.ls  in  intimate  rc>lati..iiship  with  tlie 
nature  .,f  these  hypertrophies.     It  shows  no  ten.lency  to  sp.Mitaneous 

ri'tro!iressi.)n.  ,  i    i        1 1     ♦„ 

My  s.,me  auth..rs  these  corpuscles  have  been  regar.le.l  as  blasto- 

mvetes,  but  this  vi.'W  .loes  not  seem  at  the  P'-'''^'^"^  June  tenable 
Atrophy  of  Lymphoid  Tissue,     \\-ith  a-hnncng  age  the  pharyngeal 

an.l  faucial  tonsils  exhibit  n..rmally  r..trogra.ie  changes.    J'Jf^'mu.^. 

as  the  phenomena  characterizing  these  processes  are  essentially  iden- 


726 


NOSJ-:  .lyv  TtlROAT. 


lical  in  the  tw..  situations,  tiu-  (•..nsi,i..rati()ii  will  be  limited  hero  t<. 

sX/rT,"'"  !"  ''"/'^"""'  •""•^"■^'  ^^■*'"''>  »'»^-^'  boon  num'   ul   • 
s  u.I.ed.     ll„.  retr..gr:ui.;  nu.ta,n„rplu.8i.s  lx!Rin«  in  tho  regions  wIhtJ. 

th..  conneetiv,.  tissue  or.gnuilly  ,,re,l„n.inated,  namely,  iS  the  t  ub- 

ecula.  .m.l  U.e  subnme.us  e.„u,e..tive  tissue.     It  may  ,  rogres^  Tng 

he  trahe.-ui;e  u.  the  f„nn  ..f  an  irregularly  sclerotic Voc.ls.  or  n  a 
..re  ho  nog..„eous  an.    symmetrical  n.anner,  extending  f  on.  the 

. a..   .,f  the  organ  toward  ^Ih-  n.ucous  .ne.nbrane  of  its  free  periphery 

e  s  eviX:.'!;;""    '"T;  ^^"■/''"'"''"''•=''  -"'<  -f  the  reticulum  exhib  t 
\>>  .■Mdence  ,,    prolif<.ration  an.l  become  fewer  in  n.anlx^r.     Later 

hoM.  form  ng  th."  germ-cntre  of  the  follicle  entir.-lv  disappear  „d 
there  ,s  left  to  repres<.nt  the  follicle  n.erely  a  heap  of  lynu  hoi?f 'cil  « 
u-luch  progress,v,.ly  decrease  in  .m.nber  until  finally  tl-  C  er  site 
of  the  folhcl,.  ,s  occupied  wholly  by  connective  tissue  in  which  fat 
...ay  be  deposited.  The  follicles  most  remote  from  the  rm  expl 
r  ence  th,.  greatest  amount  of  atrophy,  while  those  nearest  t^he  cryp'S^ 
and  those  particularly  nearest  the  orifice  of  the  latter  preserve  cor^ 
resi)ondu,gly  best  their  functional  activity.  preserve  cor- 


^^B^R 


CHAPTER    XVII. 

METHODS  OF  EXAMINATION;  INSTRUMENTS  AND 
APPARATUS  AND  THEIR  USE. 

By  J.  i;.  NHWCOMB.  M.D. 

TiiK  miuMtos  for  a  •  .)IM'r  examination  of  the  upper  air  passages 
■irc  a'snital)le  source  of  light,  adetiuate  reflectors,  correct  atti- 
tude of  patient  and  examiner,  anil  approved  instruments.  Students 
should  he  encouraged  to  follow  a  uniform  method  of  exanunation 
in  every  case,  so  that  no  (mint  shall  be  overlooked,  and  every  etTort 
shoul.l'lx.  made  l.y  those  giving  instruction  in  these  l'[a>'clies  to 
inculcate  careful  habits  of  observation  and  to  develop  the  faculty 
„f  definitelv  recording  the  fimUng«  "'  <''ifl>  ^■.  ,    ,  .  ,.  ,  . 

Anterior"  Rhinoscopy.     Source  of  Light.     The  ideal  source  of     ght 
i.  the  sun,  for  then'by  are  the  anatomical  structures  seen  in  their 
,ru.  color,  a  matt.T  verv  difficult  to  attain  by  artihcial  hght,  which 
has  its  own  color,  dependent  on    th."  source.     As  sunlight  cannot 
1„.  relied  upon,  houvver.  artificial    illunnnation  ..s  rn.ployed.     I  he 
.in.plest  m.'thod  is  that  of  the  ordinary  candle  flame   but  it  is  too 
U-A-  and   Hick.-ring,  except   for    emergencies      At  the  l«'' ^l^'  "" 
rxcell.'i.t  view  mav  b.'  obtain.'d  if  the  candle  flame  is  backed  b>  the 
l,„wl  ,.f  a  polished"  tablespoon  which  serves  as  an  improvised  reHecf.r. 
Here  the  light  is  thrown  directly  upon  tlie  j.art  to  be  observed.     In 
citi...  the  Welsbach-Argand  gas-burner  has  come  into  almost  uniyersa 
u.e      It  gives  a  clear  but  whije  light.     i:iectncity  n>ay  be  used,  and 
is  ...ining  into  more  general  employment      If  used,  the  glass  bim. 
..ontaining  the  inca.ulescen;  filament  must  be  frosted  <"•  ground,  othr- 
wi.e  there  will  ai)pear  in  the  reflecting  mirror  an  image  of  the  hlanent 
„bscuring  th.>  clearness  ..f  vision.     No  matter  what  source  of  hgh 
is  emi.lov.'d,  all  ai.paratus  shoul.l  be  so  arranged  that  it  can  be  raised 
and  llnvered  and  swung  from  side  to  side.     The  general  ^n-''inS<""0" 
„r  ,he  light  van  be  appreciated  by  reference  to  Fig.  363.     In  order  t 
,.,.Mcentrat<-  the  light  some  form  of  condenser  is  employed.     When 
..jcrtricitv  is  unavailable  perhaps  the  most  satisfactory  arrangement 
is  the  \\Vlsl)ach-Argtind  gas-burner  place.l  either  on  a  swinging  bracket 
or  attached  to  the  frame  of  a  student  lamp. 

Reflectors  are  eith.'r  worn  on  the  forehead  or  are  attached  directh 

t„  the  illuminating  appar  "us,  as  illustrated  in  Fig.  363.     The  major- 

itv  of  phvsicians  wear  tin    minor  on  the  forehead.  .   •     ,  • 

"Then-  an-  several  varieties  of  head-bands,  but  the  one  advisexl  is 

tint  known  as  the  Pomeroy  (Fig.  364),  which  has  an  arm  to  which 

(  727  ) 


2M 


A 'AS/;  .i.v/<  rniui.ir. 


th-  ni.rn.r  is  attaclHMl  l.y  a  m.iv,  rs.l  j.,int.  [..Tinitfinp  .,f  n.pi.l  an.l 
.a.sy  ina.i.|,ulatio„.  I  he  inim.r  slu.ul.l  have  a  .lia.nct.T.,f  fn.m  thnv 
to  tour  uu'lirs  and  a  f.,cal  ,lista.u-..  ..f  al«.ut  fourf,.,,  indi.  s      Tl... 

h.vd-l.aii.lmaylH.ina.l.M.itlH.r..fliKl,tw..|,l,i,,K,,rh."avy(-.,r,|,Mlril.l),.M, 
inatcials  whicl.  aiv  prclVrahlf  t.M-lastic.   Th.'  mirror  is  plum!  over  the 

Kiu.  36S. 


Light  ^nd  condenser. 

ovc  corresponding  to  tlio  side  from  whicii  tlio  light  comes,  and  i)inocu- 
iar  vision  is  easily  secured  hy  looiving  tiirough  the  cential  jx'rforation 
Head-I)ands  witii  a  fran.e-piece  resting  on  tlie  bridge  of  the  nose 
are  to  bo  avoided.  So  also  are  sjiectacle-frames  to  which  tiie  mirrnr 
IS  attached,  hi  warm  weather  the  use  of  the  spring  head-band  is 
more  comfortable.  This  may  be  used  to  carrv  the  ordinary  mirror, 
or  may  have  attached  cords  terminating  in  an  electric  lamij.     Such 


METIlObS  Of  hXAMISATIOS. 


72U 


;m  apparatus  i  Fmr.  Mm  is  kmiwii  as  a  ■■plu)tn|ilii)ri',"  l\w  iihmIcI 
,livisctl  liy  I'liillips  Ix'inn  in  iimsi  l'rc<|Ui'tit  use. 


Fill   Mt 


\i> 


The  Pomen>jr  hiiidband  and  mirror. 

Tlic  relative  attitiitles  of  physician  and  i)atipnt  are  seen  by  reforent-e 
I"i<r.  Mu.     A  satisfactory  arrangement  so  far  as  seats  are  concernctl 

FlO.  365. 


Spring  bead-band. 

i<  to  liavo  the  pation.  sit  on  a  stool  which  can  bo  raised  or  lowered. 
while  the  physician  sits  on  a  revolving  stool  of  fixed  height.  Behind 
liie  natient  should  bo  a  rest  for  the  head  and  shoulders  which  can 


7;m) 


XitUt:  AM*  THROAT 


lx«  raif^'d  iiml  lowered  at  will.  Tin-  object  w  ruit  mily  to  fix  the  u|i|M'r 
part  of  tlic  ImmIv,  hut  also  to  prevent  the  patient  (in  cane  he  should 
iiitike  ail  incautious  inovtMuent)  from  doiu);  hiins<-lf  harm. 


ria.  :iM. 


Phillips'  photo|ihore. 


The  in.«truinents  ie(|uire(l  for  anterior  rhiiriscopy  aro  some  form 
of  na.xal  speculum,  a  cotton-tipped  applicator,  and  a  flexible  probe. 


Fia.  367. 


AllllU'lir  "f  phy^tielnii  nml  [wlteii, 

one  of  aluniinuni  beinji  preferred.     The  fir.«1  dilate.s  the  parts  to  Ik' 
examined   the  second  can  be  used  for  the  removal  of  any  secretion, 


^^^ 


METltom  or  iCXAMJXA  Tloy 


781 


whilf  tlic  third  fimblox  us  to  oxploro  the  (Ici'iht  rpcpxtwtt  of  the  imrcM, 
ami  l>v  f.inlart  to  .li-t«'riiiiii«'  thi-  density  of  the  tissut's.  In  th«  hands 
of  the  |irii<'tis«'(l  ohwrviT  it  f)«'c«)in«-s  priwtioully  u  prolungution  of 


Bnnwortta'i  iwwl  iiwculuoi. 

Fill    :lfi». 


Uartmui'i  nu*l  •peenliim. 


Fio.  ro. 


Fio.  371. 


Dnplay'n  luual  ipeculiim. 


(•.likel'i  spec-Hum. 


Fio.  S7S. 


\lyle«'  nasal  speculum 


Oleuon'8  nual  ipeculum. 


his  fiiigor.     Of  niusal  s|)f  cula  there  are  many  varieties,  sou  t;  of  whicli 
MP'  liere  shown.     (Figs.  368-373.) 


m^ 


7:J2 


^UtiE  A.\l>  TlIliOAT. 


Tlic  so-called  sclf-rctaiiiiu};  specula  are  not  of  such  >;reat  si'ivice 
as  their  iiaiiie  would  seem  to  indicate,  for  the  I'orci'  of  the  s|)riiij; 
ajjainst  the  nasal  ahe  incessary  to  hold  the  latter  open  is  often  painful 
to  the  patient ;  nioreoxcr  they  often  sli|)  out  durinji  an  operation,  much 
to  the  surjji'on's  discomfiture,  (ileason  claims  to  h.ive  overcome 
these  objections  by  the  instrument  which  hears  his  name.  (Fiji.  -Vi^.) 
He  states  that  it  is  impossible  to  shake  the  instrument  out  of  the 
no.se,  no  matter  how  violent  the  patient's  strufTfiles.  It  may  be 
attached  to  a  head-band,  .so  tliat  tiie  tip  of  the  nose  is  elevated, 
exjiosinfi  the  cavities  tor  operation,  thus  !ea\in{;  both  the  surgeon's 
hands  free.  With  any  instrument  the  examiner  should  be  careful 
to  exclude  his  hand  from  the  line  of  vision. 

The  |)ati<'nt  having  been  seated  as  indicated,  the  light  should  be 
so  placeil  as  to  come  from  a  jioint  a  little  behind  the  jilane  of  th(> 
patient's  faci'  and  at  the  vertical  level  of  the  top  of  his  ear.  The 
liead-mirror  is  then  adjusted  so  as  to  focus  tiie  ligiit  upon  the  nose. 
The  organ  should  be  carefully  examined  as  to  its  contour  and  sym- 
metry and  the  existence  of  lesions  in  eitiier  the  skin  or  subcutaneous 
tissue.  Certain  skin  ervthemata  may  be  due  to  intranasal  conditions 
causing  pressure.  The  condition  of  the  ahe  should  be  noted,  whetiier 
they  are  freely  open  or  collapseil,  and  whether,  as  sometimes  happens, 
they  are  contracted  during  inspiration.  Thi'  instruments  are  to  be 
kept  ill  a  bowl  of  weak  carbolic  .solution  on  a  table  at  the  side  of 
the  examiner,  ;uid  after  each  usage  sjiould  be  di|)])ed  for  a  niom(Mit 
in  boiling  water.  Too  great  stress  caimot  be  laid  on  this  matter  of 
th(>  care  of  instruments.  The  first  and  middle  fingers  of  the  left 
hand  shoulil  rest  on  the  bridge  of  the  nose,  while  its  tip  is  elevated 
liy  the  thumb.  The  blades  of  the  speculum,  warmed  and  dried,  are 
now  inserted  in  the  nostril  as  far  as  the  nasal  bones,  but  not  beyond. 
( >bv'.  usly  only  the  cirtiliiginous  |iortion  is  dilatable.  The  ahe  having 
been  gently  opened,  we  first  determine  the  position  and  state  of  the 
.septum,  noting  any  deviations  as  a  whole,  any  local  thickening,  spurs, 
or  ridges,  etc.,  and  then  the  condition  of  the  imicosa,  whether  covered 
with  the  natural  moisture,  thick  tenacious  nmcus,  crusts,  oi'  erosions, 
'["lie  nature  of  doubtful  areas  will  l)e  determine(l  by  the  use  of  the 
cotton-carrier,  which  will  r'move  .secret ions  unless  unusually  adherent. 
Till'  probe  will  determine  tlie  consistence  of  any  redundancy  of  tissue. 
The  condition  of  the  turbinated  bones  should  next  be  ascertained, 
whether  of  normal  size  and  shajie,  whether  hyjjertrophied  or  atrophie(l, 
whether  in  contact  with  the  septum,  causing  intranasal  pressure, 
and  whether  the  Heshy  masses  sometimes  seen  are  polyps  or  merely 
polyjioid  degenerations  of  the  mucosa.  The  proi)e  should  be  pas.sed 
between  th<'  bone  and  the  septum  if  possi})le,  to  iletermine  the  |)atency 
between  these  structures.  It  will  also  determine  the  presence  and 
often  the  nature  of  foreign  bodies.  \'ari;itions  in  the  jiosition  of  the 
!).itient's  head  will  enable  .ill  i)oitions  of  the  nares  to  be  lirouirht  into 
view.  Thus  it  should  be  depresse(l  in  order  to  bring  under  inspection 
the  nasal  floor  which,  it  will  be  remembered,  gradually  rises  from 


METHODS  OF  EXAMINATION. 


733 


,1„.  n'lsil  .M.tranop,  passes  ovor  a  nmn.lo.l  on.in<-i.cc  ai.-l  ll.cn  s ..  .  s 

„• . t  uluallv  hackwanl.     Corn-spunclingly.  n,  ..nler  t..  n|s,..'ct  t  ». 

<•  1  no     tl.;-  lu.a.1  shuul.i  h.  ti,.p.",l  somewhat  backNvanl      I  n.l  . 

;  Ti   .  •       irr...i.stan(M.s  tl.o  sui.criur  turl.inat<.(l  h..nc  is  no    seen  u 

;  ,  .• .     V  ew^         is  sonu'tunes  visible  in  conditions  of  n.arked 

■'  iValo  t  e  posterior  pharyngeal  wall.     If  the  patu-nt  >s 


Mtrti 


,.  »i.,.  i..tti.f  "k'"'  in   ranid  succession  we  can  some- 

;';:;:: :i;.;::;;;;;;  r .!  li'v ;:/  ti'  t.:;:..;/ of  the  ten.,  paiati  m„sde 

,     lavs  around  the -hanmlar  process  of  the  internal   pterygoid 

;   .,  e    -he  sphenoid  l.one.     Another  n.etho.l  sometimes  ot  value  is 

•^    ;      '.  ,h  nares.  ilhiminat.-  one  with  tlu-  light,  and  th.-n  look  .nto 

'tie        If  the  tissiK^s  are  inflamed  we  may  hrst  spray  with  a 

.,k      <  line  s.  l.tion  or  with  one  of  adrenalin,  and  then  wait  a  few 

iiu„e.    ef ore  proc-.-ding  with  the  examination.     The  shrinkage  of 

:;  !  whi,.h  will  take  place  from  th,-se  ap-nts  w,  1    .>tten  clear  up 

,,l,.,.ure  Doints  and  bring  into  view  lesions  previously  hull™. 

Poiterior   Rhinoscopy.      This    requires    the    use    of    the     ongue 
de~  in   tlTinaniu'r  mentione.l  below,  an.l  of  the  small  post- 
i      n  rr  r.     Som.-tinu's  th.>   ,.atient  will  have  suH.cien    control 
ver   tl        ongue  to  place   it    in   the    proper  position,  but    this    is 
elv    he  cL;.     Mir  oi^  havc>  been  d<-vis.><l  whereby  the  angle  o 
!;   'elm    nt  of  glass  t<.  handle  can  be  varie.l  at  will,  but  tins  is  m.t 
;     :.'.    V      The  gla.ss  should  first  be  cleansed,  then  warme.l    ..r  a 
V  ..      nds  ov.-r  the  gas  Hame  or  some  s.mn-.-  of  hea      until  the 
'ijht  which  immediately  forms  over  its  surface  has  <  -PF-- , 

lf^,o  source  of  heat  is  at  hand,  the    gla.ss  may  be  rubb.Ml  ^M  ^  a  lu 
,  ■  soap  and  then  rubbed  off  with  the  tmger.      .mough  of  s.    p>  h  n 
i<  l,.ft  to  prevent  the  condensation  of  the  breath  on  the  gla^s      Still 
,..  i     i    I  •  s  been  suggested  bv  liaurowicz  to  substitute  Or  the  soap 
':     .-    'l    per  cent.^.lution  of  coM  lysol.     The  mirror  is  d.ppo.l  in 
1.    obi  and  then  shaken  ,lry.     l^nough  of  the  lysol  fi  m  will 
..;,,";;;  the  glass  to  pn-vct  condensation  of  f-^^;^^ 
vi..w  is  still  ..erfect.     Lvsol  being  a  valuable  dismf.rtant   '"">  'n>lj«-< 
,".,.„olic' solution  in-  the  bowl  on  the  examiners  table         so.lo 
h„w..v..r  is  somewhat  disagreeable.     I'mally.  the  tnn p.-ratirre  of      < 
Inmor  should  always  be  tested.  a«  by  contact  with  the  skin  of  the 

''''-n,;!.;';'^' lnananivr.-s  having  been  executed,  the  mirror  is  care^ 
,„lv  passed  between  the  uvula  and  right  faucial  pillar,  and  t  en 
,;;ne,'l  so  as  to  bring  its  face  upward.  It  is  a  goo. I  }>'=';>•  '-J^; 
.,t  least    to  iH.ise  the  thinl  finger  of  the  right  hand  at  the  left  corn,  i 

■         pa  ie.Vs  mouth;   the  ,H.siti..n  ..f  the  mirror  can  then  be  varun 
.        il    Iv  rotation  of  the  han.ll.'  b.-tw.KM.  the  thumb  an.l  hnger  ot 

„  1  n.l  so  as  t..  bring  successiv.-ly  int.,  view  the  vari.ms  por  urns 
,  '  th..  nas.,pl,arynx.  While  as  large  a  mirr.,r  ^.1">"'''  ^.^^  .  ^^ 
,S,i.  ,,„n>ose  as  space  will  permit,  n..  one  vi.-w  inclu.les  the  entire 

,Vt.!  be  exainin...!.  so  by  the  n.tation  of  the  in.rr.ir  a  composite 
vi,.w  of  the  entire  region  can  be  built  up  in  the  examiner  s  mind. 


734 


A'OA£'  AyV  TUUOAT. 


Atti'iition  sliould  first  Im-  fixed  u])oii  tlic  posterior  etlpe  of  the  septum 
in  the  median  line.  .No  matter  liow  miieh  deviation  from  tlie  normal 
there  may  he  anteriorly,  if  is  very  rare  to  find  the  posterior  septum 
»)ther  than  straiftht  in  its  median  line,  although  there  may  he  localized 
thiekcnings  on  either  side.  These  thickenings  are  generally  (ed<'ma- 
tous  in  nature,  and  (luickly  disappear  under  cocaine.  Next  to  he 
determined  is  the  condition  of  the  posterior  extremities  of  the  tur- 
binates. As  compared  in  color  with  the  anterior  they  are  ajit  to  ho 
of  a  more  grayish  hue.  more  va.<cular,  and  often  are  lohulated  in 
appearance.  The  patency  of  the  choanu'  should  he  looked  into,  and 
as  well  the  condition  of  the  jiharyngeal  tonsil,  whether  enlarged  or 
not,  and  whetluT  there  is  any  persistence  of  tlie  origin;  ,1  median  cleft. 
The  edges  of  the  latter  are  .sometimes  adherent,  forming  a  ma.ss 
known  as  the  "pharyngeal  hui-sa."  ("oinplete  adherence  gives  the 
coiuhtion  known  as  cyst  of  the  bursa  or  Tornwaldt's  disease.  Lateral 
rotation  of  the  mirror  Aiil  bring  into  view  on  ,ach  .<ide  the  fos.sa' 
of  Hosenmiiller  and  the  JMistachian  cu.shions. 

The  foregoing  mameuvre  is  |)erhaps  the  mo.^t  difficult  of  all  in 
the  examination  of  the  upper  air  jja.ssages.  The  least  gagging  of  the 
p.itient  raises  the  soft  palate,  and  so  .shuts  off  the  view.  To  prevent 
this  we  may  order  a  bromide  gargle  and  may  give  the  remedy  inter- 
nally, an  ice-wat(T  gargle,  or  may  apply  a  weak  cocaine  .solution. 
In  some  obstinate  cases,  and  generally  in  young  children,  a  digital 
oxaminati<m  is  necessary.  For  this  purpose  the  head  of  the  patient 
.should  be  encircle<l  with  the  left  arm.  and  as  he  o])ens  his  mouth 
the  finger  thrusts  his  cheek  in  lu'tween  his  molar  teeth,  thus  preventing 
him  from  biting.     The  index  finger  of  the  right  hand  is  then  passed 


Fin    174. 


Br40WDCH 

While's  palate  retractor. 


rapidly  behind  the  soft  palate  and  the  various  structures  j)a'pate({ 
in  the  order  mentioned  above.  In  ca.se  this  is  not  satisfactory,  or 
if  a  wide  .space  is  n<'eded  for  in.strumentation  for  any  rea.son,  cords 
m.iy  be  pa-ssed  through  the  anterior  nares.  drawn  out  through  the- 
mouth,  and  tied  over  the  upper  lij).  thus  drawing  the  .soft  palate 
forw.ard.  X'arious  palate  retractors  have  been  devised,  the  one  in 
common  u.se  being  known  cts  White's.     (Fig.  ."^74.) 

While  such  instruments  are  occasionally  of  service,  they  are  not 
well  borne  by  the  majority  of  patients.  When  well  borne  their  iLse 
is  gener.Tny  innu'ce^sarv. 

Tr:iiisillumination  as  >is(>d  for  the  detection  of  sinus  disea.se  is 
doseril)ed  in  another  chapter. 


mm. 


METHODS  OF  EXAMISATIOS. 


735 


Pbaryngoscopy.  Tlic  jjositions  of  oxaniinrr  ami  patient  are  as 
already  dcscrilKHl.  Tlie  lips  should  Ix-  cvcrti'd  and  search  made  for 
(•rui)tioiis,  excoriations,  and  for  the  general  condition  of  the  teeth. 
Of  tongue  depressors  there  is  an  infinite  variety.  The  model  known 
as  Tiirck's  is  perhaps  the  most  useful.     Several  sizes,  all  metal,  should 

Fio.  375. 


Fig.  876. 


IJrck's  tongue  depreMor. 

ho  at  hand.     For  children  the  model  devised   by  H.  I).  Chapin  has 

proven  of  much  use  to  the  writer.     It  can  he  used  in  the  youngest 

ii\f;mt.     Tiie  utmost  care  should  be  exerci.sed  in  keeping  ail  tongue 

,1.1  (lessors  surgically  cl(>an,  and  they  should  be  sterilized  in  boiling 

water  each   time   they   are   used.      Corrugated   surfaces  should  be 

avoided  in  their  coastruction,  tus  they 

•tre  harder  to  keep  clean  and  offer  no 

advantage.   The  patient  having  opened 

tiic  mouth,  the  depres.sor  is  placed  on 

the  tongue  and  gentle  pressure  made 

directly  downward.     Force  employed 

cither  to  draw  the  tongue  forward  or 

to  push  it  backward  will  surely  excite 
pigging.  The  |)arts  having  been  thus 
(•\posed,  we  note  the  condition  of  the 
mucosa  lining  the  oral  cavity,  the  ton- 
sils, whether  enlarged  or  not,  the  con- 
dition of  the  lacuna',  whether  or  not 
tlic  faucial  pillars  are  adherent,  the 
ciiiidition  of  the  uvula,  soft  jjalate,  and 
|ili;irvngeal  wall,  whether  normal  or 
iiiHained  and  presenting  ulcerations,  etc.  As  in  the  nose,  the  use  of 
the  cotton-carrier  and  the  probe  will  elicit  valuable  information.  The 
l:itter  also  enables  us  to  determine  the  condition  of  innervation  of 
the  soft  palate.  Particular  attention  should  be  paid  to  the  color  of 
the  ))harvngeal  mucosa.  An  ana'inic  a})i)earance  is  suggestive  of 
iiii)erculosis:  patchy  symmetrical  redness  may  suggest  syphilis,  esi)e- 
•pially  if  aec.)!!-.|)anied  by  pain  without  apparent  cause:  the  throats 
nf  users  of  alcohol  in  excess  are  apt  to  be  raw,  congested,  and  intensely 
irritable,  while  tobacco  habituds  present  throats  with  a  dry,  glazed 


Cbapln's  tongue  depressor. 


736 


yOSE  AXl)  THROAT. 


surtacc.  Tlic  irritability  may  Iv  rcfcrnvl  jtartly  to  tlic  gastric  rondi- 
tidii  wliicli  always  aceoinpaaii's  to  a  greater  or  less  extent  these  two 
eonditiotis. 

The  examination  of  the  tongue  is  not  eomplete  without  the  use 
of  the  large  mirror  used  in  laryngoscopy  (see  helow),  hut  here  it 
neeii  not  he  passed  so  far  hack.  A  most  careful  exi)loration  must 
)>e  made  of  that  jHirtioti  of  the  tongue  occupied  hy  the  fourth  or 
lingual  tonsil,  namely,  the  area  hetween  the  circunivallate  papilla' 
and  the  epiglottis.  Two  conditions  should  he  looked  for,  first,  a 
possihle  enlargcTuent  of  the  tonsil  itself,  which  may  present  either 
as  a  cential  mass  or  as  l)ilateral  masses  sejiarated  hy  a  dee])  furrow, 
or  still  again  as  smalli'r  ma.s.ses  scattered  irregularly  over  the  area; 
second,  enlarged  veins  forming  the  so-called  lingual  varix  or 
liemorrhoids  of  the  tongue.  These  two  conditions  are  often  respon- 
sihl<'  for  nnich  ])harvngeal  dysa-sthesia  and  ohstinate  cough.  So,  also, 
the  glosso-epiglottic  fossa'  are  often  the  receptacles  of  foreign  hodies. 
In  examining  the  jjharynx  for  the  latter,  palpation  should  never  he 
omitted,  for  the  finger  will  often  detect  the  sharp  points  of  fishhones, 
I'tc.  not  visihle  to  the  eye.  N'arious  models  of  small  electric  lam])S 
have  heen  devised  and  can  he  passed  directly  into  the  moath,  thus 
giving  a  hrillitvnt  illumination  of  the  entire  cavity. 

Flu.  S77. 


Lari'DKnacopic  iind  rhinoscopic  mlrron. 


Larjmgoscopy.  This  re(|uires  the  use  of  the  larger  sizes  of  mirrors. 
(Fig.  'M7. 1  The  |)osition  of  examiner  and  jjatient  remaining  as  hefore, 
the  latter  ])rotrud(-s  the  tongue,  which  is  grasped  hy  the  examiner 
with  a  towel,  .lajianese  pa|)er  napkin,  or  a  small  S(|uare  of  gauze. 
The  rjauze  is  greatly  to  he  preferred  to  tow(>ls,  which  may  he  the 
carriers  of  infection,  whereas  th(  gauze  can  he  thrown  away  after 
us<>.  The  left  forefinger  of  the  examiner,  gtiarded  hy  the  gauze,  is 
laid  along  the  level  of  the  patient's  lower  teeth  just  ahov(>  the  incisors, 
and  the  tip  of  the  tongue  is  held  hy  the  thumb  without  traction, 
for  the  object  is  not  to  draw  it  forw-ird.  but  to  simply  jjrevent  it 
from  sli|)ping  backward.  The  foregoing  ]>reliniinaries  accomplished, 
the  large  mirror,  held  as  shown  in  Fig.  .'^78.  invariably  clean.sed, 
warin(>d,  and  tested  on  the  skin  of  the  examiner's  hand,  is  intro- 
dufcd  either  by  a  free-hand  movement  or  with  the  third  finger  of 
the  right  hand   resting  on  the  left  corner  of  the  patient's  mouth, 


METHODS  or  HXAMiyAi'ioy. 


737 


and  earned  h:iek\v:ird  without  toiiehinR  the  parts  until  the  point 
of  junction  between  the  glass  and  handle  rests  at  the  base  of  the 
uvula.  The  latter  is  then  lifted  gently  upward  and  backward  until 
it  is  almost  horizontal   ami  the  parts  come  into  view,  as  seen  in 


FlO.  378. 


Method  of  holdiag  the  laryngeal  mirror. 

Fig.  379,  which,  however,  is  partly  schematic  and  represents  the 
positii.n  of  the  cortls  in  deej)  inspiration.  The  various  parts  named 
should  be  carefully  iivspected  for  the  possible  presence  of  foreign 
bodies,  ulcerations,  and  infiltrations,  and  the  patient  directed  to 
tak»'  series  of  short  deep  inspirations,  so  as  to  make  the  rhyth- 
iiiieal  e.Kcursions  of  the  cords  as  pronounced  as  possible.  In  this 
way  tlieir  mobility  is  the  more  easily  determined.    The  respiratorj' 


The  larynx  In  deep  ImplraUon.  1.  Ungual  surfaoe  of  epIglotUs.  i.  ''«  laryngeal  surface.  3.  Its 
I iishion.  4.  Pharyngnepigloltlc  fold.  .)  .\ryeplglottic  fold.  fi.  eushlon  of  epiglottis.  7.  Gloseo- 
<|.iglottic  llgmnent.  «.  Glos-so^plglottic  fos.ia.  9.  SlnuB  pyrlforrais.  10.  Posterior  line  of  larynx 
adjoining  iiwiphagus.  11.  Interarytenold  space.  Vl.  Arytenoid  cartilages  surmounted  by  cartilage* 
■f  .Santorini.  13.  luterarytcnrrfd  fold  14.  Cartilages  of  Wrisbtrg,  16.  Ventricular  bands  or  false 
..nls.  li;.  True  cords.  17,  Laryngeal  ventricle.  IS.  Vocal  process.  19.  Thyroid  cartilage  2U. 
'riTO-thyrold  membrane.  ■>!.  Cricoid  cartilage.  L>-.'.  Tracheal  rings.  23.  Spaces  between  tracheal 
rings.    (Cohen.) 

<late  of  the  larynx  having  been  thus  inspected,  the  patient  is  directed 
lo  plioiiate  soiiie  vowel,  as  "a"  or  "e"  in  high  pitch.  This  act 
depresses  the  base  of  the  tongue  and  raises  the  soft  palate.  .\t  the 
>aiiie  time  as  the  pitch  is  raised  the  whole  laryngeal  bo.\  rises.  In 
this  way  the  position  of  the  cords  in  phonation  is  easily  made  out. 
.Fig.  .380.) 

47 


H5^ 


738 


yosK  A  so  tul    it. 


Flo    4SU. 


Fbonalion  poaltlon  of  the 
vocal  cords. 


In  the  civso  of  nervous  patifiits  it  is  best  to  introduco  and  witli- 
(Iraw  tilt'  mirror  several  times  l)efore  any  attempt  is  made  at  actual 
inspection;  so,  also,  some  patients  do  better  if  they  liiemselves  are 
allowed  to  hold  the  tonjjue  in  the  gauze  napkin.  By  these  devices 
their  confidence  is  jtained  and  they  understand 
just  what  is  desired.  A  point  apt  to  confuse 
l)ef;imiers  is  the  fact  tiiat  in  the  mirror  the 
antero-posterior  position  of  the  )iarts  is  re- 
vii-<ed,  so  that  the  arytenoiil  cartilages,  for  in- 
stance, seem  to  he  toward  the  examiner.  This 
fact  must  especially  he  home  in  mind  in  all 
instrumentation  within  the  laryn.v.  In  ([uiet 
respiration  the  movements  of  tiie  cords  are 
often  not  ajjpreciahle,  especially  to  a  hegiimrr 
in  larynp)sco|)y. 

Two  other  methods  of  illuminating  the  interior  of  the  larynx  are 
sometimes  used.  In  one,  ;i  small  electric  hull)  is  attached  to  the 
mirror  handle  in  such  a  way  as  to  project  slightly  in  front  of  the 
gliuss.  Tii<>  latter  is  used  as  before,  and  the  examination  can  lie 
matle  with  the  physician  and  patient  in  any  position  comfortable  for 
both:  in  the  other  the  larynx  is  transiiluiniiiated  by  a  powerful 
electric  light  placed  externally  over  the  cricoid  cartilage,  the  laryngeal 
mirror  being  introduced  as  l)efore.  This  method,  however,  shows 
little  more  than  lights  and  shadows,  and  while  it  may  detect  the 
jjresence  of  infiltrations  anil  new-growths,  it  has  never  come  into 
general  use.  All  the  information  it  gives  can  be  more  accurately 
determined  by  other  means.  Still  more  recently  the  X-ray  luus 
been  used  in  a  similar  manner  to  locate  foreign  bodies.  For  clinical 
purposes  other  than  this  it  is  no*  (^s])ecially  serviceable. 

Some  years  ago  Kirstein,  of  Berlin,  revived  what  is  probably  the 
oldest  method  of  inspecting  the  larynx,  namely,  that  of  direct  vision. 
This  he  calls  autoscopy:  jus  has  been  suggested,  orthoscopy  is, 
from  a  mechanical  point  of  view,  the  more  correct  term.  In  this 
method  an  endeavor  is  made  to  have  the  axis  of  the  mouth  cctntinuons 
with  that  of  the  lower  ])harynx  and  tracliea.  This  is  effected  by 
having  the  patient  bend  the  u])per  part  of  the  body  forward,  and 
at  the  same  time  throw  the  head  slightly  backward.  Xo  mirror  is 
u.sed,  but  rather  a  specially-sha|ie(l  tongue  de|)res.sor,  to  which  may 
be  attached  an  electric  light.  The  examiner  looks  down  upon  the 
cords  them.selves  and  not  ui)on  an  image  of  them.  Kirst(>in  claims 
that  this  method  is  applicable  in  about  one-half  of  all  jiatients,  a 
statement  which  is  not  borni'  out  by  common  experience.  The  method 
is  without  ana'sthesia  often  painful  and  nM|uires  an  umisually  good 
control  of  the  parts  by  the  patients  themselves.  Foreign  IxkUcs  have 
been  removed  with  the  aiitoscope  in  positio!\  and.  we  belie\".  sonie 
tumors,  but  the  instruments  require  a  special  shape,  and  the  method 
has  never  come  into  general  use. 
Still  another  method  of  practical  value  is  that  of  Killian.     Here 


IILUUL 


METHODS  OF  EXAMlXATJoy. 


739 


tin-  patient  stands  up  or  sits  witli  tiic  iiead  IxMit  forward,  wliilc  tin- 
cxarniiicr  Ivnccis  before  liini  and  lioids  tlie  haek  of  the  mirror  up 
apiinst  tl-e  uvula.  Tiiis  enai)les  us  to  Ret  a  view  not  so  much  of 
tlie  anterior  part  of  tiie  larynx,  as  by  the  usual  method,  but  to  see 
tlie  posterior  wall,  the  |>osterior  ends  of  the  cord,  and  occasionally 
-lijihtly  underneath  their  surface. 

The  forepoing  manipulations  have  been  spoken  of  as  ea.sy  of  |)er- 
tormanee.  They  >;enerally  are  after  a  little  practice,  but  occasionally 
a  patient  is  seen  in  whom  the  configuration  or  irritability  of  the  ])aris 
renders  it  impo.ssible  to  see  anything  whatever  until  he  has  been 
-ubjected  to  a  course  of  training.  No  force  should  evt>r  be  used, 
instruments  should  be  warmed,  every  movement  on  the  part  of  the 
cx.-iminer  should  be  deliberate,  and 
rverything  be  done  to  secure  the  pa- 
tient's confidence.  On  the  least  appear- 
ance of  retching  the  mirror  should  be 


Fio.  3*1 


thdra 


(I 


il  the 


Nasal  spray  tubes. 


and  not  runserted 
patient  has  had  full  time  to  rect)ver  him- 
self. Persistent  gentleness  will  finally 
overcome  all  ob.stacles  and  enable  one 
to  secure  an  intelligent  view  of  the  laryn- 
j;ral  structures. 

Douches  and  Sprayt.  In  nearly  all 
cases  of  na.sal  disease  some  method  of 
cleansing  is  neci-ssary,  and  a.s  this  con- 
stitutes the  major  part  of  home  treat- 
ment it  deserves  detailed  consideration. 
Medicinal  agents  are  a]>()lied  to  the  nasal 
tnssu'by  means  of  spraj's,  douches,  etc., 
or  topically  by  means  of  the  cotton  carrier,  powder  blowers,  or  in- 
lialers. 

For  jjurposes  of  spraying  we  have  at  our  command  the  familiar 
-jiray  tubes  for  office  u.se.  which  may  be  supplied  with  air  from  a 
reservoir  filled  either  by  hand  |)ower,  hydraulic  motor,  or  electricity, 
for  home  use  the  Bosworth  atomizer  answers  every  need.  Many 
I  if  the  various  atomizers  on  the  market  are  objectionable  in  that 
they  throw  too  fine  a  spray.  The  ordinary  toilet  atomizer  is  entirely 
useless  for  the  treatment  of  catarrhal  states.  If  the  menstruum  for 
ilie  medicinal  agent  is  an  oil  or  vaseline,  a  special  form  of  atomizer 
i<  reciuired,  and  we  have  found  the  one  herewith  shown  (Fig.  384) 
lo  answer  every  purpose.  In  ca.se  vaseline  is  used  the  whole  bottle 
ran  b(>  immersed  in  hot  water  for  a  minute  or  two  until  the  contents 
are  li(|iiefied. 

Of  preparations  made  with  water  as  a  ba.«e  there  is  an  infinite 
variety.  M  the  outset  it  may  he  said  that  the  faithful  and  systematic 
use  of  any  one  of  a  very  large  number  that  might  be  mentioned  will 
;itVord  better  results  than  the  desultory  employment  of  some  fanciful 
and  new  formula.     In  many  cases  a  .sterilized  normal  salt  solution 


mim 


740 


yilHJ-:  A.\D  THROAT. 


answers  rvcry  rciiuirciiKMit.  Tlic  ailditioii  of  an  alkali  is  often  ad- 
visable, and  we  may  order  the  familiar  coinbination  of  eijual  i>arts 
of  connnon  salt,  IncarlHUiate  and  borate  of  soda,  one  teii.s|)o<)nfiil  to 


Air  pump  and  reservoir. 
Fio.  383. 


Naaal  atomizer. 


a  pint  of  lukowarni  water.  The  object  i.s  to  prepare  a  solution  which 
shall  have  the  saline  strength  and  temperature  of  the  nornial  blood 
plasma.     There  is  thus  no  osmosis  through  the  nasal  mucosa  from 


METHODS  OF  KX.lMIS.lTluy. 


741 


saliiK'  solutions  of  dilTcrciit  densities,  and  no  harm  to  delicate  struc- 
tures from  a  sudden  elian^e  in  temperature.  Ten  grains  of  the  salic- 
ylate of  soda  may  l)e  added  to  each  teaspoonful  of  the  ahove  mixture. 
When  distinct  antise|)tics  are  needed  there  is  a  wide  variety  to  choose 
from.  Li.sterine  and  the  familiar  Seller  tablet  are  perhaps  the  most 
widely  known.  Boroly|>lol  htu*  given  the  writer  much  satisfaction.  It 
may  l)e  us<'d  in  the  strength  of  1  to  5(K).  Of  all  the.se  i)reparations  one 
or  two  teaspoonfuls  can  lu'  used  in  a  ghtss  of  lukewarm  water.  .Many 
more  might  be  mentioned,  hut  while  the  writer  has  no  objection 
against  recommending  prejiaratioiis  made  by  manufacturing  clu-mists 
who  confine  their  sales  to  i)hy.sicians  and  druggists,  it  is  important 
to  iK-ar  in  mind  the  limitution.s  of  this  class  of  remedies.  To  say 
that  they  cure  catarrh,  as  is  alleged  by  some  of  their  promoters,  is 
not  true.  Thi-y  cleanse  the  na.sal  i)assages;  if  alkaline,  they  will  have 
a  detergent  effect  and  so  slightly  reduce  redundant  ti.ssue,  bu'  they 

Fio.  3M. 


Vaseline  atomizer. 


are  not  strictly  curative  for  other  jjrocedures  are  often  nccessarj'. 
They  h.'ive  an  antiseptic  action,  r»,Ithougli  from  the  fact  that  the  nares 
:in>  constantlv  flushed  with  bacteria-laden  air,  it  is  not  possible  to 
maintain  ui  ii.s;>ptic  condition.  With  the  foregoing  prejiarations  all 
the  jiroblems  of  intranasal  medication,  so  far  as  concerns  acjucous 
solutions,  can  easily  be  met. 

Many  persons  who  suffer  with  hypertrophic  rhinitis  are  fairly  coni- 
fortable  so  long  as  they  make  the  nasal  toilet  once  or  twice  (laily. 
They  become  accustomed  to  this  procedure  and  do  not  mind  it.  In 
iiiaiiy  such  cases  no  surgical  intervention  is  at  all  necessary.  The 
foregoing  statements  .seem  to  be  a  fair  exposition  of  what  aciueous 
<iihitioiis  do  in  the  nose.  The  indefinite  claims  of  many  chemists 
that  such  solutions  will  cure  catarrh  by  stimulating  the  mucous 
membranes  i.s  absurd.  Most  noses,  at  least  in  northern  climates,  are 
I  'verstimulated  already. 

hi  recent  yc'ti-s  various  oily  menstrua  have  become  very  popular. 
riiey  may  often  be  used  with  great  advantage  after  the  nares  are 
1  leansed  by  watery  .solutions.  They  mechanically  coat  over  and 
protect  the  delicate  tissues,  and  may  also  be  the  carriers  of  various 


742 


AOA/i  AM)  Til  IK  I  AT. 


Klu.  :i)Wi, 


Mictliriiial  .•lR(•Ilt^'.  Of  tlicsi'  oils  allxiliiic,  l)onz()iii(>l,  aii<l  cucalyptol 
may  Im-  nainril  as  types.  Tlicy  may  1m'  used  citiitT  pure,  or  contain 
in  solution  or  mixtuir  such  rctiH'dics  as  menthol,  pine-needle  oil, 
resorcin,  eamplior.  etc.  I'lvery  physician  has  his  favorite  comhina- 
tioii;  hut  here  apiin  it  is  to  l>e  noted  that  the  faithful  and  sy.stematic 
use  of  any  one  properly  indicated  will  );ive  more  satisfactory  results 
t'''in  the  desultory  employment  of  th<'  latest  pharmaceutical  fad. 
Of  course,  the  f;eneral  truth  is  applicahle  here  as  elsewhere,  that  a 
remedy  tiiay  after  a  time  h)se  its  ertcct  and  may  pro|)erly  he  replaced 

by  another,  even  of  the  same  cla.ss,  hut 
tiie  general  caution  >;iven  is  justified. 
It  should  he  added  that  there  is  a 
limit  to  the  .idvantaKes  of  oily  prepa- 
rations, for  if  continued  too  lonji;  they 
are  apt  to  caus<'  a  dryness  of  the  na.sal 
mucosa.  I'iach  case  must  he  consid- 
ered hy  itself  and  watched  to  prevent 
the  occurrence  of  this  result. 

tM'veral  other  methods  of  cleansing 
till-  nasal  fo.s.sa'  are  yet  to  he  men- 
tioned. .\  \cry  useful  device  is  that 
shown  in  Fig.  ."is.^,  in  which  a  soft  ruh- 
ber  catheter  with  a  nuniherof  perfora- 
tions along  its  sides  is  attached  to  the 
common  rubher  hand-hulh.  It  is  filled 
by  suction,  and  the  mode  of  use  is  at 
once  apjjreciated  by  reference  to  the 
figure. 

Again,  the  nares  may  be  cleansed  by  the  nasal  douche  (.jxTjited 
on  the  jirinciple  of  the  ordinary  fountain  .syringe.     This  method  has 


Iiitniiia>Hl  iutheter-syrin8:e. 


Klo    38fi. 


NiisKi  douche  fuii. 


i  i 


the  disadv  -'tage  of  being  liable  to  injure  the  lui.stachian  tube  and 
of  causing  possible  middle-ear  trouble,  M.any  pati<iils.  however,  can 
use  it  with  safety.  During  its  employment  the  mouth  sliould  be 
held  ippeii,  the  >oll  [palale  iai>cd,  and  all  ai!em|)is  at  swallowing, 
speaking,  etc.,  carefully  avoiiled.  Xo  patient  should  1k>  allowed  to 
inaugurate  the  process  himself  without  a  previous  dem(mstration 
by  till'  physician  either  on  himself  or  on  the  patient.     Many  ])hysi- 


METIIOltS  Of  KXAMIXATIOS. 


743 


ciaiis  coikU'Iiih  thp  ni.tli<i.l  i-titircly  fi«r  the  rnisoii  alx.vc  stated  An 
.Hicifut  sul)stitut.'  is  tlic  iinsal  .lmi<'  ]>.  Muny  "f  til"'**'  ^^«>l«l  m 
th.'  inark.'t  arc  •■ntiri'ly  l<>"  s.nall.  'In;-  fui.  should  hav.-  a  capacity 
(il  at  least  .V)  c.c.  The  saiii"  precautions  should  i)e  ohserved  as  with 
the  louche.  The  l.ulk  of  tluid  us.-d  in  llushii-n  the  nose  in  thit*  manner 
..,..  IMS  to  he  more  ethcient  than  thi-  hue  sprays. 

Klu.  3«7. 


nHnl  ruliber  («»tn»«l  »yrt!ife. 


For  cleansing  the  nare-<  from  Ixhind  we  may  use  either  an  atonuzer 
with  a  louK  curv<>d  tip,  which  the  patient  learns  to  l-ii-ss  In-hmd  t he 
M.lt  palate,  or  the  hard-rul.her  postnasal  syrin^'c.  (I' IR  :iSi  )  Ihe 
l-ittcr  i~  a  most  useful  instrument  for  otiice  use.  It  should  Im'  eare- 
fullv  introduced  I.etwe.M.  the  uvula  and  the  faucial  pillar,  care  beuiR 
iMken  not  to  injure  the  soft  pahite  if  the  jKitient  makes  an  incautious 


KiQ.  ;iiw. 


Phllllpn'  TOtton  holder. 

,M.,v.Mnent  Tt  so  divides  the  stream  of  fluid  hy  means  of  the  per- 
forations in  its  tip  that  the  .lelieate  Eustachian  cushions  are  not 
in.ured  and  vet  the  v<.lum.>  of  fluid  is  amply  sufhcient  to  thorouRlih 
,.|;.aM<.>  the  eiitire  postnasal  space.  .\fter  using  any  nasal  cleansmp 
Ihild  tlie  i.atient  should  blow  the  nose  gently,  always  having  one 

"' Tru'li'ppiicati.m  of  ].igments  is  generally  made  with  a  cotton-carrier. 
.\  piece  of  copper  win'  roughene.l  at  the  end  and  inserted  in  a  imrror- 


f 


744 


yost'  .IA7>  Til  no  AT. 


Imiullc  answers  t-vcry  puriM.sc.  ("otlon  should  Im-  krpt  in  a  riTcptai'lf 
such  a.s  is  shown  hrrcwith.  (liji.  '.iss.)  The  nose  is  (irst  clfanscil  and 
then  dried.  The  niedieinai  ajtent  can  lie  apphed  to  any  special  [H-rtion 
of  tissue  as  desired.  The  preparations  most  commonly  used  are 
stimulating  agents  for  atrophic  comlitions— c.  </..  ichthyol  for  atrophic 
rhinitis,  varied  in  strennth  according  to  the  decree  of  atrophy,  1h*- 
Hinninjj  with  10  per  cent  ichthyol  in  jjlyccrin  or  alteratives  in  hyper- 
trophic conditions.  A  valuable  comhination  for  the  latter  purpt»<e 
consists  of  iodine  j{r.  v,  pota.-^.-.  imlid.  ^r.  \,  in  half  an  ounce  of 
j;lycerin.  This  is  u.si-d  in  increasinn  strengths  as  the  ca.se  proj;res.s«>s 
toward  recovery.  Another  coinhination  is  made  of  cocaine  pr.  xl, 
lialsam  of  Peru  .Vs,  oil  of  peppermint  and  ali-ohol  aa  ."ivj. 

If  the  means  used  for  cleansing  the  nares  prove  ini-tlicient  for  the 
removal  of  thick  crusts,  we  may  employ  various  kinds  of  forceps. 
Knight's  dressing  force|)s  are  sutficient  for  this  jjurpose.     (Fig.  ;{,S<J.) 


Kill.  ist. 


Knight'i  iiual  ilrewing  rorc«|«. 
Flo.  ;)au. 


Ntial  insntnatnr. 


For  the  api)lication  of  powders  the  insufflator  shown  (Fig.  390) 
will  suffice.  It  is  simple  in  construction,  eiusy  to  keep  clean,  and 
answers  just  as  well  as  the  more  elaborate  powder  blowers. 


MKTUOltS  OF  EX.IMIXATIOX 


(4a 


liiuilly.  wp  iiiiiy  affect  the  imsal  iiiucdta  l>y  hiiviiiK  tlx-  |.atn-nt 
mlialf  various  n-iuc<lifH,  hut  fur  tliin  purpose  no  s|M'cial  a|»paratus  is 
n',|uireil.  The  »u><lieiiuii  apeiit  may  In-  <lrop|M'(l  on  ••.ttoii  phiced 
ill  an  onhnary  sinelHiiK  salts  lM)ttle.  This  hitter  is  as  rooiI  sis  the 
more  ehiborate  inhalers. 

Oocaine  and  Suprarenal  Extract.     The    n-medy  generally  ein- 
plove.1  for  local  anusthesia  in  the  now  is  oocuiTie  muriate.     It   is 
iv.ciiiunended  ih.it   the  remedy  U"  kept  in  the  physicians  oHice  in 
powi'  'i-s  of  definite  strength,  so  that  one  dissolved  in  a  drachm  of  sterile 
water  will  make  a  10  per  cent .  solution  which  can  he  diluted  as  desired, 
lor  the  ordinary  intranasal  operations  10  or  even  20  per  cent,  may 
lie  used.     There  is  doubt  as  to  the  necessity  of  such  strengths.    Some 
time  may  In*  gained  by  their  use,  as  naturally  thf  stronger  the  solu- 
tion the  more  of  the  drug  absorbed  in  a  given  time;    but  for  such 
procedures  as  the  u.se  of  the  cautery,  saw,  cutting  f-)rceps,  snare, 
etc.,  a  .'»  per  cent,  solution  is  .strong  enough,  especially  if  there  Ix? 
added  then  to  2  per  cent,  of  sodium  sulphate.     The  latter  remedy 
lavors  absoiplion.     It  is  a  good  plan  to  spray  the  nostril  first  with 
a  _'  per  cent,  solution,  and  then  apj.ly  the  5  per  cent,  on  cotton,  which 
>liould  remain  in  contact  with  the  field  of  operation  for  at  least  ten 
minutes.     If  the  spray  Ik-  used  care  should  1m'  taken  that  the  amount 
of  drug  used  does  not  exceed  a  safe  internal  dose,  and  for  that  reason 
the  atomizer  or  sprav  tube  should  1m>  graduated.     The  cotton  i)ledget 
^llollld  l)es(iupezedsufhciently  to  prevent  dripping,  and  after  its  ai)pli- 
<ation  the  patient  should  incline  the  head  slightly  forward,  so  that 
tiiere  can  b(>  no  possible  trickling  of  the  overflow  into  the  iiiuscjpharynx. 
!:  this  occurs  i)haryngeal  reHexes  are  set  up  and  it  is  difficult  to 
control   the  i>aiient.     IdiosyiuTMsy  to  cocaitie  is  one  of  the  things 
that  cannot  1h"  foreseen,  and  the  iihysician  .should  always  handle 
this  [lowerful  remedy  with  circumspection. 

Where  constitutional  symptoms  occur  we  most  commonly  note  a 
Iceliiig  of  constriction  about  the  throat  and  jKissibly  the  chest,  with 
|.;i!e  face,  dilated  pupi'.s,  and  rapid  pulse.     If  these  syini)toms  sujier- 
\rii,.,  all  further  attempts  at  operation  must  for  the  time  be  discon- 
tinued.    The  patient's  clothing  should  b'  loosened  alM)Ut  the  neck 
:ind  chest,  he  should  lie  with  head  low,  and  a  simple  stimulant  given 
-e.  (/.,  an  matic  spirits  of  ammonia.     In  seven"  cases  stn)ng  coffee, 
latTeine,  or  spirits  may  1h'  needed.     The  utmost  caution  should  be 
.xeipised  in  placing  solutions  of  the  remedy  in  the  patient's  own  hands. 
It  it  is  ever  necessary  it  is  advisable  to  keep  him  in  ignorance  of 
'he  nature  of  what  is  onlered.     The  freedom  with  which  cocaine  is 
^niil  by  druggists,  the  familiarity  of  the  laity  with  it,  and  the  numerous 
•  ases  of  the  cocaine  habit  which  in  n-cent  years  have  been  n-ported 
jiv  i'ollowing  its  use  in  the  nose,  all  render  these  cautions  more  than 
!'^rf'.!!K-(()ry.     We  know  of  no  fatal  c.i.ses  fmm  the  «'ffect  of  a  single 
iiitranasalapijlication,  but  there  have  l)«>en  s«'veral  narn)w  escaiK'S. 
In  view  of  attendant  risks,  an  effort  hius  been  made  to  find  a  sub- 
-titute  for  cocaine  possessing  equal  aniEsthetic  power,  but  devoiil  of 


I 


11 


n 


^     II 

J; 

fi 
u 


746 


yoSlC  AM)  TlinoAT. 


iliiimn  .  \  ai'imis  iiiodifictitidiis  of  (■(icttiiic  itscll'  liavc  Ix'cii  sii<rf;('st('(|, 
ncilal)ly  plii'iiatc  of  cDcainc.  wliicli  is  liifihly  (•oiiiiucikIimI  hy  various 
(•liniciaiis.  It  needs  to  l)e  f;iveii  in  sli^Hitly  stnmjier  slreiifitii  than 
does  tiie  cocaine  itself.  TnijMicocaine.  an  alkaloid  oi)tained  tnun 
.lava  cocaine,  is  another  sui)stitnte,  Imt  has  iiover  come  into  jjeneral 
use.  liucaine  cX"  and  'W')  has  heen  (|uite  extensively  eni|i!oyed 
in  a  t)  per  cent,  solution  in  the  same  f;(>iieral  way  as  cocaine.  IIolo- 
caiiie  is  another  remedy  of  this  class.  The  three  latter  are  undoiiht- 
edly  less  fjenerallv  ellicient  than  cocaine,  hut  accordiiif;  to  universal 
experience  are  freer  from  toxic  efTects. 

Ignite  another  class  of  remedies  for  the  i)uri)o.se  of  aiuesthesia  is 
represented  hy  guaiacol.  Its  etTects,  however,  are  more  or  less  uncer- 
tain. It  may  he  dissolved  in  .-ileohol  or  preferably  in  olive  oil,  as 
the  latter  metistnunn  is  less  irritatinj;.  (iuaiacol  does  not  mix  re.adilv 
with  olive  oil  even  the  purest.  Th(>  latter  imist  first  he  cleared  df 
its  allmminoids,  resinoids,  and  coloring:  matters  hy  zinc  sul])liate, 
and  of  its  fatty  acids  by  ahsoluto  alcohol.  The  followini;  mode  of 
preparation  has  been  foimd  by  exjierience  to  be  a  suitable  one:  To 
a  friven  wei>;ht  of  oil  10  per  cent,  of  dried  zinc  sulphate  (by  w(>ight  i 
is  added  ;uid  the  mixture  heate(l  ovei  a  water-bath  for  one  hour. 
It  is  thi'ii  filtered,  and  then  12..')  jier  cent,  'by  weifjht)  of  absolute 
alcoiiol  is  added.  Tin  n.ixture  is  frrMiuently  shaken  for  a  few  davs 
anil  then  decanted.  The  result  is  a  cle.ar  limpid  fluid  with  which 
Jiuaiacol,  say  .')  per  cent.,  mixes  re:i<lily.  The  aiuesthetic  action  of 
jiuaiacoj  is  much  slower  th.an  that  of  cocaine,  as  we  nmst  wait  some 
fifteen  iriinutes  for  absorption  to  occur.  It  h;is  no  adv.antafie  over 
cocaine,  but  is  often  a  reliable  substitute  if  for  any  reason  the  cocaine 
i>  inailmissible. 

It  may  be  tioted  here  that  the  effect  of  cocaine  is  greatly  prolonf;ed 
by  the  subse(|uent  apjilication  of  a  4  \m-  cent,  watery  solution  of 
antiiiyrine.  The  latter  is  also  an  excellent  ha'inostatic,  but  has  no 
direct  ana'sthetic  etTect. 

A.  \.  dray  has  recently  siisigested  the  followinfr  modification  in 
the  use  (pf  cocaine.  He  employs  two  solutions.  Solution  \  consists 
of  cocaine  hydrochlorate,  20  per  cent,  in  rectified  spirit:  solution  H 
ol  from  l.">  to  20  per  cent,  of  eucaine  "H"  in  aniline  oil.  Some  of 
the  euc'iine  does  not  entirely  dissolve  in  this  strenjith,  and  the  bottle 
should  be  well  shaken  whenever  used.  Ten  minims  from  each  solu- 
tion ,ire  mixed,  the  (hiiil  speeilily  becominj;  clear,  (iray  .admits 
that  this  combination  is  somewhat  burninji  in  the  nose  and  throat, 
hut  claims  that  this  dis.advantasre  is  more  than  comi)ensated  for  by 
the  deeper  .ana'sthesia  obtained.  ;ind  es|)ecially  by  the  absence  df 
syiMiitoms  of  cocaine  intoxication.  He  a<lvises  its"  application  on  a 
strip  of  jrauze  nitlier  th.an  on  cotton.  The  .|uantity  mentioned  is 
i|uite  suHicieiit  for  the  |)aiiiless  ri'inoval  of  .septal  spurs,  cauterization, 
etc..  .and  even  f,.r  the  painle<s  excision  of  toiwijs  !n  tipjilyin-r  tlie 
remedy  theelTe'.l  appears  to  be  j:re;itly  (Mlhanced  if  it  is  jrentiv  niijbed 
for.a  few  seconds  over  the  field  of  oper.ation.     ( )ne  di.sadvanta<'i'  noted 


METHODS  OF  EXAM  ISA  TloX. 


i4; 


marked 
fibre  of 


in  one  or  Uvo  iiislanccs  lias  he,>ii  tlie  effect  of  tlie  aniline  oil,  wlucli 
i.  a  powerful  n.nii.uiM.l  aiul  has  eause.l  a  peetihar  l.lueiU'ss  ot  the 
lips,  siipi.osedly  due  to  the  conversion  of  oxylueniojilohin  of  the  hlood 
into  nietlueniojilohin.  .    . 

Si  I'UAHKNAi.  KxTKACT.   Quite  a.s  valuable  n.  ii.    •«  n  field  as  cocaine 
l',,r  aiuesthesia   is   the  su]>rarenal  extract,     .inli  iiu-   su. 
iK.niostatic  properties.     It  acts  on  the  uti  tiip^  d  jnnsc  ul 
tlic  vessel   walls,  whereas  cocaine   prodiic      it-   constii.ig:  ijl  ettects 
ihroURli  the  inedimu  of  the  vasomotor  n.   ""      At   first   the  dried 
saccharated  fjlaiid  wa.s  employed  in   powder.     A  rei>;-    (luantity. 
<-,v  twenty  firains,  mav  be  a.hh-d  to  a  drachm  of  sterile  water  and  the 
n-ultinf:  inixture  eni|')loved  on  cotton  i)ledpcts.     A  more  satisfactory 
method  is  to  allow  the  !nixtun>  to  stand  for  twenty-four  hours,  with 
fr,..,uent  shakliift,  and  then  to  filter.     The  result  is  a  fluid  of  a  port- 
wine  color  with  an  odor  like  that  of  pepsin.     All  th.'  foregoing  troiibl." 
lias  iK.w  b.rn  obviated  bv  the  isolation  of  the  active  principle  known 
•,..  adrenalin,  which  in  waterv  solution  makes  a  colorless  lu|Uid,  an( 
i-  <old  in  the  streiifith  of  I  to  KKM).     This  may  be  dilute.l  for  clinical 
,,<,.  to  even   1   to  oOOO.     It  possesses  all  the  ha-mostatic  i)ropenies 
.,t  the  crude  extract,  and  is  much  more  agreeable  to  handle.     More- 
over it  can  be  sterilized  at  each  use  without  impairment  of  its  lueino- 
Matic  pro|ierties.     If  then  we  prejiare  our  operative  field  by  cleansiiifi. 
(Irvin'r    cocaine  application  for  ten  minutes,  anil  adrenalin  ai)i>lica- 
ti,;,,  fur  hve  minutes  more,  we  have  an  ana'sthetic,  bloodless  area    or 
id.'al  conditions  und.'r  which  to  operate  (luickly,  safely,  and  agreeably. 
Cocaine  and  adrenahn  can  al.so  be  combined  m  the  same  solution 

In  the  use  of  this  class  of  remedial  agents  it  must  never  be  for- 
.'olten  that  reaction  alwavs  follows  the  immediate  effect  an<l  that 
[here  is  alwavs  subse(|iient  rela.xatioii  of  the  vessels,  with  jiossib  e 
l„anon-ha"'e  '  ('onse(|Uentlv  the  post-oi)erative  tamponment  should 
never  be  neglected.  Following  the  general  law  that  action  and  reac- 
tion are  e.|ual.  though  opposite,  it  might  be  supiiosed  that  vascular 
nl.axation  after  adrenalin  would  be  dangerously  severe.  On  this 
point  clinical  opinions  are  at  variance.  Personally,  we  have  never 
had  reason  to  temper  our  first  enthusiasm  over  the  immense  value 
nf  liiis  agent  in  rhinological  i)ractice. 

\.lrenalin  taken  internallv  raises  the  blood  pressure  to  a  m)talile 
ae.M-ee  It  Would  .seem  the  remedv  par  excellence  for  con.htions  o 
i  lit  umescent  rhinitis,  such  as  occurs  in  hay  fever  and  other  allie(  clinical 
Mates.  That  it  has  a  >st  admirable  effect  here  cannot  be  d.mbted. 
li  ,iets  promi.tlv,  do,  lot  seem  to  lose  its  j.ower  by  frequent  repe- 
iiti,,n  .and  causes  no  svstemic  disturbance.  The  claim  is  made  that 
it.  inlern.al  a.lministrat'ion  is  beneficial  in  hay  fever.  On  thecmitrary 
it  is  asserted  bv  some  eminent  jilivsiologists  that  it  is  decomposed 
111  stomach  abs.iri.tion,  :md  that  it  cannot  possibly  exert  through  this 
...,i,!,!ab«ut  channel  anv  local  effect  on  the  nasal  mucosa.  On  such 
,1  point  as  this  we  need  'furthiT  testhnony.  ( )ccasionar.y  its  n  action 
I-  so  severe  as  to  cau.se  an  actual  (cdeiua  of  the  mucosa. 


r48 


SUHE  ASO  TlIliUAT. 


Epistaxls.  llxcluiliuK  llu'  call's  due  to  accidciytai  or  surgical 
trauma,  tlic  most  lfc(jii("iit  source  of  misal  lieiiiorrliaf;e  is  tlic  septum. 
Its  anterior  mucosa  is  relatively  thin. and  i)earin<j,as  it  does,  the  im])act 
of  the  vjirious  irritants  from  the  iiisjjired  air,  it  easily  becomes  eroded. 
TIk-  liability  of  this  accident  is  increa.sed  if  a  spur  exists  at  this  point. 
A  crust  is  formed  by  the  ini.vtiire  of  dust  and  mucus,  and  this  is 
carelessly  removed  by  the  jjatient,  who  takes  otf  some  of  theei)itlielial 
covering  of  the  nuicosa,  generally  by  the  coimnon  habit  of  '•pickiiij; 
the  no.sc."  The  moist  surface  tints  left  attracts  other  dust,  new 
crust.s  form  and  are  removed,  and  finally  we  have  a  true  erosion. 
Ilemorrha.fje  at  this  site  is  favored  also  "by  the  distribution  of  the 
se])tal  artery,  which  is  a  branch  of  tlie  upper  coronary  from  the  facial. 
Tl-.e  erosion  prows  deeper  and  (h'e])er,  and  may  finally  perforate  the 
septum.  After  this  happens  the  edfr^.s;  ,,f  the  oi)eninfi  generally  heal 
and  the  liability  to  bleedin<;  disappears.  Hlood  effused  in  one  nostril 
may  run  backward  around  the  posterior  edge  of  the  septum  and 
escajM'  anteriorly  from  the  other  side. 

Most  nose-bleeds  cea.se  of  their  own  accord.  The  familiar  cold 
etTusion  to  the  back  of  the  neck  acts  through  the  medium  of  the 
vasomotor  nerves,  and  checks  some  of  the  milder  ca.ses.  In  those 
coming  uiuler  the  attention  of  the  physician  the  tii-st  thing  to  do  is 
obviously  to  locate  the  bleeding  point.  The  nose  should  therefore  be 
cleansed  with  cotton  pledgets  or  by  syringing  with  a  warm  alkaline 
(<T  common  .salt  .solution.  Hot  water  alone  is  .sometimes  efficacious. 
If  the  bleeding  area  is  small,  pressure  with  a  It  of  gauze  may  be 
sufficient.  It  is  well  to  coat  the  gauze  with  a  bit  ol  .soft-rubber  tis'sue, 
so  that  its  removal  will  not  start  up  the  bleeding  afresh.  The  appli- 
cation of  the  solid  silver  .stick  often  stojjs  the  hemorrhage  instantly, 
although  it  is  well  to  protect  the  area  subsequently  with  a  bit  of  cotton. 
Instead  of  the  silver  we  may  use  chromic  acid  or  the  galvanocautery 
heated  to  a  dull  cherry  red.  If  the  bleeding  comes  from  a  i)oint 
which  we  cannot  definitely  locate,  such  local  measures  are  inapjili- 
cal)le,  and  we  may  use  a  syringeful  of  ])ure  hydrogen  jieroxide.  This 
generally  causes  immediate  cessation  of  the  "flow,  and  gives  us  time 
in  which  to  arrange  more  permanent  measures.  Cocaine  and  adrenalin 
solutions  are  not  of  much  .service  in  checking  bleeding  which  has 
been  going  cm  for  some  titne.  for  the  fkiw  prevents  proper  absori>tion 
of  these  remedies.  ( )ccasionally,  however,  adren:din  will  under  these 
conditions  act  surprisingly  well". 

W  hen  it  becomes  necessary  to  i)ack  t:i-  naris  a  long  strip  of  gnuze 
not  over  li.alf  an  inch  in  width  may  be  used  either  drv  or  dipped  in 
some  iistringent  .solution.  We  have  found  a  l.')  per 'cent,  solution 
of  the  aceto-tartrate  of  alum  very  valuable  for  this  purpose.  It  is 
antiseptic  ;is  well  as  .astringent.  By  means  of  nasal  dressing  forceps 
the  end  of  the  strip  is  laid  .aN.ng  th'e  floor  of  the  no.se,  which  is  then 
packed  in  sui-cessivi-  loops  from  ixlow  upwani,  I'are  lieing  taken 
that  the  'oops  are  carried  back  bey  id  the  bleeding  point."  In  re- 
moving the  gauze  it  is  well  to  moisten  it  by  allowing  it  to  soak  up 


METUODH  OF  EXAMIXATIoy. 


749 


Fio.  391. 


.mu>  wann  alkalin.'  s,.luti.m;   if  it  ,    vnnoyvd  when  hll<  Ij  •       In." 

n.l.lMT  tissue  nuMitionoa  al...vc  is  .>si...cially  scrv.cca hlo  lu-n-.    A  bli  ul 
,H.4>in.'  ..f  the  gauze  int..  the  nostril  is  t..  he  (•(.n.U'nuie.l,  us  is  a  so 
e      ;rof  iron  solutions,  which  leave  a  thick  n.ag.na,  ''-"""S  "  ^J 
i  ,<,„.ction     The  antero-posterior  jiackinfj  is  i.-eh  the  pre  erahle  plan. 
u:0  harpen  that  xL  bleeding  point  is  v  h-M-k  that  plugging 

„f    lie  posterior  nares  is  calle.l  for.     The  instrument  generally  sug- 
.es  el  L  this  purpo.se  is  known  as  liellocq-s  canula.     A  sinal    so 
nihlxT  catheter  is  just  as  serviceable  and  far  more  likely  to  be  at 
,         O  -ith  a  little  vaseline,  it  is  pa.ssed  through  the  nans 
t  fit  ap  K>ars  in  tlu-  pharynx,  whence  by  means  of  torc-ps  it  m 
.    ,   ou  'through  the  mouth.     To  its  end  is  attache.l  a  cord  which 
i'   passed  in  the  mann.T  above  describe.l.     T..  the  end  ..f  the  cord 
hanging  out  of  tlie  mouth  is  fastened  a  tampon  of  gauze   and  then 
l,y  traction  on  the  cord  from  the  nares  the  tampon  is  drawn  into 
the  mouth,  being  guided  by  the  finger 
ui.  behind  the  soft  palate  into  the  naso- 
pharvnx    and    posterior    naris.      The 
manipulation   is  seen  by  reference  to 
I'ig.  im.      The  tanijK)n  should  be  so 
att'liched  to  the  conl  that   one  end  of 
the  latt<'r  still   hangs  froin  the  mouth 
after  the  former  is  in  position.      This 
end  is  fastened  to  the  nasal  end,  and  the 
l,„,p   niav  be   led   over  the  ear.     Such 
I ampons" should  m)t  be  left  in  positir.n 
more  than  twenty-four  hours,  owmg  to 
tlic  iiossible  danger  of  decomposition  of 
the  blood  and  consecpient  septic  inva- 
-^ioii  of  the  I'Aistachian  tulx-s.     Hofon> 
their  removal  is  attempted  it  is  well  t(' 
iiislil  a  little  warm  oil  into  the  nostril 
(the   patient   being    recumbent),  as  it 

Softens  the  gauze.      The  loop  is  tlien  cut  piuggiim  the  iweterior  n»res, 

:ii„l  the  tampmi  removed  by  traction  on  .     *  ♦!,„  i.,tt,.r  «n 

„,„  nu.uth  el.d  of  the  cord,  the  finger  being  hel.    against  tho  a  ter.  so 
as  to  make  the  directi.m  of  traction  baekward  and  downward. 

\ari..us  rubb,>r  receptach's,  such  as  con.ioms.  etc.,  have  bun 
,.e..;;m,nen.led  for  anteior  insertion,  to  In-  filled  with  -ater  wlm-h 
will  ex.Tt  elastic  pressure,  or  with  cotton.  In  place  of  anterur  am- 
pons we  mav  use  the  Rernay  comi^ressed  sponge,  as  advocate  dbj 
Simpson.  Th.-se  sponges  are  made  of  cotton  material,  stenl.ze.l,  ami 
an-  h.ghlv  absorbable,  exerting  by  their  expansion  hrm  compress  om 
('ha,.i«-H  suggests  the  advisability  of  attaching  by  means  of  co  h..li(  n 
..  JX  of  "iVtta  perr-ha  on  the  si.le  of  the  sponge  corn>sponding  to 
tlu'  blee,rin;  point,  so  as  to  off.-r  a  smooth  rather  than  a  roughened 
surface.    This  facilitates  removal  without  bleeding. 


7oO 


yOSE  AM'  Tim  OAT. 


Ill  cases  (if  r|)i.>  (axis  wliicli  arc 


as  cirrhosis  of  tiic  liver,  etc. 


II  expression  o 


f  sol 


lie  visceral  lesion 


we  iiiav  in  connection  witli  local  nieas 


ures  (inler  a  larffe  blister  placed  over  tlie  hepatic  reirioii.  This  is  of 
service  in  alcoholic  patients.  So  al.<o  we  shouM  always  examine  the 
condition  of  tlu>  heart,  and  order  whatever  may  he  approjiriate  for 
the  individual  case.  In  seven-  ca.ses  Iwnefit  lias  heen  derived  hy 
temporary  ligation  of  ;i  linih,  so  as  to  shut  off  for  the  time  being  a 
portion  of  the  lilood  from  the  gciieral  circulation,  and  so  reduce  blood 
pr(>ssure. 

Removal  of  Foreign  Bodies.  These  are  found  more  frecpuMitly 
in  chiidicn  than  in  a.dults.  and  should  always  be  sus|M'cte(|  whenever 
a  child  has  a  unilateral  nasal  discharge.  The  bodies  an-  <renerally 
smooth  fjieas.  shoe  buttons,  beads,  etc.)  and  cause  no  pain.  They 
may  become  incrusted  with  lime  salts,  and  .so  form  true  rhinoliths.  In 
attempting  removal  the  naris  should  first  be  well  illuminated  and 
the  location  of  the  body  (|et(>rniined.  Gentle  syrinjiinp;  will  remove 
accumulated  s(>cretion,  and  the  na.sal  probe  may  V  of  use  if  the  body 
is  not  visible  to  the  eye.  Unles-s  it  is  firmly  impacted  an  ordinary 
dressinii  forceps  will  easily  remove  it.  If  it  prese'its  a  smooth  surface 
on  which  the  forceps  will  not  hold,  a  bent  flat  wire  ma\  be  passed  over 
it.;md  it  can  then  bescoojied  out.  If  it  is  impacted  the  u.se of  cocaine 
and  adrenalni  .solutions  is  to  lw>  commended,  as  by  their  action  on 
the  surroundiiift  tissues  the  latter  contract  and"  thus  loo.sen  the 
foreign  body.  If  the  latter  is  very  far  back  the  finger  may  Ih' 
passed  into  the  nasopharynx,  and  there  field  until  the  forceps  is  intro- 
duced anteriorly.  Such  a  maiKeuvn-  jirevents  the  i)ushing  of  the 
body  into  the  na.sopharynx,  and  will  steady  it  until  it  is  gras|K'd 
by  the  forceps. 

Ordinarily  the  foregoing  man(ruvros  can  lx>  [x^rfnrined  without 
general  aiup.sthesia,  but  'f  the  patient  is  unrul;-  and  the  exact  location 
of  the  body  cannot  lie  de;erniined,  it  is  advisable  to  give  a  few  whifTs 
of  chloroform.  The  extraction  of  rhinoliths  re(|uires  the  eniploy- 
iiient  of  .some  kind  of  crashing  forceps,  and  the  mass  is  then  removed 
piecemeal.  In  all  instances  no  after-treatment  is  necessary  lieyond 
simjile  cleansing  for  a  day  or  two.  With  loo.se  l)odies  in  "the  nares 
of  very  young  children  a  blast  of  air  through  the  patent  nostril  from 
a  Politzer  bag  may  exjiel  the  offending  mass. 

Acid  Caustics.  While  all  the  caustic  acids  have  at  times  been 
ii-sed  in  the  nose,  we  now  generally  confine  ourselves  to  chromic, 
monochloracetic  and  trichloracetic  acids.  All  should  Ix'  preceded  by 
local  aiueslhesia.  and  an>  [ireferably  employed  fused  on  one  side  of 
the  end  of  a  flattene.l  prolw.  Care  should  Tm-  taken  that  tlieir  action 
i.s  acpunitely  confined  to  the  spot  desired,  and  the  n>st  of  the  no.se 
may  be  protected  by  pledgets  of  cotton  or  by  the  us<>  of  sfiecial  .specula. 
Mosworth  has  clearly  set  forth  the  fact  tliat  the  object  of  this  class 
of  remedie.-.  is  "not  to  destroy  ti.ssue.  but  to  constrict  the  blocMJ- 
ves,sels.  diinini.>;h  nutrition,  .'ukI  thus  counteract  hypertropt>y."  In 
the  latter  st.ate  it  is  the  deeper  layers  of  the  mucosa  that  an>  affected. 


METHODS  OF  EXAMISATIOy. 


751 


('(.nso(iuontly  any  inc 


T(>ly  siiporficial  caustic  destroys  only  the  cpi- 


ih( 


•Ihl  lavcr,  while  not  at  all  reacliiiiK  the  true  s(>at  of  the  troui.l. 

1  in  the  nose  for  one  of  two  jjurpos 


In  jieneral,  caustic.!  are  uset 


i'it 


hereto  (lest r.iv  the  vitality  ..f  the  stump  or  pedicle  of  a  new-g;  -wth 

to   reduce   hypertropiiu'd   tissues. 

as  much  !is  possible  the 

ith  adrenalin,  and 


iir  intlannnatory  excrescence,  or 
I'licrefore  the  i)referal)le  plan  is  to  U 


sen 


inhination 

ll'i,",'\o'hii'Hr'd<.wii"tiio  Tissue  thus  constrinjied.     I'or  this  purpose 
..Inomic  acid  is  an  ideal  aR.-nt.     It  acts  l.y  oxi.lation  on  the  tissues, 
.,„d  is  self-limited  in  its  effects  in  that  it  becomes  m  tlie  very  process 
of  oxidation  of  organic  tissue  onverted  int..  ox.de  ot  chronnum, 
which  is  insoluble  an.l  inert.     It  ctui  be  easily  hand  e.l,  but  must  be 
kept  from  the  air,  for  it  readily  deli(,uesces.    It  may  be  drawn  m  lines 
MloiiL'  the  turbinal  borders,  or  maybe  used  in  the  mgenious  manner 
.u.r.r,.sted  bv  M.  A.  Cloldstein,  who  inserts  a  fine  trocar  and  canula 
intT  the  turbinate.1  tis.sue  parallel  to  the  surface    then  withdraws 
,!„.  trocar  ami  u.serts  a  probe  on  which  is  the  chromic  ;icid,  and 
which  projects  slightlv  l)eyond  the  end  ol  the  canula      The  whole 
apparatus  is  then  withdrawn,  making  a  continuous  submucous  cau- 
terization. .        . ,  1  f     .1        ,.,„ 
The  monochloracetic  and  trichloracetic  acids  are  used  for  t  ><>  sa  u 
„ur|...ses  as  the  chromic,  the  monochloracetic  acid  being  slightly  the 
'tionger.     Thev  niav  be  used  on  probes  or  cot  ton -earners.     A  special 
advantage  of  these  two  agents  is  that  after  application  they  absorb 
uinisture  from  the  air.    They  therefore  act  as  a  nu.i.st  protective 
,|ressing  on  the  area,  leaving,  after  their  slough  is  detache.  ,  a  smooth 
surface      Nitric  acid  is  now  rarely  used  in  the  nose,  and  the  sanu 
may  be  said  of  glacial  acetic  acid,  though  the  latter  makes  an  excel- 
lent application  to  the  stump  of  warty  growths. 

Intranasal  Adhesions.    Thes(>  may  aris«-  from  processes  of  disease, 
hut  more  commonlv  follow  ill-adviseil  or  carelessly  performed  oi.era- 
lions  within  the  nasiU  chambers,  whereby  the  opposing  ^"rfaces  be- 
,.,„..,-  bare.!  and  are  not  kept  .separated  until  healing  ..ccurs  on  bot 
.ides      The  adh.'sion  mav  be  small  or  large,  soft  or  dense.     It  can 
b..  easily  severed,  but  will  quickly  reform.      An  endeavor  shoul. I  be 
made  to  not  merelv  cut  through  the  a.lhesion  band,  but  to  actuall> 
remove  a  definite  Width  of  it.     For  this  purpose  some  iorm  o    sc  >- 
.ors  with  double  cutting  edges  may  lie  used.     After  .sectu  n   a  ui 
eheeking  of  bleeding  a  thin  spatula  of  gutta  iktcIw  may  be  sli.. 
between  the  raw  surfaces,  or  gr(>ased  tampons  may  1k^  applied  or 
drv  tampons  surrounde.l  bv  soft  rubber  ti.ssue.     The  dressing  should 
heehan.i-d  dailv  and  every  can>  b<'  taken  to  keep  the  surfaces  apart 
until  thev  have"l)ecome  coate.l  with  epithelium.     It  h.as  been  recom- 
mended "to  i^rartise  systematic  friction  of  the  adhesions  by  means 
of  a  cHon-carrier,  the  claim  1  >ing  niade  that  it  is  thereby  possible 
to  thin  out  til.,  a.lhesion-ban.i    uid  gradually  cause  s'   t"  '^^f]Wf 
without  caus--.g  any  l^reach  of  surface.     (Hhers  have  «"SS<'sted  the 
a.lvisabilitv  of  passing  a  wire  loop  around  the  band  and  r      'tally 


752 


yu!ii:  Aso  riiuoAT. 


tiglitcning  it  from  day  to  day,  so  as  to  slf)\vly  rut  throiijih  the  adho- 
sioii.  Still  others  have  iMiiploycd  silk  threads  in  the  same  luaime;- 
as  for  separatiiif;  adhesions  of  tiiifjers  whieli  hav(>  become  wehhed 
from  a  hum.  The  obvious  lesson  is  to  prevent  as  far  as  possibl(>  the 
orcurronre  of  the  condition.  This  can  be  done  by  the  use  of  some 
sort  of  shield  speculum,  so  that  when  the  acid,  cautery  tip,  or  cutting 
instrument  is  applied  to  the  tissues  the  opposiii};  areas  shall  Ije  pro- 
tected from  injury. 

Electrolysis.  Electrolysis  in  tlie  nose  is  practically  confined  to 
the  removal  of  .septal  spurs  and  deviations,  rareh-  of  certain  tumors. 
In  the  former  class  of  ca.ses  it  is  of  value  only  where  the  sejttal  excre.s- 
<'ence  is  cartilaginous.  We  do  not  feel  disposed  to  admit  the  truth 
of  tiie  claim  that  true  bone  is  destroyed  by  electrolysis,  although  this 
result  follows  under  certain  conditions — electro-cauterization.  The 
principli  '  of  ai)])lication  of  electrolysis  are  the  same  with  organic  as 
with  inorganic  substances,  namely,  the  evolution  of  oxygen  from  the 
positive  and  of  hydrogen  from  the  negative  pole.  The  mere  fact  of 
organization  of  tissue  does  not  interfere  with  electro-chemical  decom- 
position. 

True  --artilage  is  destitute  of  nerves,  and  therefore  of  sensibility. 
It  is  e(iually  devoid  of  bloodvessels,  (>xcept  for  certain  loops  which 
here  and  there  run  in  from  the  jjerichondrium.  It  is  nourished  by 
imbibition  from  the  mitritive  supply  of  the  neighboring  part.s.  In 
the  nose  it  is  covered  by  a  mucosa  which  is  both  higlily  va.scular 
and  highly  sensitive.  .Most  of  the  outgrowths  removable  by  elec- 
trolysis have  nere  a  covering  of  thickened  mucosa  and  an  increase 
of  cartilaginous  elements,  a  true  hyiK-rplasia.  In  cases  of  long 
standing  there  is  generally,  in  adilitioi;,  an  infiltration  of  lime  salts 
and  sometimes  at  the  base  of  the  iniiss,  tnie  bone. 

For  electrolysis  we  may  employ  by  means  of  modern  apparatus 
either  the  street  current  .>i  the  usual  galvanic  battery.  If  the  latter  is 
usecl  it  should  have  at  least  thirty  elements  and  a  steady  deliverv 
of  current.  \  rheostat  and  ampere  metre  are  rc(|uire,l,  and  also 
double  needles,  for  the  bipolar  met  hod  has  been  found  i)referable  to  the 
monopolar:  that  is,  both  positive  and  negative  needles  are  to  be 
in.serted  into  the  tissue  to  he  removed.  The  needles  may  be  of 
either  steel,  iridoplatinum,  or  gold.  Steel  needles  are  cheap,  firm, 
and  p(>netrate  easily.  The  needle  ordinarily  used  by  sailmakers  is 
recoimnended  on  account  of  convenient  size,  finish,  and  esjM'cially 
fineness  of  point.  Its  diameter  varies  from  0..")  nun.  to  I..")  mm.,  and 
length  from  7  to  10  cm.  The  instrunuMit  makers  furnish  a  mon' 
delicate  apparatus,  but  these  nee(lles  in  .small  gutta  percha  handles 
comiected  with  the  battery  wires  answer  every  purpose.  The  aver- 
age seance  should  not  exceed  fifteen  minutes.  Cocaine  an;esthesia 
should  lie  employed,  though  f!;irel  asserts  that  there  is  only  insic- 
nificant  pain  when  the  needles  pierce  the  nuicosa,  and  none  at  all 
when  they  finally  rest  in  the  area  of  .selection.  This,  however,  has 
not  been  the  writer's  exfx'rience.     Not  more  than  30  millianipdres 


ilETUODS  OF  EXAMJyA'J'Ioy. 


ToJ 


:iri'  necossiirv,  and  1")  jiciu-rallv  siiHicc.  The  rheostat  slioulil  l)c  |ilacc>l 
ill  tlx"  niaxiiimm  of  rcsistaiicr,  and  the  latter  slowly  diiniiiislu'd  until 
the  proper  reading  is  observed  on  the  ampere  meter.  The  aim  is 
I,,  detaeh  the  onViKUnK  mass  in  a  plane  parallel  to  the  normal  plane 

of  the  sei)tum.  ,       ,      •  ■  i 

\  horie-acid  wash  will  sutHce  to  wash  away  the  detritus  ahout  the 
needle  holes,  and  its  use  should  !)e  followed  by  the  insufflation  of 
H.me  aiitisc])tic  powder  (aristol,  nosophen,  europhen.  ete.).  An 
rschar  is  formed  whieh  eomcs  away  in  the  course  of  eipht  or  ten 

Several  weeks  (>lapse  before  the  parts  finally  mould  down  into 
what  will  be  their  eventual  shape.  Small  exerescences  about  the 
line  of  seetion  ean  l)e  triminetl  with  the  Raivaiiocautery. 

The  advantages  of  this  method  are  the  following:  it  is  blootllesf', 
the  held  of  o!)eration  can  l)e  kept  in  view  throughout  the  entire 
(.IM-ration:  there  is  no  inflammatory  reaction;  no  possibility  of  after- 
intrana.sal  adhesion.s  or  deformity:  it  is  an  alternative  in  certain 
cases  of  marked  thickening  associated  with  deviation  of  the  septum 
where  an  operation  for  straightening  is  deemed  likely  to  prove  unsatis- 
fictorv  and  it  will  often  l)e  ix-rmitted  when  a  cuttuig  operation  would 
l',e  irfused  bv  the  patient.  Its  disadvantages  are  the  somewhat 
elaborate  ajMiaratus  reijuired,  the  time  necessary,  ami  the  fact  tl.-t 
it  is  not  api)lical)le  to  bonv  growths.  In  general  it  may  l)e  sau 
that  th(>  results  eHVcted  bv  electrolysis  can  be  more  easily  secured 
bv  other  methods.  The  use  of  sujirarenal  extract  has  robbed  mtra- 
iKisal  operations  of  their  greatest  disadvantage.  These  can  now  be 
made  perfectlv  bloodless.  Furthermore,  perforations  of  the  .septum 
l,v  electrolvsi.s  (no  matter  how  carefully  used)  are  not  beyond  the 
i,ounds  of  possibility.  However,  it  is  a  resource  at  our  comnand 
when  for  anv  reason  a  cutting  operation  is  not  jM-rmitted. 

MetaUic  Eectrolysis.  I'nder  certain  conditions  it  is  possil^le  to 
introduce  din'ctlv  into  the  tissues  the  salts  of  certain  metals,  espe- 
cially the  salts  of  copi)er,  although  zinc  and  iron  have  also  been  used. 
Ihe'inode  of  eniplovmeiit  consists  simjjly  in  makuig  the  positive  pole 
.,!  the  metal  to  be  used.  This  is  applied  directly  to  the  mucous  sur- 
t:.ce  to  be  treated,  while  the  negative  may  b'  place.l  on  the  back  ot 
(lie  neck  The  salt  formed  in  the  tissue  by  the  passage  of  the  current 
H  an  oxvchloride.  The  advantages  claimed  for  this  method  are, 
first  that  the  salts  can  be  carried  by  diffusicm  to  the  most  obscure 
•md  inaccessible  parts;  .seeoml,  that  these  na.scent  salts  are  much 
more  active  than  in  their  usual  chemical  combination;  and.  third, 
that  as  the  pathological  conchtions  usually  lie  deeply  under  the  mucous 
membrane  thev  can  lie  reached  by  the  imiiregnation  of  the  tissues 
with  the  metallic  salt  far  better  than  when  it  is  simply  ajiphed  to  the 
mucous  surface.  The  particular  line  of  cases  which  seem  to  l)e 
lieiiehted  are  hypertrophic  rhinitis,  excessive  secrelion  of  th(  nasal 
mucosa,  irritable  cough  due  to  catarrh  of  the  pharynx  or  larynx, 
and  epistaxis  with  excoriations,  etc. 

4S 


04 


yOSt  AXn  TUllOAT. 


f 

f 


Massage.  (Vrtain  intranasal  (•(tn(  lit  ions  arc  jircatly  honctitcil  hy 
the  a|i|)l;cati(in  of  the  (icncral  principles  of  niassajrc  inoditicvj  to  nicct 
local  anatomical  cundilioiis.  Its  general  result  here  as  elsewhere  is 
t>  restore  the  circulation  to  its  normal  state  and  to  remo\-e  the  effects 
if  disturlK'd  circulatory  activity.  In  atropine  rhinitis  massage  leads 
to  an  increased  biooil  supply,  and  thus  to  a  restoration  of  the  normal 
in'riMiasal  moisture.  In  hypertrophic  conditions  it  .seems  to  have  an 
alterative  etTect,  leading  to  the  removal  of  the  products  of  nutritive 
hyperactivity.  Certain  etTects  may  follow  also  from  a  n-fle.v  inllueiice 
on  more  distant  structures. 

I'ndouhtedly  the  credit  of  introducing  this  therapy  into  rhinnlogy 
heloiigs  to  Hraun,  of  Trieste,  who,  at  the  Merlin  ("onj;res.s  of  1S!M),  gave 
an  ex])osition  of  his  method  ami  its  results  after  an  extensive  clinical 
e.xperience.  Tliis  author  unfortunately  surrounds  the  subject  witii 
a  certain  amount  of  difficulty  l)y  stating  that  tlie  projK'r  application 
of  ma.ssago  in  this  locality  i.s  very  hard  to  ac(|uire.  Then'  is  a  gen- 
oral  insistence  that  the  movements  of  the  ma.s.seur  shall  lie  n-gular 
anil  of  e(|ual  intensity,  otherwise  infiannnatory  conditions  ^^'  made 
worse  ratiier  than  In'tter. 

The  two  main  methods  of  intrana.sa'  massage  are  stroiiing  and 
vil)ration.  In  the  former  simple  prolM's  wound  at  the  end  with 
cotton  are  used.  They  sliould  Im"  stiff  enough  not  to  liend  under 
pressure,  and  the  cotton  should  l)e  firmly  wound  and  carried  a  short 
distance  down  the  stem.  Cocaine  m  weak  .solution  is  first  ap[)lie(l 
to  the  parts,  and  th(\v  are  then  ruhhed  witii  the  prol>es  dipjied  in 
whatever  medicated  solution  is  indicated. 

Seme  advise  the  api)lication  of  a  lubricant  previous  to  massage. 
Hraun  suggests  mentholated  vaseline,  I'enivian  i)alsam,  camphor, 
menthol,  etc.  .\  series  of  ])robes  should  !h'  |)repared,  so  that  each 
portion  of  the  nasal  mucosa  shall  receive  its  (lue  sliare  of  tlie  topical 
agent.  Tiie  duration  of  friction  of  eacli  area  sliould  vary  from  a 
few  seconds  to  a  inimite.  It  is  ot)vious  that  the  old  leathery  nuico.sa 
of  a  marked  ca.se  of  atrophic  rliinitis,  esiwcially  one  .attended  witii 
crust  formation  and  oza-na,  will  nvpiire  a  more  forcitile  and  per- 
sistent friction  tlian  a  case  of  hyperpla.stic  deposit  where  a  restoration 
of  circulation  is  .  !1  that  is  desireii.  If  the  niatKcuvre  is  properly 
executed  the  patient  will  cxim  rienco  no  pain  nor  will  there  l)e  any 
liemorrhage. 

In  addition  to  tlie  common  hyi)ertro])liic  conditions  and  atrophic 
conditions,  it  may  be  added  that  some  cases  of  the  liay-fever  tyjx^ 
wliich  jiresent  distinct  local  sjiots  of  hyiiera-stliesia  iiave  lieen  l)eiie- 
fited  by  friction  over  these  areas.  Such  a  treatment,  if  carried  out 
in  the  intervals  between  attacks,  has  seemed  to  less<>n  the  preilis- 
position  of  the  patient  to  the  disea.se. 

Tt  seem?--  p.'iradoxicnl  to  prescribe  the  s.tuio  fre;itinent  for  condi- 
tions so  opposite  as  hypertrophy  and  atrophy.  Tlio  answer  is  that 
vari.atioti  of  duration  ami  intensity  of  massage  makes  of  it  really 
two  dilTerent  agents  so  f.ar  as  its  effects  are  concerned,  and  that 


METHODS  OF  EXAMIXATIOS 


<0U 


clinical  pxporionrp  juslifics  the  statonionts  nuulu  as  to  its  curativr 
clTccts  in  Ixitii  tlx'sc  conditions. 

Ccrtai"  advantages  of  tlio  method  ut  once  suggest  themselves. 
.No  cumi  crsome  apparatus  v.-  re<|uired.  It  is  all  on  the  examiner's 
talile.  The  treatment  can  Im-  definit<'ly  localized,  and  by  a  suitable 
bending  of  the  probe  every  part  of  the  na.sal  cavity  can  Ik-  reached 
The  i)atient  bears  the  treatment  well,  and  then-  is  an  entire  absence 
of  anvthing  calculated  to  terrify  the  nervous. 

In  "ad.lition  to  the  stroking  or  friction  method  we  have  the  vibration 
method,  which  is,  |;erhaps  the  one  mor<'  (ommonly  us(mI.  The  fatigue 
attendant  upon  its  employment  has  le.i  t>>  the  application  of  electricity 
as  the  moving  force  of  the  proln-,  and  several  in.struments  have  In-en 
devised  for  this  purpose'.  That  of  Freudenthal  is  the  most  practi- 
cable. The  immber  of  vibrations  can  be  regulated  up  to  nearly  S()0() 
per  mimite.  This  is,  of  course,  a  far  greater  number  than  can  Ix- 
reached  by  the  manual  method.     Some  of  the  statements  of  the 


PIQ.  S92. 


Freudentbal'B  electric  vibrator. 

laitidity  of  the  vibrations  of  the  arm  muscles  seem  to  the  writer 
little  siiort  of  absurd.  By  the  electric  vibrator  the  strength  of  the 
vibrations  can  lx>  delicately  adjusted.  Seances  should  not  be  held 
iift<'ner  than  two  or  three  times  weekly. 

Still  another  and  ingenious  method  may  be  mentioned,  thi>t  of 
Dioiiisio,  who  inserts  into  the  nasal  passages  a  flexible  rubber  bug, 
which  is  then  inflated  with  air.  The  bag  is  connected  with  a  chamber 
ill  which,  by  means  of  a  piston-action  and  cylinder,  there  is  a  rajnd 
increase  and  decrease  of  air  pK«ssure.  This  is  obviously  transmitted 
tluinigh  the  tube  to  the  bag.  The  method  is  an  easy  one  loT  the 
pliysiciiin,  ami  several  sets  of  tubes  may  be  connected  with  the  pressure 
ciiamber,  and  thus  several  patients  treated  at  the  same  time.  The 
strength  !ind  fre(iuency  of  the  pressure  variations  can  be  regulated 
to  a  nicety.  The  sen.s'ation  experienced  by  the  patient  is  likened  to 
a  tremor  of  the  parts  treated.  Dionisio  claims  that  in  this  method 
the  vibrations  are  homogeneous  in  character  and  are  not  shocks. 


« 


750 


yoSE  A.\l>  TlinoAT. 


Septal  Spars  and  Deviations.  Tlic  iiMsai  septum  i:^  nin'ly  iHrfcctly 
stiaiuht,  :illliiii|i;li  in  tlif  iiiiijnrity  of  cases  the  ilcpal'l lire  in  tliis  icspcct 
friim  the  nnrinal  dues  rmt  call  fur  (i|M'rativ('  iiitcrvi'iitinn.  If  fur  any 
cause  the  fartilaninous  portion  of  the  scpliiin  IxTonics  markedly 
deviated,  the  turbinates  on  the  side  liecomin};  uiuisually  patent 
eiilarjic  so  as  to  functionally  compensate,  as  it  wen',  for  tiie  lessened 
function  of  those  on  the  occluded  siile.  It  is  a  common  e\|HTieiice, 
iiowever,  that  as  soon  as  the  se|>tum  is  strai>;htened,  (s|M'cially  in 
younj;  patients,  the  turliinates  resume  their  normal  size.  Our  first 
duty  then  is  to  put  the  septinn  in  a  normal  position,  and  the  turbinates 
will  thereafter  <;enerally  take  care  of  themselves. 

For  the  removal  of  mere  excrescences,  such  as  the  ordin.ary  crests, 
ridpes,  spurs,  etc.,  wo  have  at  our  disposal  various  knives,  the  saw, 
and  the  trephine.  Some  of  thes(>  excrescences  are  made  up  principally 
of  mucosa,  and  can  hi-  n-nioved  by  the  cautery,  (ireat  care  must  Im' 
exercised  in  the  ap|)lication  of  this  powerful  agent  to  the  cartilage 
itself.  Reaction  is  apt  to  be  severe,  and  if  much  cartilage  has  been 
attacked  there  may  Im'  a  necrosis  around  the  operative  field.  These 
outgrowths  reiniiring  removal  may  contain  lime  salts,  ami  even  true 
bone  and  the  choice  of  instruments  is  conditioned  on  the  finding  of 
the  composition  of  the  part  in  each  individual  case.  The  |)robe  may 
assist  us  li(>re. 

Tlie  nostril  should  be  cl^  ui  and  then  cocainized,  .\drenalin 
may  be  applied  subsequently  to  or  along  with  cocaine.  It  is  advis- 
able to  aiuesthetize  a  ticM  consider- 
ably larger  than  the  sjKit  to  lie  ope- 
rated upon,  so  that  the  cont.act  of 
instruments  with  surrounding  parts 
does  not  aiuioy  the  I'atient.  Simple 
cartilaginous  growths  call  !«•  removed 
with  a  stout  scalpel  having  ;i  thick 
short  l)lade,  or  with  in  instrument 
constructed  on  the  principle  of  the 
s]iokeshave.  The  objection  to  many 
instruments  of  the  latter  c!as.s  is  tliat 
they  are  difHcult  to  engage  in  the 
substance  of  the  growth,  and  do  little 
more  than  scrape  off  the  mucosa. 
Where  the  growth  is  larger  and  the 
use  of  the  knife  is  iisappiicable  we 
may  use  a  gouge,  chisel,  or  saw.  The 
latter  is  in  most  common  use,  and 
the  model  of  Hosworth  meets  every 
mechanical  need.  (Fig.  394.)  It.s 
bla<ic  is  a.-  thin  a.>  pn.ssihlc  con- 
sistent with  strength,  ()ne-«'ighth  of  an  inch  wide,  five  inches  long, 
with  a  cutting-edge  of  three  inches,  with  thirty  teeth  to  the  inch, 
each  tooth  being  an  exact  e(iuiiateral  triangle,  with  no  'To.ss-cut  or 


Nichols*  spokeshave  knife. 


MJCTIKJJJS  or  AAM.V/.V.1I70A'. 


767 


set  to  tlic  tci'tli.  iIk'  IimikIIc  Ix'iiijt  thrrc  inches  Iomr  aiul  <.l  suMici.'nt 
.iz..  til  lM'C'a.<ilv  nn.  -x-il  1)V  til.'  liiiiul.  Tlic  cutting  l)lii.lc  iimy  iM-.-itlicr 
upward  i.r  (l.'.wiiwa'rd.  Tin-  ..l.j.-cl  is  t.i  rciiiov.'  ti.c  prnj.Tliuii  in 
-.well  a  niainuT  as  to  leave  the  side  of  the  s-ptun-  smooth.  \\  liere 
the  projeetioii  slo|M's  downward  toward  th.'  nasa.  tioor  it  may  !«• 
necessary  to  start  with  the  saw  l.lade  nearly  horizontal,  uradually 
1 1, rninc  It  toward  the  vertical  as  the  plane  of  the  septum  IS  approached. 

In  cases  in  which  it  is  iiniMwsibk-  to  p-t  the  l.lade  ot  the  saw  past 

Flu.  394. 


Boavrorth'i  ntMl  utw. 

the  projection  we  mav  mi'ke  a  channel  at  tlie  bottom  by  the  romovnl 
,,|  a  core  of  tissue  with  the  tn'phine  in  thi'  manner  to  be  mentione(.. 
•I'lirouj;!!  the  channel  thus  maile  the  saw  is  thrust,  and  by  .uttmp 
,ither  outward  or  upward,  as  th.'  cas<-  re.|uin>.  th<-  lU'cessary  amount 
of  tis-^ue  is  removed.  The  saw  ..[M'r.ation  is  al.so  api)licaNe  to  Ix.iiy 
.uitjrrowths  from  the  ).osterior  portion  of  the  seinuin.  The  use  of 
adrenalin  makes  all  those  i)roce(liires  i)ractically  bloodless. 


Nual  burn  and  trephines. 

.Vuother  method  of  removal  of  septal  outgrowths  is  by  means  of 
Inirrs  and  trephines.  (Fig.  395.)  These  are  inserted  m  a  flexible 
hand-shaft,  and  power  is  supplied  either  from  the  dental  engme, 


i' 


758 


AO.SA'  AM>  Til  IK)  AT 


(Irivfii  hy  the  foot,  or  by  ;iti  I'lcrlric  motor,  Tlic  itn'p:initioii  of  the 
ticlil  is  tlic  same  a.-*  hcforc.  The  |iortioii-;  of  tis>iic  rcmo\i'i|  an'  in 
llif  form  of  cNliiKlrical  cores,  ami  tlic  iionli'rs  of  tlic  cut  must  Ik- 
triiiimcil  hy  scissors  or  some  similar  instrument.  The  fact  that  the 
surfiwe  is  not  left  ;ts  smooth  us  with  the  saw  ieails  many  to  prefer 
the  latter  instrument. 

After  any  of  ilie  forecoinj;  operations  the  riaris  shouhl  Im'  Husheil 
out  with  some  antiseptic  solution  ami  thoroujihiy  dricil.  ,S>me  anti- 
septic p(>wi|er  shoulil  then  Im'  Mown  in  iiristoi,  europhi'ii.  nosophcn, 
etc.).  Opinions  ilitTer  as  to  the  ailvisaliility  of  packing  with  jiauze 
or  inserting  plujts  of  any  kimi,  with  a  view  to  the  prevention  of 
hemorrhage.  In  any  event  the  patient  must  keep  i|uiet  for  the  iirst 
few  hours.  Then-  is  houiul  to  Im'  a  vascular  reaction  as  the  effects 
of  till"  cocaine  and  ailre!i;ilin  pass  off,  ami  if  this  he  too  active  hieeiliii); 
may  occur.  Some  physicians  pve  their  patients  ji  solution  of  ;iilre- 
iialin.  with  ilin-ctions  to  use  it  ;is  a  matter  of  routine  every  tew  hours: 
others  prefer  to  insert  tam|M)iis,  its  mentioned  in  the  para^rraphs  on 
nose-hleed.  These  rem.ain  in  position  twenty-four  hours,  are  care- 
fully removeil,  and  not  replaced.     It  is  advisahle  for  the  patient  to 


Hush  the 


strils  two  or  three  times  ( 


lailv, 


an( 


1   wl 


lenevi 


r  he 


IS  m 


the  o|)en  air  to  wear  a  loose  plu)i  of  antiseptic  cotton  just  within 
the  vestihule.  This  sifts  out  the  dust  frotii  the  inspired  air,  and  thus 
furthers  sjM'edy  liealin;i.     The  nmco.sa  is  .'is  a  rule  ((uickly  restored. 

In  all  the  forepoinjr  fri'-at  can-  should  he  taken  not  to  hreak  throupli 
into  the  patent  nostril.  While  no  special  harm  n'sults  from  this 
accident  (certainly  none  from  a  pliysio|oj;ical  point  of  view),  a  septal 
perforation  is  an  amioyance  to  the  |)atient.  I'ortunately  most  per- 
forations made  hy  surgical  trauma  lical  kindly,  pro\  ided  they  are 
kept  clean.  During  the  actual  time  of  operation  a  clo.se  watch  sliould 
Im'  kept  on  the  nnuo.sa  of  the  sound  side,  .so  that  the  .'iccideiit  alluded 
to  may  lie  avoideil.  It  has  Iweii  I'ecommended  to  inject  sterile  w:iter 
under  the  mucosa  on  the  sound  side,  correspondinj;  to  the  o|K'rative 
field  in  the  occluded  nostril,  so  as  to  lift  it  up  from  the  c;irti!a);c  for 
the  time  l)eiii<r,  and  thus  lessen  its  danger  of  perf'iratioii.  It  has 
Im-cii  found  that  as  the  water  is  ahsorhed  the  tissues  return  to  their 
normal  condition.  Patients  shoulil  1m'  cautiotied  not  to  attemjit  to 
remove  the  crusts  which  form  over  a  healing  area,  as  they  will  event- 
ually separate  of  their  own  accord.  Premature  removal  delays 
healiiifr. 

There  are  some  ca.ses  of  septal  deformity  in  whic!  thi'  estahlish- 
ment  of  ;i  jiennanent  jx-rforation  has  relieved  the  .sy!h|)toms  of  which 
the  ])atient  has  complained,  hut  the;  v  very  few  ca.ses,  if  any,  in 
which  the  ohstruction  to  the  hreathwa.  caimot  lie  otherwi.se  removed. 
I'^ven  if  the  perforation  is  ]iurpo.se|y  made,  healinp  of  the  edpes  is 
conditioned  iii>.)n  tlip  ahsr-iice  .:[  any  dyscra.sia.  f-an-fu!  afii-r-treat- 
nient,  iind  a  sufficient  intelli<;ence  on  the  part  of  the  p.atieiit  to  (;uar- 
antee  that  the  wound  will  Ih>  protected  from  nuchamcal  irrita- 
tion. 


MtynioDS  of  KXAMISMin.W 


759 


Straightening  of  the  Masai  Septum 


Aftrr  tilt'  rrllinval  of  luc;il 
,.X,T.sn.ncrs    tlir    SfptUni    in;iV    still    hr   LoWt-.l    ..V.T   t..   ..Iir    :^hI.-    Mll.l 

„.,,uin"  slraiKlil.'iiinn  m,  ;.  wl.nlc.  Whil.-  many  .li»T.T.'nt  ..,HTaliuhs 
Invc  Iktii  .l.'vis.-.!  with  til.'  latt.r  .'11.1  in  view,  that  kn-.wn  as  tli.' 
\<(\i  .,|M'.'ati..ti  is  lUHloul.t.'.lly  a|.|.liraMc  t..  iiior.-  ca.s.'s  ihan  is  any 
uth.T      Sudp'stcMl  l.v  Dr.  M.  .1.  As,-h  s.,.m.-  ten  y.ars  aj:-.  -r  ni-.r... 


Kiii.  ;i3«. 


Kl'i.  w. 


rui.  3*. 


Fiu.  ;iiw. 


Plo    40O. 


Aich'i!  «et  of  septam  liwtniment*. 

it  has  hmi  givon  a  nmst  faithful  trial  an.l  has  fulfilio.l  all  tho  noressary 
n-<niir."nionts  for  restorii.K  pat.'ucy  to  both  nostrils  llu;  mstru- 
„„!..t.  -irp  h<"-..vvith  shown  an.l  as  well  th.-  tubular  splints  t..r  inser- 
tion in  tho  n..s.>.  Thon>  an^  vari..us  nio.l.'ls  of  the  latter,  soin.-  p.'i- 
f..ratc.l  an.l  some  solid.  The  pcrf..rations  have  never  seeni.'.l  to  the 
writ.T    t..  offer  anv  advantage  except  that  they  make  the  splmt 


r" 


760 


SOUE  AXO  TIIHOAT. 


«iiii('\vli;it  liplit(>r  in  wcifiht.  Cork  splints  have  Ih'cii  iisod  in-  Mcrriis 
and  (itlicrs.  Hut  no  matter  wliat  particular  splint  is  iiscil  it  is  to  l)c 
r<'ini'inl)cr('(l  that  in  each  case  the  splint  is  to  Iw  fitted  to  the  nostril, 
and  not  the  nostril  to  the  sjjjint.  Hence,  we  may  be  ohlifjed  to 
shorten,  rouml  off  corners,  etc.,  so  as  to  ensure  a  proper  tittiiifr. 

The  Asch  operation  reijuires  fieneral  ana-sthesia.  but  nitrous  oxide 
will  ;niswer.     Adrenalin   solution   should   be   thoroufihly  applied   to 
both  sides  of  the  sejitum  previous  to  the  administration  of  the  ana's- 
thetic.  although  .s(>vere  bleeding  is  unconnnon.  and  is  checked  by  the 
gentle  pressure  of   the  .splint.      If  any  adhe- 
Fio.  401.  sions  exist   between  the  .septum  and  the  tur- 

binates they  are  broken  up  by  the  use  of  the 
curved  gouge.  The  ste|)s  of  the  operation  are 
thus  described:  Tiie  blunt  blade  of  the  ::>  i.ssor> 
is  inserted  into  the  obstructed  nostril,  and  the 
cutting  l)lade  into  the  other.  A  crucial  in- 
cision is  then  made,  the  scissors  being  with- 
drawn for  change  of  position  in  the  si-cond  cut 
a-  near  as  possible  at  right  angles  at  the  point 
Asrhv uttsai sriiute.  of  greatest  convexity.     The  .same  instrument 

may  be  used  for  both  incisions,  although  two 
instruments  are  here  shown.  (Figs.  '.MS  and  .{97.)  The  forefinger  is 
then  inserted  into  the  obstructed  nostril,  the  segments  made  by  the 
incision  are  pushed  into  the  ojjposite  nostril,  and  the  pressure  con- 
timied  until  they  are  thoroughly  broken  up  at  their  base  and  t.. 
resiliency  of  the  se|)tum  destroyed.  On  this  ixnnt  dciifiuh  thi  success 
of  the  openitiiin.  jitr  unless  the  jraeture  of  these  seiimenis  is  nssured,  the 
resilieiiei/  «/  the  eartiliKje  irill  not  he  orercome.  and  the  i>}>er(iiiim  will 
fail.  The  septum  is  then  to  be  str;iightene<l  with  the  f1at-t)Iaded 
forcei)s.  The  nostril  is  then  wiped  out  and  the  tubular  .sjjlint  inserted 
on  each  side.  These  support  the  septal  fragments  and.  as  stated, 
tend  to  prevent  secomlary  hemorrhage.  The  jiatient  should  Ih'  kept 
in  bed  for  two  or  three  days,  iced  cloths  being  l.-iid  over  the  nose  for 
the  relief  of  pain  and  swelling.  Jioth  sides  may  be  sprayed  out 
every  two  or  three  hours  with  an  antiseptic  .solution,  .\fter twenty- 
four  hours  the  sjilint  on  the  originally  patent  side  is  removed  and 
not  replaced.  The  nostril  is  cleansed  and  an  antiseptic  powder 
insulHated.  Ii  is  well  for  the  |)atient  to  wear  a  loose  phii;  of  cot- 
ton in  this  side  for  a  d;iy  or  two.  The  tube  on  the  originally 
ocluiled  side  may  be  allowe<l  to  remain  in  position  for  another  day, 
when  it  is  removeil,  the  nostril  cleansed  and  dusted,  and  the  tnlie 
ri'iitnrrd.  it  acts,  as  s.aid.  as  a  splint  for  the  se])tum,  and  should 
now  be  removed  and  cleansed  daily  for  a  week,  then  on  alternate 
lays,  and  at  lengthi'ning  intervals  until  healing  is  complete.  If  it 
is  properly  htte(|  it  is  worn  without  pain,  and  is  not  visible.  The 
patient  if  not  too  young  can  bo  taught  to  attend  to  the  latter 
niaiiijiiilatiwiis  liim.srlf.  The  tube  nuist  be  of  such  size  that  it  can 
be  inserted  without  any  pre.s,sure,  el.se  it  will  gradually  Ijo  crowded 


METHODS  Of  EXAMINATIOX. 


rei 


out   l)y  the 

l)Ut  i)arti;illy  success 


tissues  l)oliinil,  ami   the  operation  will  i)e  at    the  most 


(•OMSK 


.;ful.     It   should  he  worn  for  five  or  six  weeks. 

J 1k>  seen  daily  by  the  sur«;eon,  this  time  may  be 

lerably  shortened.     Small"  bits  of  graiiulati(m  tissue  in  the  nos- 
lUioii  or  removal  with   forceps,  in  order  to 


If  the  patient  can 


I  care  should  1h'  taken  to  so 


iril  mayreciuire  cautenz 

leave  a   perfectlv  smooth  surface,  an( 

make  the  crucial  incisions  that  the   tube  will  rest   on    the    Hoor  of 

the  nose. 

.\nother  oiM-ration,  devised  by  A.  W.  Watson,  is  especially  appli- 
cable to  those  cases  in  which  the  deviation  is  marked  but  low  down, 
so  that  it  is  nnpo.ssible  to  brinp  the  lower  fragment  into  place.  In- 
stead of  cutting  out  an  ellii)tical  piece,  iis  is  recommended  by  some 
authors.  Watson  makes  a  bevelled  incision,  the  edge  of  the  knife 
licing  directed  ujjward  and  to.ward  the  opjxisite  side  and  carried 
liirough  the  cartilage,  but  not  the  mucosa,  of  the  opposite  side.  The 
incision  is  made  on  the  cn'st  of  the  deviation.  If  a  vertical  deviation 
exists  at  the  same  time  a  triaiigular-shai)ed  portion  with  the  ajK'x 
upiH-rmost  must  1«^  removed.  The  ui)iM'r  portion  in  the  horizimtal 
iiiiision  is  ])ressed  over  toward  the  other  side,  where  it  hooks  on  to 
tiie  lower,  and  is  thus  held  in  i)lace.  The  projecting  base  can  after- 
ward be  removed.  . 

(ilea.son  has  devised  a  procedure,  thus  describctl  by  him:  The 
licid  of  operation  is  cocainized  and  exposed  by  a  self-retaining 
sjiecuium.  A  thin  .saw  is  introduced  along  the  floor  of  the  septum 
heiieath  the  deviation,  the  sawing  is  begun  in  a  horizontal  direction 
until  the  blade  has  jH'netrated  somewhat  deeply  into  the  tis.siies, 
when  the  direction  of  sawing  is  rajmlly  changed  from  horizontal  to 
iH'arly  vertical.  It  is  of  the  utmost  importance  that  the  saw  .should  be 
licld  "exactlv  parallel  to  the  .septum  in  order  that  the  cut  shall  be 
;iroiiiid  and" not  through  any  part  of  the  deviation.  The  length  of  the 
vertical  crura  is  then  (juickly  increased  by  means  of  a  small  bistoury 
curveil  on  its  Hal.  and  the  Hap  is  thru.-t  through  the  hole  in  the  sejjtum 
vith  the  forefinger. 

While  the  Hnger  is  still  in  th(>  nares  it  is  carried  up  along  the  anterior 
:ni(l  i)<)sterior  crura,  in  order  to  Ih"  certian  that  the  edg<'  of  the  flap  has 
coiiiplct.'lv  cleared  them,  and  the  neck  of  the  Hap  is  then  sharply  bent, 
h  is  not  iiecessarv  to  ilenude  the  edges  that  are  in  contact,  as  the 
pressure  results  in  necrosis  at  least  of  the  superficial  epithelial  layer 
nl  the  mucosa,  .'liter  which  the  i)arts  unite.  The  sjiecial  claim  ma<le 
tnr  this  operation  is  that  it  destroys  the  resiliency  of  the  Hap  (a  condi- 
fi.iM  of  success  in  any  oi)erati(m)  at  its  neck,  for  it  is  at  this  point,  and 
practically  here  alone,  that  resiliency  i  ■  active,  that  is,  at  th.e  neck 
if  a  comparatively  long,  narrow  tongue,  and  hence  has  a  powerful 
leverage  to  overcome  before  it  can  thrust  the  inferior  edge  of  the  fli.p 
l>ack  through  the  septum.  The  neck  should  be  bent  to  nearly  a  right 
iiligle. 

The  Pin  Operation.     One  of  the  earliiT  oj-.f-nttions  is  known  as  the 
pill  o|ieration,  because  after  the  septum  is  crushed  or  fractured  by  the 


f 


702 


SOtiE  ASD  TUUO.IT. 


A(l:iiiis  or  Stoclc  str'.tatc  l'nrcc])s,  causiiifi  iiiulti|ilf  incisions,  a  pin  is 
used  to  ri'taiii  tlic  I'rafiincnts  in  |)laci'  until  licalinj;.  'I'lic  pin  is  inscrtcil 
from  the  concave  siilc  of  the  septum  just  l)ack  of  its  anterior  horder, 
passed  diafionally  throufrli  to  t lie  convex  side,  peiietratitif;  the  latter, 
tluMi  across  the  vertical  incision  failher  on  into  the  tissues  back  into 
the  sejitum.  much  as  two  pieces  of  cloth  are  pinned  to>;ether  edfje  to 
edjre.  It  shoulil  he  puslied  home  far  enough  to  bring  the  head  to  lie 
on  the  septum  at  the  \><nM  of  entrance  It  may  he  covered  by  a  bit  of 
rubber  tubing,  and  care  must  be  taken  that  it  d(M's  not  become  lost  in 
tiie  tissues  during  the  iiifianmiatory  swelling  of  the  latter.  It  should 
be  n'lnoved  in  tin-  course  of  thr(>e  or  four  weeks.  In  the  nu'autiine 
iiotii  nostrils  are  free  for  breathing,  and  should  be  kept  scrupulously 
clean  by  mild  antiseptic  washes.  Sterilized  normal  salt  solution 
will  answer  every  purpose.  If  the  bony  se|)tum  has  been  fractured, 
the  pin,  of  course,  will  not  jM-netrate  it,  and  so  the  former  must  be  kept 
in  position  by  pads  of  antiseptic  gauze  renewed  freciuently  for  a  week 
or  ten  days. 

In  addition  to  the  foiegoing  varieties  of  septal  deflections  and  out- 
growths there  are  others  which  cannot  well  be  brought  under  any 
well-de(ined  category.  In  some  the  mucosa  may  be  di.s.sected  off 
from  the  cartilage,  enough  of  the  latt<'r  removed  to  restore  |)atency 
to  the  nostril,  and  the  nuicosa  replaced,  being  held  in  position  by  fine 
sutures.  The  dis.section  of  the  nuicosa  is,  liwwever,  rather  a  ditficult 
matter.  Still  again,  various  punch-fore  jis  have  Ihm'ii  devised,  such 
as  the  one  here  figured.     With  such  instruments  the  sei)tum  is  frae- 


SU'liMte  iniiich-fc)n'eii(* 

tured,  the  resiliency  of  the  fragments  destroyi-d,  and  the  parts  held 
in  |)ositi<in  by  various  splints  or  tampons.  In  such  ojM'rations  general 
aiKcsthesia  is  necessary,  with  preceiling  apjilications  of  adrenalin. 

Forward  Prolongation  of  the  Septum.  Occasion.illy  the  septum 
seems  to  have  such  an  .antero-posti'rior  measurement  that  it  cannot 
be  accommodated  within  the  bony  framework  designeil  for  it.  As  a 
conse(|uenci'  one  end  .appears  to  bend  forward  at  one  anterior  naris 
and  shows  |)rominently,  pushing  the  lleshy  colunma  to  the  other  side. 
Till-  obvious  syrii|itoms  due  tn  this  condition  are  those  arising  from 
moderate  nasal  obstruction,  aggravated  by  a  tendency  of  the  ahe  to 
collapse,  excoriations  from  lodgement  of  dust,  etc.,  on  the  projecting 
end  of  the  septum,  and  dislodgement  by  the  linger  of  theiiatient,  lead- 
ing to  cracks  and  fissures.  The  nose  seems  distorted.  es|)ecialiy  on  its 
tij).     I'or  the  relief  of  the  condition,   Farlow,  who  has  |)aid  sp.ecial 


3IETU0Df>  OF  EXAMISATIoy. 


Ids 


Httcntitm  to  these  cjis)  s,  iidvises  tlie  removal  of  enough  of  tlie  anterior 
(■ml  <if  the  eartihi<:e  to  relieve  the  tension  under  the  skin,  and  in  ease 
ilie  eartihige  is  ocrhKled  to  cut  otT  enough  to  allow  free  respiration, 
lie  thus  deserihes  the  jiroeedure:  An  ineision  should  lie  nia^le  through 
I  he  mucous  memhrane  parallel  with  the  free  edge  of  the  septum  and 
near  enough  to  it  so  that  the  perichondrium  can  be  stri])ped  back 
troni  the  cartilage  on  both  sides  through  one  incision.  Wheti  the  car- 
tilage has  been  bared  it  is  trinnned  ur.til  sufficient  tissue  has  been 
reuMived  to  relieve  jiressure.  If  the  se|)tum  deviates  higher  up  in  the 
other  nostril,  or  if  the  deviation  and  prolongation  are  in  the  same 
nostril,  it  is  well  to  make  several  cutsinto  the  cartilage  at  right  angle  to 
ihc  original  incision,  or  even  to  remove  a  triangular  piece  from  the 
cartilage  to  reduce  its  size  and  elasticity  and  allow  it  to  Ik-  jnished  to 
liie  other  side,  .\fter  tiie  above, procedures,  bleeding  is  checked,  the 
edges  brought  together,  dusted,  and,  if  neces.sary,  a  tine  stitch  or  two 
taken.     Healing  promptly  results,  and  the  symptoms  disapiK'ar. 

Nasal  Polyps  and  Hypertrophies.  The  liistory  of  the  treatment  of 
nasal  polyjjs  presents  tlire(>  distinct  periods.  In  the  first  ixTiod  thes-^ 
iirowths  were  removed  by  ai)i)lications  of  various  caustics  either  li])- 
plic.l  to  the  surface  or  injected  into  the  nia.«s  of  the  polyps.  This 
caused  a  sloughing  with  its  attendant  danger  of  sejjsis,  though  this 
accident  does  not  seem  to  have  been  very  freciuent.  Tannin  was 
insufflated  and  occasionally  some  iron  solution  was  injected  into  the 
mass.  It  is  needless  to  say  that  all  such  plans  were  .slow,  disagn-eable 
to  the  patient,  and  unrelia'ble  in  result.  Polyps  were  then  considered 
tumors,  and  some  of  the  older  text-books  .still  sj)eak  of  them  as  myx- 
omatous in  nature.  We  now  know  that  this  is  far  from  the  truth. 
Myxomatous  tissue  is  homologous  with  fat  tissue,  and  both  urc  almost 
iiiikiiown  in  the  nose.  Present-day  teaching  is  t't  the  effect  that 
polvps  are  nothing  liut  cedematous  iiiHanmiatory  outgrowths,  merely 
the  histological  elements  of  tlie  na.sai  mucosa  under  jK-culiar  n-  x-hani- 
lal  conditions. 

The  second  period  «as  marked  by  nMuoval  with  forceps  uiserted 

lares.     The  mti.ss  was  grasjx'd  and  pulled  away 

'  .mage  was  thereby  done  to  the  delicate  intra- 
,ch  use  of  forceps  is  in  the  light  of  our  jiresent 


lo, lowed  the  clarification  of  our  ideas  of  pathology 


lather  blindly  iiit 

I  ly  brute  force. 

nasal  strurtures 

knowledge  iiiadi    i 

Tlie  third  peril. -  ... 

nd   the   introduction  of  cocaine,  which  by  the  contraction  of  sur- 

:   undiiig  ti.-;sues  more  clearlv  isolated  the  ])olyps.     It  was  seen  that 

lirirl)!isescouhlbeeneircle<i  by  a  .stiff  wire  ami  that  they  couhl  bo 

-moved  on  the  principle  of  ecrasement.     The  credit  for  perfectmg 

ills  method  is  given  by  common  consent  to  the  late  W .  0.  Jarvis. 

hose  snare  is  herewith  figured.     (Fig.  40:?.) 

Later  models  substitute  for  the  pins  at  the  handle  a  screw-clamp. 
riiis  snare  is  somewhat  slow  in  action,  but  it  is  jireferrecl  by  many, 
iiid  IS  of  special  service  in  cases  in  which  the  polyp  is  silualeil  far 
liack  in  the  nares,  n-ijuiring  the  paying-out  of  the  wire  to  encircle  the 


764 


yoSE  AXD  Til  It  OAT. 


l)asp  hoforo  tlic  looj)  is  tiplitcncd.  Sajous  iiKxlificd  tlic  snare  in  such  a 
way  tiiat  a  iimcli  shorter  piece  of  wire  is  re(|uire(i.  Tiie  jiriiiciple  of 
hotii  instruments,  iiowever  is  tlie  tianie.     Hoswortli  lias  devised  a 


Klo.  403. 


Jarvis'  nasal  tfiiaix-. 


Fli..  4U4. 


I 


Bosworth'8  snare. 


O 


Flii.  406. 


WrIght'H  snare. 


pnare  in  which,  after  the  haw  of  tlio  |K>ly|>  is  tnieirded,  hnt  a  ■^ing!:- 
inovemont  is  recpiired  for  detarhnient.  Wripht  has  ennil)ined  tlie 
ideas  of  the  thn'e    snares    named    in    the    instniinent  bearing  hi- 


METHODS  OF  EXAMINATIoy. 


liio 


naiiip.  It  is  :i  jjowcrful  and  rather  rapidly  acting  snare.  It  euii  In- 
manipulated  with  one  hand,  however,  and  meets  every  rwiuirement 
in  the  removal  of  polvps. 

In  the  actual  operation  the  nostril  is  first  cocauuzetl.     As  the  ixjlyps 
often  completelv  hlock  it  up,  it  is  .litticult  and  often  nn|)ossil)le  to 
eompletelv  ana'sthetiz.-  the  operative  Held,  hut  the  use  ,>\  a  strongly- 
driven  spi-av  and  of  cotto.'  p''Mlgets  will  Renerally  eflect  the  desired 
result      Suprarenal  extract  m.. .  he  used  with  a  view  to  the  prevention 
of  hleediiiji,   l)iit   this  is  rareiv  severe.     The  favorite  site  of  polyp 
■Towth  is  from  the  edges  of  the  hiatus  semilunaris  under  the  middle 
Uirhinate.     The  snare  selected  aiul  threaded  with  No.  o  .<teel  piano 
wire  is  pas.^ed  with  the  K.op  at  Hrst  vertical  and  then  horizontal  so  as 
to  slip  aromid  the  polvp.     Much  is  said  about  the  pedicle  of  these 
j;rowths.  hut  we    rarclv  we  the  exact  .seat  of  attachment.     After  the 
boi.  is  passed  it  is  graduallv  tightened,  and  just  as  we  feel  that  sever- 
ance is  al)out  to  take  place  it  is  well  to  give  a  .«udden  traction,  so  ijs  to 
remove  a  bit  of  thi'  niiicos,  to  which  the  polyp  is  attached.     Ihis 
maiueuvre  can  be  rei)eated  until  the  naris  is  clear,  the  oju-rative  held 
being  cleansed  bv  svringing  from  time  to  time.     It  often  liapjX'ns  that 
the  patient   leaves"  the  surgeon  with  a  nose  jjerfectly  tree,  but  in 
twentv-four  hours  tinds  it  as  much  stoi)ped  as  ever.     The  explanation 
is  that  other  polvps  from  practically  the  same  or  neighboring  bases 
have  b-en  crowdJ'd  bv  mutual  pressure  up  into  the  accessory  sinuses 
.,r  the  sinuosities  of  the  nasal  chambers,  and  that  by  the  n moval  of 
ilie  masses  in  front  and  lowest  down  they  are  by  gravity  and  nose- 
l.lowing  dislodged  from  their  position,  and  thus  fall  down  to  tak,-  the 
place  of  tho.se  Krst  removed.     A  continuation  of  treatment  will  hnally 
live  the  nose.     In  regar.l  to  cauterizing  the  ba.se  to  i)revent  recurrence, 
authorities  ,liff.>r.     Hosworth  .says  that  he  has  ••never  been  able  to 
ivco.niize  the  base  from  which  a  i)oivpus  has  bwn  severeil,    and  conse- 
•  lucntlv  he  thinks  it  uiiwi.-^e  to  subject  healthy  tissue  to  nijury  m  the 
blind  attempt  to  cauterize  a  region  that  cannot  be  seen. 

If  as  occasionallv  happens,  the  polyi>  slips  away  from  the  wire  loop, 
M  luav  be  held  by  a  slender  hook  or  forcei>s  while  the  loop  is  adjusted. 
Ket  w^en  .sittings"the  patient  .should  keej)  the  ikw;  clean  with  some  aiiti- 
sciiiic  solution:  no  other  after-treatment  isreijuired. 

^mw  have  recommended  the  galvanocautery  loop  for  the  removal 

-if  polyi>s.     It  is  not  easv,  however,  to  manipulate  the  .<ott  platinum 

loop  of  this  instrument."    This  difficulty  is  somewhat  overcome  by 

using  iridoplathium  wire  instead  of  simple  plaiinum.     Moreover,  the 

.■urient  acts  as  a  cauterizing  agent  and  produces  a  slough  \vhich  may 

!,(.  followed  bv  intlanimatorv  action  hi  a  region  in  which  it  is  most 

Icsiiable  to  av(Md  it.     Sad  accidents  have  followed  the  use  ;-,f  the 

autery  in  anv  form  in  the  n-gion  of  the  middle  turl)inate,  owing  to 

•he  importance  of  structures  higher  up.     I':iectroly.  ■    has  been   sug- 

,-t<d  but  thi.«  belongs  to  the  category  of  curious  rati.,  r  than  of  prac- 

"ic.il  tiierapeutics.     It  is  tedious,  and"  at  the  present  time  practically 

never  used  for  the  removal  of  polyps. 


i 


r 


7«« 


XoaJi  AM)  THROAT. 


lor  th(>  roniDViil  i.f  nasal  liypcrtropliirs.  that  is,  rodun.Iaiit  turhinat.^ 
tissue,  the  ('(ild-win-  snare  is  a  most  useful  instruineut.  While  tiieiv 
is  a  eoUMiiendahle  reaction  against  the  excessive  zeal  of  a  few  year- 
apo  for  the  .lestruction  of  turbinate  tissue,  there  are  cases  in  which 
the  tissue  has  U'conie  useless  for  functional  purposi-s,  and  its  removal 
is  rightfully  demanth'd.  For  this  purjxise  the  snare  can  he  u-d  ;h 
for  polyps.  If  the  amount  of  tissue  to  he  removed  is  small  or  of  such 
a  sha|)e  that  the  wire  will  not  easily  enpige  arouiul  it.  it  mav  he  trans- 
fixed with  a  needle  over  which  the  loop  can  Im-  slipped. 

For  the  removal  of  an  entire  turbinate  bone  we  may  use  the  tur- 
hmotoiue,  so-called,  which,  constructed  on  the  jmnciple  of  the  spoke- 
shave,  IS  pa.ssed  behind  the  ma.s.s,  which  is  removed  with  a  (juick 
motion.  More  often  the  n>moval  of  onlv  a  portion  is  necessarv  and 
the  snare  suffices.      (Fig.    407.)      Portions  of  the  middle  turbinate 

Flo.  407. 


Snare  engiglng  posterior  turblntte 


can  al.so  he  removed    by   cutting  sci.ssors,  the  cadges  of  ;vhich  mav 
Iw  .serrated,  or  by  instruments  constructed  on  the  rongeur  principle.  " 

Fl(i.  40H. 


Serrated  nciswrB. 

Oalvanocauterization.  The  use  of  acid  caustics  has  alrea.lv  h'or 
nientioned.  There  remains  to  s|H.ak  of  the  galvanocauterv,"  whicl) 
lias  come  into  such  general  emplovment.  It  is.  perhat)s  better- 
adapte.1  lor  work  .m  the  hiferior  than  .m  the  middle  turbinate:  ii 
used  m  the  latter  regi„„  it  .houid  he  with  the  greatest  caul  ion  ..„ 
account  of  the  vital  structures  high.T  up.  The  source  of  electricitv 
may  he  either  tli.>  street  current   properly  reduced  and  controlleii 


METHODS  OF  LWAMlSATWy. 


767 


or  any  one  of  thn  various  batteries.  Tiie  cords  should  he  attached 
•()  an  interrupting  handle,  and  of  the  many  varieties  on  the  market 
iliat  known  as  the  Schecii  liandle  answers  every  re(iuirement.  It  can 
l»e  used  also  for  tlie  electric  snare.  The  various  forms  of  cautery 
points  are  herewith  figured. 


Fia.  400. 


Scbecta  cautery  handle. 


The  part  to  Ijp  cauterized  is  anspsthetized  with  cocaine,  and  the  point 
is  then  druwn  along  its  ci-nvexity,  .laking  one  or  two  deep  furrows, 
the  object  IxMiig  to  pin  down  the  n-dundant  tissue.  The  electrode 
-should  be  heated  a  little  beyond  cherry  red.  After  its  withdrawal 
the  nostril  should  be  sprayed  with  an  antisejitic  solution  and  a  dusting 


Flo.  410 


Cautery  points. 


powder  insufflated.  The  patient  may  Ik-  given  a  powdei  of  a  little 
lociiiiic.  bismuth,  and  acacia,  to  us«'  on  subse(|uent  days  to  allay  severe 
•'■action,  and  tie  should  wear  cotton  in  the  vestibule  to  keep  out  the 
lust.  Seances  may  be  re|)eated  after  a  week  or  so,  when  the  .slough 
'ollowing  the  cauterization  will  have  come  away. 


CHAPTER    XVIII. 

..^KLAMMATOUY    DISEASKS   OF   THK  UPPER   AlH 

PASSAGES:  HAV  KEY  Kit ;  RmNOUHIKEA; 

ASTHMA;  INFLUENZA. 

By  CHARLKS  W.  lUrHARDSON,  M.D. 


Acute  Rhinitis.  Acute  rliinitis  is  an  acuU'  iiiHamination  of  the 
nmcoas  iiicinl)raii<'  lining;  the  nasiil  pavitics.  This  inflaiimiation  is 
attended  with  tiie  usual  iiiieiioinena  tliat  attend  acute  inHauunatory 
cliauftes  when  at^'ectinR  iiuious  surfaces  in  general,  i)ut  is  altered 
soniewiiat  in  the  nasal  chanihers  on  account  of  the  underlyiiij;  vas- 
cular turhinal  tissues.  The  inHanmiatinn  is  rarely  limited  to  the 
nasal  chanihers,  more  often  extending  into  the  communicating  acces- 
sory cavities,  as  the  frontal,  ethmoidal,  and  antral  cavities,  and  frc- 
<|uently  extendinji  downward  into  the  pharynx,  larynx,  or  outwanl 
through  the  Kustachian  tulws  into  the  inuhlle  ear. 

The  term  catarrh  i>as  U'cn  u.sed  from  earliest  days  to  designate 
an  alteration  in  the  |)hysiolo<;ical  function  of  the  nose  characterized 
hy  an  increased  How  of  .-iecretion.  (iaien,  ("elsus,  and  others  of  the 
earlier  medical  authorities  suiijMised  the  flux  which  attends  this  dis- 
ease in  the  acute  stage  to  have  been  an  outixiuring  from  tl;e  brain: 
therefore  tlii'  comlition  was  supposed  to  Im>  of  be;  :it  to  the  affecteil 
individual,  and  on  this  account  the  (lennan  custi.  i  of  congratulation 
on  sneezing  is  supposed  to  have  its  origin. 

Etiology.  There  is  no  disease  in  the  whole  rangi  of  meilicine  in  which 
so  many,  so  diversified,  and  often  su(  h  -ontradictory  factors  ap|)ar- 
ently  enter  as  causative  elements  in  its  prodtiction  as  in  acute  rhinitis. 
Tl;.'  jiredisposing  factors  are  first  to  be  considered.  There  is  no  doul)t 
that  as  long  as  the  bodily  condition  is  maintained  at  a  perfi'ctl,\ 
normal  tune  liy  proper  attention  to  the  .skin,  the  digestive  organs, 
and  the  ordinary  hygi<'nic  rules  with  regard  to  clothing,  exercise, 
ventilation,  ami  rest,  that  a  reasonable  amount  of  exposure  to  heat 
and  cold  may  be  made  without  interfering  with  the  physiologic,! I 
function  of  tlio  nasal  mucous  membrane.  The  most  potent  preilis- 
posing  cause  of  acute  rhinitis  is  therefore  tlie  lowering  of  the  bodily 
tone,  rendering  it  incapable  of  resisting  the  exciting  causes.  Sucli 
cond.itiims  may  be  brought  about  by  improper  clothing,  uiulue  ex- 
posure of  certain  portions  of  the  body,  improper  attention  to  thi' 
skin,  acute  indigestion,  constipation,  acute  or  chnmic;  mental  excite 
ment,  and  excess  in  mental  or  physical  activity.  The  various  dia- 
thetic contlitions,  by  lowering  the  g(>neral  tone  of  the  individual. 
( "<w  ) 


iMLAMMATOIiY  DIHEASEH  OF  THE  It'l'Eli  AlJi   rAS.'^AUEH.    7G9 


rcinlcrs  liiin  siispcpvil)!^  to  attacks  upon  the  sliRhtost  ox|)osurp.  Thin 
1-  iiotKMl  ill  tlic  uric-acid  (liathesi:^,  in  tlioso  suttVrinn  from  nourats- 
tiicnia  and  other  nervous  iilicnonicna.  It  is  also  very  conmioiily 
noted  that  certain  indivithials  have  a  marked  predisposition  to  cold- 
catchinji,  and  that  tiiey  will  have  seizure  after  seizure  throughout 
the  chaiiKeahle  season.  This  condition  is  said  to  !«•  hereilitary,  and 
Dl'tcn  I'lanifests  itself  in  other  ineinlM-rs  of  the  same  family.  Altera- 
lioii  in  habitat  is  oft<'n  attended  with  freijU-'it  attacivs  of  acute  coryza. 
i'lii^  is  |)articularly  noticed  when  the  change  \>--  very  marked,  as  when 
persons  accustomi'il  to  live  in  high  altitudes  move  to  th  ■  lowlands, 
or  when-  the  rev<'rse  takes  place.  This  is  no  doubt  due  to  the  process 
of  acclimation  and  want  of  jiroper  appreciation  of  the  altered  atmos- 
pheric surroundings.  Thos<'  occui>ations  wliidi  expose  individuals 
enii)loy:>d  in  them  to  sudden  and  marked  variations  in  the  character 
and  temiM'ratun'  of  tiie  atmosphere  render  them  especially  prone  to 
rold-catdiing.  Chronic  changes  witiiiii  the  nasal  cavities  or  naso- 
pharvnx  are  a  decided  predisj)osing  cause  of  acute  rhinitis.  The 
chronic  dianges  which  are  most  potent  as  provocative  agents  are 
spurs  and  deflections  of  the  sei)tum,  chronic  hypertrophic  rhinitis, 
Mdenoids,  and  postnasal  catarrli.  The  above  enumerated  chronic 
cniiditions  have,  by  their  alteration  of  the  mucosa,  placed  it  in  a 
receptive  state,  whereby  only  a  moderate  degree  of  exiM)sun>  under 
unfavorable  concUtions  is  followed  by  an  acute  attack.  All  ages  are 
susceptil)le  to  attacks  of  acute  rhinitis,  although  i'  is  more  fmiuciit 
during  child  life  and  adolescence.    The  aged  seem  to  find  a  certain 

dcjir if  exemi>tion  from  acute  rhinitis.    The  male  sex.  on  account 

nf  being  (Muploved  in  all  occupations  which  ibject  them  to  exposure 
ti.  a  gn-ater  extent  than  the  female  sex,  a  the  most  frecjuent  suf- 
I'l'rcrs. 

Exciting  Causes  Tlie  gn-atest  and  most  fn-quent  exciting  cause  of 
nil  acute  rhinitis  is  the  exposure  of  a  portion  of  the  body  to  the  in- 
lliience  of  a  moist  atmosiihere  at  a  moderately  low  temperature  and 
niiiving  at  a  medium  average  of  velocity.  In  other  words  the  expo- 
smv  of  the  bodv  to  a  draught  of  moist  air.  It  is  a  common  obser- 
v.ition  that  colils  are  much  more  fre(|Uent  during  the  changeable 
d.iiiii)  weather  of  the  fall  and  spring  than  during  the  extremely  dry 
cold  weather  of  winter  or  the  hot  weather  of  summer. 

A  teiiiperatuiv  Ix'tweeii  .3')°  and  40°  V.  whicli  is  moist  is  the 
Micist  active  exciting  cause.  At  certain  periods  of  the  early  fall  and 
<piing.  in  which  the  above  atmos]iheric  comlitions  are  fre(|uent,  colds 
MMiirto  l)e  epidemic.  Is  the  epidemic  the  result  of  a  given  .specific 
i:mse.  or  the  n>sult  of  a  number  of  jM'ople  iM'ing  exposed  to  the  same 
atmospheric  change?  A  number  of  workers  in  this  field  have  at- 
irmiited  to  isolate  a  micro-organism  as  the  active  agent  in  acute 
rhinitis,  among  whom  might  be  mentioned  Reinsch,  Hajek,  Klebs, 
Wright,  and  othere.  W  hile  it  is  possible  that  acute  rhinitis  is  an 
infectious  disease,  no  one  has  yet  discovered  the  acceptable  micro- 
organisH),  nor  has  it  been  possible  by  inoculation  with  the  serous 

49 


770 


SOUE  A  XI)  Til  HO  A  r. 


ox.Klat.on  fn.m  the  afTcrful  ,„i.s.il  raviti.-s  to  pro.luco  the  .lisoa.so 
11.0  woar.i.^'  of  wot  apparrl,  ..s,MTially  of  ^^ot  ,„  .la.ii..  s\uk>h  an.! 
.to,.k„.Ks    tl„|.s  allow...K  u  IhorouKl,  ..hilli,.^,  of  a.,  .-x,;.,^..!  ,K,rti..n 
of  tl...  l.o,ly.  .s  u  v.-ry  art.y,.  ..x.-itiuK  oau.s...     Tl.r  al.i.lii.K  ii,  ov.r- 
h..at..,l  a.ul  .ll-vo..t.lat..,l   phu-.-s  of  a...us,.,.»...t..  th.-atn's    n.n.-ert- 
hall.s,  oil,,.,.  r,)o„.s,  fa,-tori,-s.  a.i.l  privat,'  ,lu,-lli.,gs  an-  .H.t,...t  .-aii^.s 
Many  of  the  acut,'  ...f,-,-tiou.M  .lis,.a.s,-.s  aro  .■x,'itinK  fa,'tors    in  th.t 
th,.y  are  an,-n<l,.,l  w.tlx  an  acut,-  rhinitis  as  one  of  the  ac-innDanv- 
inK   symptoms.    S..,.;,   a.v   nu-ash-s,  whoopin^r-c,,uKh,  s,-arl,.t    f,-v,-r 
rotl.,>!n    typi.us    mt,-rm.tt,.nt    f,.v,T.  an,l   smallpox.     ( ortain  ,lruKH' 
c  .,'m.(..ls.  ,-,T,.als.  an.l  .Insts  from  manufm-turinR  pl.H..ls,  tl.ronKh" 
thoir  pl.ys.,al  proiKM-t.t's   or   by  m,.chani,-al    irritation   uiv,.  ris,-  to 
ooryza.     .-VIso  n..Kl.t  Im-  m.-i.tioncl  tl.,.  rhi.iitis  ('x.^itcl  hv  tho  action 
of  til,'  stroptocw,.us,  ,-rysi|M.latous  coc<...s,  ai.,1  the  gonococeus. 

Symptoms.    The  syn.pt..n.s  of  an  act,,  rhinitis  are  u-suallv  of  •. 
m.l.l  const. tnt.,.nal  an.l  active  local  charact.T.     Th,-  invasion  n.av 
.0  pn.c^,l,.,l  l,y  a  MmfT  of  lassitn.le,  l.,.a,la,.he.  or  slight  chilly  .sensa- 
tion.     Ihe  ear.,.st  an.l  otl,..i  pathoK..on.onir  local  sv.ni.to.;,  of  an 
.np,.n,l.,.K  ool.l,  o(t,>n  n.an.fest,.,!  tw,.nty-four  ho..rs*  In-fore  consti- 
t.,t.onal  ,,r  o  Iwr  L.ca   syn.pto..,s.  is  a  f,.,.|in«  ,.f  h-ritatio...  .Irvness, 
....,   h,.at  ...  the  r,.of  ot  the  nasal  cha...b,.rs  an.l  vault  of  the  pharynx 
W  tl.  the  ons,.t  of  tl.,.  attack  «e  have  a  f,..|ing  of  .lepr,.ssi,;n,  hea.l- 
ac  ...   .nab.hty  to  ,.,)n,.,.ntrat,.  the  ,..in,l.  in.pair...,.nt  ,;f  the  apix-tit,. 
(.....st.pation,  an.l  a  febrile  .l.sturbance  varving  from  •»!>  to  100(leert.,.s' 
Tl.,.re  .s  ....,mn-n.ent  ,.r  ron.pI,.te  lo.s.s  of  the  special  .s,.ns,.s  of  sm,.|| 
an.l    aste.     The  local  syn.pt,..,.s  .luring  the  first  twentv-fo.ir  hours 
ar,.  thos,.  of  f.iln,.ss  an.l  h.-at  an.l  ,lryn,.ss  in  the  nasal  cavity,  with 
ore  or  ess  .l.th....lty  ,n  Im-athhig  through  one  or  iK.th  nasaUham- 
rs.     U  .,.  ..asal  chamnT  may  be  fr,M.  while  its  f,.llow  is  open,  an.l 
th.s  c«n.l.t.on  n.ay  .,u,,kly  alt.rnate  as  to  the  ..hamln.rs  afTecte.1 
S  H.ez.ng  ,lur.ng  tins  stage  .s  oft,.,,  a  very  ,)ron,.unc,..|  an.l  ,list.vssi„g 
sx  n.pt..,.,,  an.l  .nay  ,.ont.n.ie  so  thro.ighout  the  h.vasion  until  rv^u- 
lut.on  ,s  brought  about.     Th,.  s,.,.,.zi„p  paroxv,.ms  an-  m  ,v  ^r  - 
nounc,..l  ,lur.ng  the  n.orning  hours.     .At 'this  -period  we  have't  ..■ 
vo.ce  ,..or..  or  l.-ss  m..lil...|,  charact,.riz,.,|  as  the  nasal  v.m-e     Tl,. 
su..,.,.,..l..,g  .st...g,.  ,s  on,.  att,.n,l,.,l  with  a  profuse  salin,.  s,.rous  trans,  - 
.1  t.on  wl.,ch  .s  of  an  ,.xm.,ling|y  irritating  charact..r.  oft,-,.  ,.a..si,K 
xc..r.at.on  al.o.it  the  ah..  a.,.|  upjK.r  lip.     WV  also  ,  ft,.n  n.,tice   .7 
tl.,s  t.me  a  crop  of  labial  or  nasal  l„.rp,'s  which  a,l.l  gn-atl  -  to  tl  ,' 

, ,         \    f  r.  'V'"','"''""^,  '"  '^••'•""=;-'--'>'-^.  ••""!  •"...•o.,s  to  ..,u..opun.- 

^^.th   br.  k,.n-,lown    an.l   .l,.s,|ua„.at,..|   ,.ellular  ,-l,-„„.n..s  an.l   le.u-o- 
e.vt,.s,  .t  beco,nes  less  Hui.l  an.l  t,...,|s  t..  c.llect  in  incmstati.'ns      Th. 

Y-nos    2,^atly  n,  ,|,ff,.n.nt  m.hvi.h.als  an.l  in   il,e  san.e  i,..iivi.iuaH 

a  pat.ent  n.ay  be  fa.rly  fn-,.  of  sfnosis  .luring  the  day,  yet  up,m 


ISFLAMMATOHY  DISEASEH  OF  THE  I'J'PEJl  A  IK  PAHS  AUKS. 


rctiriiiR  at  night  it  is  iioticod  that  almost  iiiiiiicfliatciy  a  (•"niplctc 
;iii(l  |HTsistf'iit  l)I(wl<a)i('  i>f  iMith  chariilMTs  occurs,  th«>  ol)stna'tion 
iM'iiig  mori'  |)roiioiinwil  in  the  dcix-ndcnt  chanihcr.  t'ouphing  at 
rnght  is  an  cxtrcin^'iy  distressing  syniptoin  to  many  patients,  and  is 
|iarticularl}  noticed  in  children.  This  night-coughing  is  due  to  the 
irritation  excited  by  mouth  breathing  and  the  acricl  secretion  irri- 
t;iting  an  already  ()ver-s<'nsitive  pharynx.  Cough  may  In-  more  (»r  le.s.s 
|>res<'nt  throughout  the  waking  hours.  Besides  the  characteristic 
alteration  of  the  voice,  due  to  the  i)lockage  of  the  nose,  we  may  have 
liojirseness  to  aphonia,  due  U>  the  amount  of  synchn)nous  involve- 
ment of  the  larynx.  The  severity  of  the  headache  is  dependent  upon 
ilie  amount  of  fever  and  the  extent  of  the  imf)lication  of  the  ethmoidal 
;ind  frontal  sinuses,  llarly  in  the  attack  then-  may  Ik>  noticed  a 
tceling  of  stuffiness  or  fuhiess  in  the  ears,  often  ringing  or  undue 
resonance  of  the  voice,  acute  .son'ne.ss  or  actual  j)ain,  and  dizziness. 
'  >ften  in  children  and  in  .severe  rhinitis  in  adults  we  have  acute  simple 
■r  suppurative  otitis.  Freciuently  there  is  congestion  and  reilness 
lit  the  conjunctiva. 

Diagnosic  Tlie  diagnosis  is  readily  made  from  the  local  and  con- 
-titutional  symptoms  present.  In  all  cases  a  thorough  ahd  careful 
I  \l)loration  of  the  nasal  chamlH-rs  should  Ih?  made  by  anterior  and 
|i<ist<'rior  rhinoscopy.  During  the  initial  stage  the  mucous  mem- 
lirane  will  be  noted  as  intensely  livid  and  fn>e  from  moisture,  and 
the  turbinates  .so  swollen  as  to  come  quite  or  almost  in  contact  with 
r:i(li  other  ami  the  septum — practically  obstructing  the  view  beyond 
tlic  vcs'St.ie  of  the  nose.  During  the  second  stage  the  membrane  will 
lie  noted  to  Ik*  of  a  deep-red  coIct,  .succulent,  and  with  descjuamated 
(•(■lis  here  and  then'  disseminattnl  on  its  surface;  the  amount  of  ob- 
-tniction  due  to  turbinal  engorgement  is  not  as  great  as  in  the  primary 
-tajie.  During  the  third  stage  the  membrane  is  not  so  vividly  red, 
tlic  turbinal  engorgement  is  not  so  great,  and  the  inferior  and  middle 
iiicatus  will  be  noted  as  showing  more  or  less  mucopunilent  di.scharge. 

The  complications  of  acute  rhinitis  are  those  conditions  due  to  a 
lirccf  extension  of  the  inflammation  through  continuity.  We  may 
li.ive  extension  to  the  accessory  cavities,  temjxjrary  occlusion  of  the 
lacrymal  duct  with  epiphora,  conjunctivitis,  pharyngitis,  tem|)orary 
'l)stmction  of  the  Kustachian  tul)e,  acute  catarrh  of  the  tul)e  and 
liie  middle  ear,  acute  simple  and  suppura*'  ■■  nfiammation  of  the 
middle  (>ar. 

riie  prognosis  is  very  favorable  as  to  recovery.  Caution  should 
''(•  (liiserved  as  to  pn)gnosis  in  the  very  youn;^  and  the  aged,  as  exten- 
sion may  give  rise  to  serious  involvement  of  pulmonary  tissue.  Due 
I  lort  should  be  made  to  bring  about  complete  resolution  in  order 
t(i  prevent  the  catarrh  from  passing  into  the  chronic  state,  or  the 
'  -tablisliM'.eiit  of  the  tendency  in  rer'iTence 

TreatmeLt.  It  is  greatly  to  be  deprecated  that  an  acute  rhinitis 
w  con.sid,  red  such  a  trivial  affair  by  the  avonige  layman,  and  that 
it  is  permitted  in  the  large  j)roportion  of  cases  to  follow  its  own  course 


772 


.VOAi   .'.V/.    nil!>M 


I 

I 
i: 

I 

h 

m 

r 
i- . 

ii 

1'  ^ 


without  i'fT(  rt  to  lirifip  al>niit  [HMit  n'-.lutioii.  It  woulil  he  well 
it  \vi'  could  ccliicatc  tlic  l;iity  ..  to  tl  ri  .iistii-ss  oi  iicglcitcil  ;icutc 
rhinitis,  ami  ihr  iiii|Hirtaiii(  i.f  Uriiiniiij;  I  to  a  (|uifk  ri'soiiitioii 
There  seems  In  he  no  ilouLi  that  iliiririK  tli-  •■arly  slap'  the  attack 
can  Ih'  siM'eilily  hroupht  to  resolution  hy  n'sirtin^f  to  ahortivc  ireal- 
niciit.  The  patient  should  Ix-  |>ut  to  iVmI,  .'•  at  lea-l  confined  for 
twenty-four  or  forty-eifjht  hours  n  \  dom  .  This  ronhnrnieiit  is 
not  always  possihle.  hut  it  is  de.-i 'n!,!.  vhei  practic.iiile.  j'he  im- 
portant part  in  the  early  tneatmeM  .~  'l.e  .  .(oration  of  the  equi- 
lii)riuni  iiriucen  the  disturlM-d  ai-'iiiii  ..i  tic.  vin  and  the  engorged 
iiiusal  niucoiLs  memi)rani',  which  i»  i'  -t  accoiMj  Ushed  lhrou>;h  active 
diaphoresis  and  local  de|>letiou.  '.:i>  ii.jphore-is  can  Ik-  as  well 
excited  i)y  the  administration  of  .»  wifyious  ,\  ,  i,jfi,t  of  ta.siefui  hot 
drink  as  throujjh  the  agency  of  druic? .  Tl.  lei  i-'iou  i  Im'  Hmiteil. 
better  liniite<l  to  a  strict  liipiid  r'  iracter  A  Dover's  powder  of 
10  grains  may  Ih;  given,  or  ()..«)  of  hmmide  o,  j.il.JU'  iiiuy  I..-  given 
at  hedtime.  A.S  a  gcxMl  derivation,  as  well  ;u4  for  il-  active"  depletory 
effect,  ralimiel  in  diviiled  doses,  followed  f)y  a  saline  purge  in  the 
moniing.  materially  aids  the  resolution.  For  pur|M)se-  <  active  Kn-al 
de|)letion  I  know  of  no  remedy  that  acts  :i.s  thomii  iv  jis  a  tablet 
of  O.ill  of  cliloride  of  sodium  introduced  in  each  na -iT  chumlxT,  .- 
suggesteij  |)y  Kyle.  When  the  patient  cannot  he  i'ontinp<i  ab,so- 
luteiy  to  the  hou.se,  hut  is  able  to  remain  within  doors  the  greater 
jxirtion  of  the  day,  I  have  found  codeia  and  ammonia  carlMmat",  ii> 
cherry  laurel  water,  by  its  mild  di.iphoretic  action,  to  uccomplibi 
great  good.     It  is  administered  as  follows: 


e.Kleia, 

Oi»! 

Ammonli  carboiiat.. 

i.ao 

Syr  tiiltitan.. 

ai.oo 

Ulyr,  rirni-. 

H.UIl 

can  ho 
atTord 


Aqui»-  liiun>-c«nu«l      art   ito.uo 
91g.— Te«8p<«.iiful  every  hour  uiili;  C.urth  done,  itien  evtry  two  hours. 

For  relief  of  lieail  p;iin  I  imd  that  applications  a.-  not 
borne  applied  to  '  .c  forehead  as  continuously  .x*  pos.v.hl.' 
the  great,  -^t  relief.  If  the  .abortive  treatment  fail-,  as  it  will  in  niany 
cases,  the  further  treatment  must  \h^  .sympton-itic.  The  bowels 
.should  be  k.  pt  freely  evacuated  with  morning  a'ld  evening  doses  of 
.sixteen  grains  of  so.lium  phosphat<-.  Aeiite  rhinm  occurring  in  the 
litha'-  i.c  can  b.  q  be  eombated  by  a  strict  dietam  and  the  adirinis- 
tration  of  jiiliia  and  ()hi!sphate  "of  sc  linin.  In  the  rheumatic  tin 
constitutional  treatsiient  should  1m'  the  .salicylate's  or  salicm.  Jr;  ilu 
malarial  brisk  purging  with  calomel,  foil. wed  bv  the  ailministr.  'ion 
of  quinine.  Should  the  <li,stention  of  the  turbiisites  Ik'  so  gr.it  a.« 
to  give  rise  to  distressing  symptoms  temiMirary  rehcf  may  1m>  art  nied 
through  the  application  of  cocaine  ■  r  siiorarena!  OYtru.t.  (  .  ;..,. 
and  suprannai  (wtract  deplete  tiir.Kigh  c.ntraction  of  the  ti  mal 
vascular  tissue.  It  is  pxcreme  y  uKwi.se  to  jl.ice  cocaine  in  th«'  luuuU 
oi  the  patiei't  for  self  local  adriiinistrii-  !i,  on  account  of  tlie   ;asipr 


ISHAMMAruHY  Ul^EAsty  of  THE  1'Pl'i.H  MK  l\i«>  i',£f,.     77y 


liirh  t'S'vT  cxistK  of  *'\i 
unless  it  cair  1m  >>ri'scnlM-i 
iiii;r,v  in-  nf  iIk>  iiatiin'  ul 
u-cil  i  i  |x'r  (•<■  t.  !ii|i 
tnry  It  shmiM  In-  r(|H'iil( 


IIJ5  in  liic  imlivi'unl  tho  c     ,tiiw>  liuhit, 

-uch  fi  rtn  'imi  tliv  [cili'  lit  will  Im'  t'tully 

(Iriis;  litiHK  I'tnjiloytMl.     (  'icuiiic  is  ln-sl 

OILS  sc)hlti=>ii       As  !!-     I'tJon  i-  very  tnnisi- 

:)>.  fr<i|U<-iir!     iu*  (•     I     i'liii      lurs.     It  may 

licttrr,  h    siuuru!    if  1  f(ljp-t.s  '>f  al»M>rh'-!it 


itoti  with  tlu'  .soiutldii  ami  iiitri'MHiijn  ;iti's«>  iiii'i  the  nusnl  rhrun- 

loi-scnts.  after  wi  ^ch 


»T,  winTt'  tlicy  an-  ;ilKm'"'il  !i»  ren  :un  :i  few 
hi-  (•<■!! 'M  is  niiiuvctl.     isi,;>ran'iia^  ■•vra'-i  i 
Inn;  'p!  ilc|(lotiuii  I  ■    '■<wih-aoti<in,  a-  i'  ii-is 
IS  w   ;l  ,(-  a  mort'  pn  i.tiijifd       tioii  ti        i-o«'a.  it 
uith  any  <■!  tin  iliitif  "^  whii"   .n-coii'  thv 

rile  su[intr('ii  il  i-\tnifi    m  i     iispd  .mi 
not  sf«-iii  1(1  li:     ■  any  u(i)ili;i«ant  (tin^' 
•I'll  locally.     .     -  iH'Ht  iKiil  :i    (irdiiii:  ^ 
ijIC^  >rcil  liy  Iii|i;il     aiiil    nay  I'    IntnKluc 
use  of  focuine,  or 


I  I 

Vf'li 


■'t  ailvatit.if      IS 
nior*'  till  n  .ugh 


rati, 
iti'iii 

ti.r 


if  'lie  i, 

fr     iy.  .,- 

IT''    w' 


1'     'llH'S 
'llllS 

ila,  as 
il  tin 


M     Maeente  fur  four 


spraj  iMg: 

A.!'-l.,         * 
Ar-=    l«: 
A.iu.    .       ,|- 

then  fill'  - 

.ttci 


ted), 
hot), 


r  I 


111     ,!■  <*'('('!   1  staj. 
iliic  1     illii     hat  till-  >pr:iyi  iii  n 
Kaliiie  K'piil  ,      I'ioii  thr  ■■  or  fi 
riiis  solution  iii;i     eonsi>»t  .  f  bicarlmn 

oi  •■,■!.  '■:  to  ',\0  (i!    'I'pi.i      :tt\:  -Ul'!  as 

the  >,-iin('  pur|i(i>'    '   ii^   ■  adi'  II".     1^ 

talilct- 

]>■<■  till 

\t<  the  uiirc  nt  tcj.iil  milk 
(•(■lit.  ution  '  •'  horir  acid. 
-'  iiK-.     Iff  this  cleans!"!;  with  "th 


!i  (M)  i-'aii   -los         rp 
[MirjMi.'^c  en     Ik*  made 


'i(i|-cai;ip!;  >r  imHiip  fMi!iit!"ii,' 


in 


■•tin/'ij  111.  uiii  is  th<        -nstn 

iiiiiii  'lic  •:>!  (nit        i!  also 

iiti-ii  -hv  1.1-  ;i  ci        tion  s«'iiis  to  1m^  followiiijt  a  protracted 

(iiirsc  .      pit«-  nt  i 'M»  :mt>uts  pinplo ved,  it  is  wise  to  u.se  so?.,    •nild 


rofuse  niueopurulciit  dis- 
of  the  nose  with  a  mild 
'.>    .lily  gives  marked  relief, 
and  liilxirate  of  soda.  0.(50 
I,  if  not  blotter,  .solutio'    for 
1^  w.ff  one  of  the  nasal  |>lasiiiii 

\  very  eomfortitifr  solution 
iiijr      iO  (if  sodium  chloride 
(■xp(        I  solution  is  a  'i  per 
ions  11     ie  twice  daily    it  this 
i  the  abt.vc  sfilutions,  of  a  inen- 
liich  iK'iiEoinol  or  other  form  of 
11,  adds  not  only  greatly  to  the 
laterially  in  liringiiig  alxmt  reso- 


jmprnin.  i  ;iil>' 

-m.   oual  (It             i j- 

McFiirl«ne) : 

iuiii  chlori 

' 

'■'    >t. 

VMM  gr>mme« 

-ttum  unlplit. 

(1.0!»7L> 

•• 

Sodium  fhosphite. 

0.0I«2 

" 

I'ott^     iih  fhloriite. 

".(WM 

" 

PotH^^ium  ttiilplmli* 

" 

O.OlBi 

M 

Potassium  phosphatu. 

1,, 

" 

O.OTK! 

" 

Menthol. 

u 

'• 

0MVi2 

" 

Form '-.la  for 

hol-€amphor-iodlne  solution ; 

Menthol, 

L.-iO 

Camphor. 

0,60 

Iodine. 

UtB 

Bcnzoinol 

32.00 

774 


AOA£'  AX  J)  THROAT. 


i 


f 


astringont  in  :iquo(ni><  solution  to  aid  in  Ijrinping  al)out  rosolution. 
Tiip  two  iM'st  agents  of  this  class  arc  cither  a  ]  jut  cent,  solution  of 
silver  nitrate  or  chloride  of  zinc.  The  acute  rhinitis  occurring  in 
early  infancy  is  an  extremely  distressing  atfection,  as  through  its 
obstruction  of  normal  rcspinition  it  interferes  seriously  with  the 
slrep,  prevents  the  infant  from  nursing,  and  may,  hy  in'ii)airing  the 
nutrition,  give  rise  to  more  serious  complications.  Great  relief  can 
be  given  these  little  sufferers  by  irrigating  the  nasal  chamber  with  a 
tejiid  alkaline  solution  introduced  l)y  means  of  an  eye  drop|)er.  The 
head  is  well  held  a-id  the  tip  of  the  eye  dropper  is  introduced  just 
within  the  V(>stil)ule  of  the  no.se,  and  the  solution  forced  through 
drop  by  drop  until  each  na.sal  chamber  is  cleaned.  The  use  of  the 
alkaline  .solution  can  Ix>  followed  by  a  few  drops  of  a  1  jht  cent, 
solution  of  camphor  in  benzoinol  or  albolene. 

Prophylaxis.  It  woul.l  seem  irrational  to  close  this  subject  of  acute 
rhinitis  without  referring  to  the  importance  of  proi)hvlaxis.  Proper 
clothing  and  proiH>rly  protective  clothing  are  most  in\])ortant  in  the 
prevention  (.f  colds.  Too  heavy  do*'  ,ng  is  as  i);iil  as  insufficient 
dothmg.  W(  il-sel(>cted  underclothing  of  medium  weight  is  ami)ly 
sufficient  for  use  in  t<'niperate  climates.  Proper  regard  should  be 
had  to  the  foot  covering.     The  shoes  for  out-of-iloor  wear  should 

have  thick  soles,  and  when  allowed  to  bee le  damp  should  1k'  changed 

nmnediately.  Rubber  overshoes  siiould  alwavs  be  worn  on  damp 
or  ramy  <hiy.s.  Mufflers  about  the  neck,  scarfs,  and  furs  should  be 
discarded.  ( )f  all  means  to  prevent  cold-catching  I  know  of  no  means 
so  potent  as  a  moderately  cool  bath,  between  ()0°  and  70°  F.,  taken 
every  morning  or  evening.  Chronic  conditions  of  the  na.sal  chamber 
should  be  corrected. 

Chronic  Rhinitis.  Simple  Chronic  Rhinitis  and  Hypertrophic 
Rhinitis.  Chronic  rhinitis  is  a  chronic  inHainmation  of  the  mucous 
membrane  lining  the  mtsal  cavities.  It  is  characterized  bv  an  altera- 
tion of  the  mucous  membrane  and  a  change  in  the  ([uantitv  and  (luality 
of  the  secr(>tion.  In  the  milder  typ(>  the  swelling  of  the  mucous  mem- 
brane is  moderate  ami  the  change  in  the  secretion  more  i)ron(nmced 
th<-  so-called  simi)!e  chronic  rhinitis.  In  the  more  severe  tyjK-  the 
swelling  m  the  mucous  in(>nibrane  is  greater  and  attended'  with  a 
permanent  dilatation  of  the  bloo.jve.ssels  and  incn-a.'ied  growth  of  the 
mtrava.scular  connective  tissue,  with  an  alteration  <,f  the  (lualitv  of 
the  secretion,  th.;  hy|MTtropliic  rhinitis.  As  a  i.  Milt  of  the  .swefling 
of  the  mucous  membrane  and  increase  in  submucus  intravascular 
tissue,  we  have  more  or  less  encroachment  upon  the  iiurmal  lumen 
of  the  nasal  chambers,  whereby  there  is  interference  with  free  nasal 
respiration.  This  engorgement  of  the  tnrbinal  tissue  may  involve 
only  the  inferior  turbinate  or  afTect  both  the  inferior  and  middle 
turbmate.  It  may  .show  tumor-like  m;is,ses  affecting  the  anterior 
extremitii's  of  the  inferi.ir  turbinates,  or  similar  con.jitions  nfTectin" 
their  posterior  extremities.  In  either  circumstance  \\\v<.v  enlarge'^ 
njents  are  known  as  hyiK-rtrophiea  and  are  designated  as  anterior 


ISFLAMMATOliy  DISEASES  OE  THE  Vl'l'EH  AJJi  I'ASSAUES.    77.5 


or  posterior,  apponling  to  their  location.  Ofttiincs  wo  find  on  tiie 
surface  of  the  sei)tuni,  esiwcially  about  its  cartilaginous  portion, 
masses  of  erectile  tissue  under  varyinj;  states  of  iiypertrophy.  A 
similar  condition  is  often  observed  at  the  posterior  border  of  septum, 
where  it  stands  out  as  elliptical  masses  rounding  out  on  either  side 
of  the  free  |Misterior  edfie  of  the  se])tum  as  observed  in  the  rhinoscopic 
mirror.  The  pradalion  between  the  two  types  of  chronic  rhinitis  is 
Ml  difficult  that  it  is  sometimrs  almost  impv  ibie  to  determine  where 
the  simple  form  ends  and  the  hy|)ertropluc  oeghis.  The  application 
of  <'ocaine  will  often  enable  us  to  make  this  ilistinct.  After  the  appli- 
••ation  of  the  cocaine  solution,  if  the  swelling  all  disappears,  the  nmcous 
membrane  apparently  being  tightly  adiierent  to  the  turbinal  body, 
the  condition  is  one  of  hyjM'ra'mia,  and  should  be  classed  as  a  simple 
chronic  rhinitis.  If  after  the  api)lication  of  the  cocaine,  however, 
the  nmc(tus  membrane  does  not  contract  down  up(jn  the  turbinal 
bodies,  but  presenting  here  and  there-  redundance  of  tis.sues,  we  recog- 
nize that  we  liave  a  true  hyperplasia,  and  the  comlition  should  be 
designated  as  a  hy])ertroi)hic  rhinitis. 

Etiology.     W  h('n  one  considers  the  physiological  functions  of  the 
nasal  chambers  and  the  varying  chiuig's  to  which  this  action  must 
acconnnodate  itself  during  the  twent}  /our  hours,  we  can  readily 
understand  how  it  can  become  the  sut)ject  of  varying  degr(>es  of 
(hsease.     The  various  organs  and  structures  of  the  Ixi  y  are  subject, 
more  or  less,  to  periods  of  increa.sed  activity,  but  no  organ  is  called 
upon  to  meet  such  varied  changes  in  physiological  functions  a>  ihe 
nasal  chamlxTs.     The  atmosphere  in  its  varying  vagaries  as  to  its 
density,  humidity,  and  temperature,  the  changes  produced  in   Ihe 
:itmos"pher(>  by  artificial  agencies,  as  heating  and  overcnwding,  dust 
and  emanatiims  contained  tlnTcin  from  animal  contamination,  all 
call  upon  the  nasal  chambers  for  varying  active  changes  in  its  vascular 
ii'iision.     The  most  frtMiuent  cause  of  the  chronic  tyjx>s  of  rhinitis 
IS  the  acute  rhinitis.     The  occurrence  of  fn-qucnt  acute  attacks  which 
are  n(>glected  and  not  brought  to  complete  resolution  leave  after  each 
>ucceeding  attack  a  certain  amount  of  residual  inflammation  which 
often  terminates  in  hypertrophy.    Climatic  influences  no  doubt  exert 
,1  most  potent  influence  in  the  production  of  hypertrophic  catarrh. 
A  moist,  temperate  climate,  with  freipient  and  sudden  changes  both 
ill  the  degr(>e  of  humidity  and  tein|)«>rature,  are  most  potent  iigents 
lor  the  i)roduction  of  chronic  rhinitis.     The  bi'fore-mentioned  con- 
ditions i)revail  along  the  Atlantic  .seaboard  and  in  the  lake  O'gion  of 
our  country,  and,  as  is  well  known,  this  type  of  catarrh  is  very  preva- 
lent in  these  regions.     In  the  high  plains  of  our  Western  country, 
strong  winds  laden  with  alkali  dust  also  produce  these  changes.     It 
is  remarkable  how  a  change  in  atmospheric  surroundings  will  often 
produce  a  most  marked  temjjorary  benefit  to  chronic  rhinitis,  the 
-risri'ial    state   n'curring  when    the  patient    returns  to  his  former 
habitat. 

I  l)elieve  this  improvement  is  often  as  nmch  due  to  the  alteration 


' 


7(G 


SOUE  AyV  TUllOAT. 


in  the  indiviiluiil's  Iml)its  of  life  tliroujili  ahscncc  Iroiii   his  formal 


(lailv  lif 


(',  as 


Tl 


to  the  alteration  in  the  atniiisplicric  surnuindinjis. 


If  actiun  of  various  aiiniixturcs  wliicii  arc  convcvcil  hv  the  atinos- 
phore.  as  the  (hist  of  the  streets  siireharKcd  witii  ti 


certain  chemical   fact( 


he  excreta  of  ani- 
ls, millers, 
•rk  in 
iries  and  reducing  estahlisliments,  and  under 


mals.  the  dusi  I'n.m  factories,  the  dusts  to  wliicli  stonemaxn. 
and  l)r()nze-\\drl«'rs  are  exposed,  the  chemicals  set  free  hv 


this  ftroupin};  could  he  included  the  inijalatii.n  of  heated  atniospju., 
observed  in  such  occupations  as  tiiat  of  plaie-|jrinting  and  hook 
hiuditifi.  have  their  deleterious  effect 


th 


riie  hahits  of  life  and  (>ccui)ation  are  instrumental  in  prod 


ucini: 


ondition.  Thorn  can  he  no  douht  that  the  excessive  use  of 
tobacco,  either  hy  chewinji  or  sinokiiifi,  tinDugh  its  constant  irritation 
<if  the  nasal  mucous  memhrane  and  its  toxic  action  on  the  vascular 
system,  causes  enjiorgement  and  chronic  ( hanges  in  the  nasal  mucous 
memhrane.  The  same  may  he  said  of  the  action  of  alcohol.  A 
.sedentary  occu|)ation  which  permits  of  only  a  moderate  degree  of 
general  muscular  activity  and  out-of-<loor  life,  with  abiding  in  over- 


heated and  l)a<liy  ventilate.!  rooms,  exerts  its  deleterious  inHuiiic 


Various  disturb;mces  on  the  part  of  other 


•••gans  or  systems  of  the 


body,  such  as  the  cardiac,  hepatic,  gastro-int<'stinal.  and 


thet 

Tl 

m 


tile  svm 


pa- 


mucosa. 


u- 


ic  nonoiis  system  are  attended  with  changes  in  the  nasal  

lose  constitutional  conditions  which  are  known  as  litluemia.  rlu\. 

atism,  and  neurasthenia,  scrofula,  syphilis,  and  tuberculosis,  are  ail 
predisposing  f.ictors  in  chronic  rhinitis.  I  am  verv  much  inclined 
to  doul)t  whether  there  is  a  condition  which  might  Im-  called  the 
catarrhal  diathesis.     I  am  more  inclined  to  believe    hat  the  coMstitii- 


tional  conditions  ju.st  enumerated  ar 


changes  o 


f  a  <-li 


more  iiistr  imeiit:il  in  producing 


ronic  typ(>  in  the  na.sil  mucous  membrane  than  main 


le   nasal   chambers 


are   willing  to  admit.     I.oc.d   changes   within    tl 

acces.sory  cavities,   and   pharynx  are  often   the  primarv  disturbing 

factors.     Hy  far  the  most  fre.iuent   of  these 


an  influence  is  an  alter, 'ion  in  th 


local  ( 


•hange 


ertmg 


iiiisiil  septum,  either  in  the  form 
ol  a  dellectioii  or  of  a  s,'ptal  spur.  Through  the  instrumentalitv  of 
'jmrs  and  deflection  of  the  septum  the  i 


ias;il  cavities  are  im 
iirrent  in  the  nose  is  disturbed,  the  f 


obstructeil.  the  ;iir  ( 

stances  which  gain  .'iccess  to  the  nasal  chamiiers 


■  '<r  less 


th 


oreign  sub- 
are  not  removed  in 


K'  usual  way,  the  secretions  accmnulate.  and  the  local  nutrit 


sutlers.      When  the  nas;tl  chamlM-r  is  obstructed  bv  a  deflect 
spur  of  the  septum,  the  incoming  column  of 


ion 


ion  or 


:iir  is  carried  over  th.it 


portion  of  the  tnrbin.ite  body  behind  the  ileflection.  upon  which  it 
diminishes  the  atmospheric  pressure.  This  diminish<'d  .atmospheric 
pressure  when  persiste.l  in  continuously,  gmduallv  results  in  tur- 
gescence  . -111(1  hypera'ini;!.  which  in  turn  are  followed  bv 
tissue  growth  in  that  jxirtion  of  the  turbinate  affecteil.    Di 


ceessory  sinus  by  the  irrit.ant  actior,  of  tli^ 


increased 
.fthe 


sease 


the  iia.s.'il  mucosa  give  ri.se  to  n 


purulent  discli.'irge  upori 


In  ethmoid  disease  the  d 


lore  or  less  swelling  of  the  turbinal  ti.s.--uo 


lange  produced  in  the  middle  turbinate 


mf 


IXFLAMMATORY  DISEASES  OF  TUB  UPPER  AIJi  PASSAGES.     777 


alw.iys  very  i)roiiouncP(l.  Ailcnoid  growths,  as  well  as  ciilargfiiiciit 
dl'  the  faiK'ial  tonsils,  an-  very  active  factors  as  primary  agents  in  the 
|iro(liiction  of  chronic  rhinitis.  They  not  only  act  l)y  interfering  with 
the  return  of  venous  hlood,  thus  |)ro<lucinj;  a  passive  congestion,  hut 
also  by  interferign  with  the  proper  ventilation  of  the  nasal  chambers. 

The  consideration  of  the  etiology  would  be  inconiplet"  without 
taking  into  consideration  the  |)ossil)le  activity  of  the  various  micro- 
cirganisnis  which  are  found  in  the  secretions  of  chronic  nasal  catarrh. 
The  pus-producing  micro-organisms  are  fre(|uently  fo;::;;!  in  the  secre- 
tions of  chronic  rliinitis,  but  the  same  organisms  are  never  found  in 
the  substance  of  the  mucous  membrane.  The  mi<To-organisms  so 
found  are  tin;  same  as  those  found  in  normal  nasal  chambers,  and 
therefore  have  no  influence  in  producing  chronic  rhinitis,  which  is 
i-lciuiy  a  non-infectious  inflammation  of  the  nuicous  membrane, 
('inonic  rhinitis  ah'ects  most  fre(iuentiy  young  adults,  the  male  to  a 
greater  extent  than  the  female  sex. 

Symptoms.  The  most  pronounced  symptoms  which  are  noticed 
by  the  sufferer  is  the  alteration  in  the  nasal  secretion  and  tiie  obstruc- 
tion to  normal  nasal  respiration. 

Tile  nasal  secretion  is  altered  in  (juantity  and  (|uality.  The  amount 
"f  secretion  normally  s»'creted  by  the  vascular  tissue  of  the  nasal 
cliamber  during  health  is  about  a  pint  during  the  twenty-four  hours, 
which  is  taken  up  during  the  nr^ural  jirocess  of  respiration  by  the 
incoming  air,  so  as  not  to  be  appreciated  as  moisture  within  the  nasal 
iliambei"s.  .\dded  to  th's  -crous  secretion,  which  may  be  increased 
"I-  diminished  as  hypeuemia  or  liy|)ertrophy  is  present,  we  have  an 
iiKicased  admixture  of  mucus,  leucocjies,  and  epithelial  cells  as  a 
iv>ult  of  the  eiigorg(  '  r-ondition  of  the  chronic  inflamed  mucous 
inembrane.  During  tin  arly  stages  of  chronic  rhinitis,  when  liyjK'r- 
:i'inia  of  the  mucosa  is  more  jiroiiounced,  we  have  an  increase  in  the 
:imount  of  secretion  jiroduced,  the  amount  varying  greatly  in  indi- 
^  idual  cases.  Often  jiatieiits  note  the  amount  of  s<'cretion  produced 
liy  the  tumiber  of  handkerchiefs  used  during  the  twenty-four  hours. 
Till'  secretion  not  only  is  removecl  through  the  anterior  nares,  but 
niicn  gravitates  back,  and  is  drawn  out  of  the  pharynx  iiy  the  un- 
plfisant  nasal  screatus  which  we  so  often  notice.  When  the  liyjjer- 
'niphy  becomes  great  there  is  stagnation  in  the  turbinal  bodies  and 
III  interference  with  the  exosmosis  of  serum,  wliii-h  naturally  diniin- 
i-iiis  the  amount  of  discharge.  In  this  latter  condition  the  patients 
iiiMiplain  of  a  feeling  of  f'l'-u'ss,  as  though  secretion  existed,  which, 
I'li'W  as  they  may,  they  .:"i.  '  remove.  They  speak  of  a  feeling  of 
!i<'Mt  and  dryness.  Tlu  j  i.i  y  of  the  .secn-tion  is  also  variable. 
\\  hen  the  discharge  is  ab.  ■  i  it  it  is  more  sero'i.ucous  or  mucous  in 
'lianicter.  When  less  abun  lant  it  is  more  mucopurulent,  showing 
I  iiiiHlerate  admixture  of  leucocytes  and  epithelial  cells.  It  often, 
■lull  dcliciciit  in  water  elrmeiits.  dries  on  the  sejuum  and  cm  the 
turbinal  bodies  in  the  form  of  flaky  crusts.  The  secretion  rarely  has 
anv  odor. 


778 


At*.Vi,'  AM)  TlJJi'JAT. 


i 


As  a  n-sult  of  the  vasruliir  growth,  tho  thickciiiiip;  of  the  mucosa 
and  tlu'  uncertain  vascular  tension  of  tlic  vessels  coniposin<i  tlie  tur- 
hinal  tissui',  we  liave  a  varying  amount  of  steno.-is  of  the  nasal  chain- 
t)ers,  an.l,  as  a  H's  ih,  tiie  interference  with  normal  nasal  res|)iration. 
It  is  interesting;  to  observe  how  the  character  and  (le>;ree  of  stenosis 
manifests  itself  in  the  tlitferent  individuals  and  in  the  same  individuals 
at  (litTcn'iit  limes.  The  stenosis  may  l)e  most  marked  in  o;  i-  nasal 
chamher  constantly  or  affect  one  nasal  chamber  solely.  It  fre(|uently 
.shows  a  very  vacillating  ti'iidency,  obstructing;  the  rif;ht  cavity  at  one 

nient,  the  left  beinj;  practically  free,  and,  without  apparent  rea.son, 

.suildeiily  reversing;  the  situation.  Many  individuals  note  perfect 
freedom  of  bi-eathinp;  while  moving  about  dunii;;  the  day,  noticinj; 
the  obstruction  only  when  lyinj;  down  to  rest  at  ni<;ht.  Tliis  ob.struc- 
tion,  wiiich  is  present  at  night,  may  obstruct  both  nasal  chambers, 
or  may  Ix-  noticed  in  the  na.sal  ciiamlwr  which  is  undermost.  The 
change  of  atmospheric  surroimdings  will  often  diminish  or  intensify 
the  stenosis,  that  is,  while  abiding  in  ove,-|ieated  and  overcn)wde(l 
rooms  the  stenosis  is  usually  most  profound,  whereas  moving  about 
in  the  open  usually  gives  the  greatest  freedom  jxTinissible.  As  a 
n'sult  of  this  stenosis,  and  mouth-bn'athing,  which  it  entails,  we  have 
resulting  changes  jjroduced  in  the  naso-  and  oropharynx.  The  changes 
set  up  in  the  u])per  jiharynx  are  usually  in  the  way  of  chronic  inflam- 
mation in  the  mucous  membrane,  with  increased" glandular  activity. 
A.S  a  result  of  these  changes  we  have  that  train  of  sym|)t<)ms  often 
pn-sent  which  are  due  to  tiie  accumulation  of  thick,  ropv,  vi.scid  secre- 
tion in  the  nasopharynx,  ♦he  effort  to  remove  this  s(>cretion  being 
often  attended  with  retching,  nausea,  and  vomiting. 

Another  result  of  the  nas;d  obstruction  is  enlargement  of  the  unila 
and  intiltratioii  of  the  pillars  of  the  fauces.  The  mouth  is  usually  dry 
and  the  tongue  coated,  especially  on  awakening  in  the  morning. 

Cough  is  not  only  fre(|uently  present,  but  ofttinus  is  an  exceed- 
ingly distn-ssing  symptom.  Some  individuals  mav  be  practically 
free  from  coughing  during  the  day,  but  upon  lying  down  at  night  i"t 
(|uickly  makes  itself  manifest.  This  night  ccmghing  is  due  partly  to 
the  mouth-!)reathing  and  often  to  the  irritation  of  the  secretion  which 
|)asses  into  tlie  pharynx  while  the  patient  is  in  a  n>cunibent  position 
Cough  which  is  present  more  or  less  luring  the  waking  hours  is  due 
U)  the  changes  excited  in  the  pharynx  and  larynx. 

Headache  is  a  very  fre(|uenf  and  often  very  distn>ssing  .symptom 
of  chronic  rhinitis.  Its  freipiency  would  makeit  one  of  the  iiiost  pro- 
nounced of  the  secondary  symptoms  of  chronic  rhinitis.  Most  fn'- 
quent'y  it  is  a  brow-pain,  being  located  over  the  forehead,  more 
marked  in  the  morning  on  arising,  almost  or(|uite  disapfM-aring  during 
the  day.  \  feeling  of  jiressure  or  general  fulness  about  the  head  or 
occi|)ital  uneasine.s.s  is  often  noticed.  A  general  feeling  of  hussitude  is 
froijuentiy  |)re.sent  in  the  morning.     Snoring  is  coimnon. 

Impairment  of  the  .senses  of  taste  and  smell  are  occasionally  present 
in  chronic  rhinitis.    The  obstruction  of  the  nasal  chamber?!  aa  well 


^ 


ISFLAMMATOUr  Vl!iEAiii:s  OF  TUK  UPPER  Alii  PAHSACiES.     77!) 

iis  actual  structural  changes  in  the  mucosa  of  the  olfactory  orfcan  arc 
rcsijonsiblc  fur  these  conditions.  With  the  impairment  of  tlie  olfaction 
we  have  its  correlated  sjM'cial  sense  also  suffering.  These  changes 
are  in  no  sense  an  essential  anosmia,  as  there  is  usually  a  comj)lete 
restoration  with  tiie  return  to  the  normal. 

Sneezing  is  a  common  symptom.  Fre(|uently  patients  have  ))ar- 
oxysms  of  sneezing  when  rising  in  the  morning,  which  suhside  during 
the  picparation  of  the  toilet.  Paroxysms  often  manifest  tiiemselves 
when  the  ])atient  isexijo.sed  to  the  direct  rays  of  the  sun.  The  gn'ater 
the  hyjK'rtrophy  in  the  middle  turbinate  region  the  more  marked  is 
this  disturbance. 

The  timbre  and  character  of  the  voice  is  altered  in  proportion  to  the 
|H'rsistency  and  amount  of  the  na.sal  .stenosis.  The  voice  is  that 
characterized  as  na.sal,  and  differs  markedly  from  the  voice  produced 
by  enlargeti  tonsils  or  adenoids. 


no.  411. 


Anterior  rhlnoacopy,  showtDK  anterior  hypertrophy  of  Inferior  turbinate.    (Cohcm.) 

The  diagnosis  is  made  complete  through  physical  examination  of  the 
nasal  chambers  by  anterior  and  posterior  rhinoscopy. 

\W  anterior  rhinoscopy  it  will  l)e  ol)ser\'ed  that  the  nmcous  meni- 
lirune  is  of  a  deep  re<ldish  api)earance  and  (juite  succulent,  with 
strands  of  mucus  nitming  between  the  turbinate  bodies  and  the  .sep- 
tum. In  the  mild  types  the  turbinal  tis.sue  will  be  projecte<l  outward 
toward  the  septum  in  an  even,  round  manner,  nearly  a]>proaching 
<i intact  with  the  septftl  walls.  Often  wel)-likp  crusts  of  dry  mucus 
will  be  found  in  the  vestibule  of  the  no.se  and  over  the  surface  of 
the  turbinate.  More  or  less  mucus  is  observed  in  the  inferior  meatus 
in  this  condition.  In  the  hyix>rtn)pliic  fonn,  on  account  of  the  pro- 
liferation of  the  cellular  elements,  we  find  the  nmcous  membrane 
paler  than  in  the  h\i)era'inic  form.  The  swelling  of  the  mucosa  in 
I  ills  type  is  more  irregular  than  in  the  iiypera'iiiic  tyjM>,  and  shows 
:i  marked  tendency  to  the  development  of  re<linidances  at  the  ante- 
rior and  posterior  extrctnitios  of  the  inferior  turbinates,  whicii  often 


780 


yasE  AMt  rnii'iAr 


show  a  nijiDsc  appearance.  At  linies  the  liyiMTtrnpliied  tissue  over 
the  aiilerii)!-  extremity  shows  ahimst  a  tiiiiKir-hke  swelhii};  haii^iiijr 
linwii  ainl  lilliiii:  lip  till'  inferior  meatus.  The  ni"<'ater  liie  rechiniiancv 
of  lissui'  the  p.iier  its  color.  \\'e  often  timl  liypertropiiied  mas.ses  of 
erectile-like  tissue  on  the  septum  wail  ant<'riorly.  Ky  posterior  rhin- 
o.sc()|»y  we  find  varyinji  decrees  ;  '.-n  of  swelling  of  the  p<'sterior  ex- 
tremities of  the  turbinates.  Tin-  posterior  cii'l  of  the  inferior  tur- 
binates is  most  frei|iieiitly  alTected.  ,ind  they  vary  from  a  sinjjle 
roundin<r  of  the  posterior  extremity  to  larp'  tumor-like  masses  that 
till  out  liie  posterior  nasal  orifices  and  pn'trude  into  the  pharynx. 
They  are  either  ru'j;ous  in  .ipiwaraiu'e.  or  s!  iw  that  singular  indented- 
like  surface  which  his  caused  them  to  be  likeiieil  to  a  mulberry.  Tiie 
color  of  posterior  hy|n'rtrophies  is  j;rayisli  white.  Tiie  imic<-ia  of  tiie 
|K)sterior  extremity  of  the  .se|)tuiu  often  shows  an  I'lliptical  jirayisii- 
white  swelliu'.;.  Tliroiiffh  the  use  of  cocaine  ami  the  ])robe  we  are  able 
to  (lifTerentiate  with  a  dettree  of  iiic(>ty  the  liypera'inic  ca.ses  from 
the  hypertrophic  and  the  amount  of  hy|K'rtropiiy  |)res(>nt.  .\  .">  per 
cent,  solution  of  cocaine  sutlices  for  this  purpose.     It  is  Ix-st  brought 


Fill.  41i. 


Flii.  413. 


*  .  f 


\  / 


Ki(i.  Ill'  -HyinTtrojihy  nf  posterior  cxtremiiies  of  inferior  lurbinate  an  obwrved  IhroiiKh  iwsterior 
rhiti(i»icopy. 

Kui.  413. -KIlipiicHl  swi-llliiu'son  i>'nlcriur  fiiinlus  of  «L-pluio,  with  hypertrophy  of  right,  midilli-. 
antl  iiiferior  lurbiitateH. 

into  contact  with  the  mucous  membrane  by  introducinji  a  small 
pleiijret  of  cotton  saturateil  with  the  cocaine  .solution  into  the  na.sal 
chambers.  The  cotton  is  allowed  to  remain  in  contact  with  the 
turbiiial  tis.sues  for  a  Tiionieiit.  when  it  is  withdrawn,  .\fter  waitini; 
a  few  moments  for  the  action  of  the  dmjr,  on  inspection  we  will  find 
the  mucous  membrane  very  much  contracted  umler  the  influence  ol 
the  coc.'iine.  In  the  simple  hyjM'ra'inic  condition  tlie  cavitv  will  be 
([uite  roomy  and  the  turbinal  tissue  firmly  drawn  down  over  th'' 
turbiiial  bodies,  eNcejitinK  where  here  and  there  will  be  iiot<?(i  slighi 
swelliiifis  which  will  indent  upon  the  use  of  the  probe. 


IM'LAMMATOUY  J)ISEASi:s  OF  THE  Vl'PKH  AIR  I'AHiiAaES.     781 


In  the  liyiMTtropliic  form  tlicro  will  alsti  Im-  consiilcral)!!'  retraction: 
l)Ul,  ncvcrtlu'lcss,  tliorc  will  he  iiotcil  a  ciLshioii-likc  iiia.s-i  on  thf 
anterior  extreniity  of  the  inferior  turbinate,  slightly  mobile  on  the 
use  of  the  probe,  likewise  masses  on  the  body,  which  aiv  velvety  to 
the  feel  of  the  prolK'  and  which  indent  upon  |)ressure.  It  is  remark- 
able how  the  action  of  cocaine  causes  the  almost  complete  disajjjx'ar- 


th. 


Ixv 


Flu.   414. 


Mulberry-like  enlargements  of  poaterior 
extremitiea  of  inferior  turbinate.    (Cohen.) 


.nice  ot  |)osterior  hypertrophies,  liowever  ponderous  tney  may 

\\v  fre(|uently  note  also  pciiduious-like  inass<'s  which  hanjr  from 
I  he  lower  border  of  the  middle  of  the  inferior  turbinate,  and  which  can 
Im-  lifted  u|)  from  the  floor  of  the  nose. 
The  middle  turbinate  [ircsents  vary- 
inj;  defirees  of  swolliiif;.  showing 
enlargement  along  its  inferior  bor- 
der, about  tiie  middle,  or  increase 
tiiroughout  its  whole  contour.  Oft- 
times  we  find  the  middle  turbinut« 
showing  almost  a  myxomatou's  de- 
geiierativft  change-,  approachin;;,  if 
not  ((uite  passing  nto  the  change 
known  ;us  ethmoiditis.  It  is  remark- 
aiile  to  observe  how  often  one  nasal  chamber  will  be  continuously 
more  seriously  affected  thiiii  the  other.  It  is  ([uite  inii>ortant  in 
making  these,  a.**  well  as  all  examinations  of  the  nasal  chambers,  to 
UM'  the  na.sal  probe  lilM'rally,  not  only  before,  but  after  the  instilla- 
tion of  cocaine. 

Complications.  The  most  fre<]uent  as  well  a.-  the  most  distressing 
com|)lications  of  chronic  rhinitis  are  those  due  to  changes  in  the 
.luditory  apparatus.  There  is  no  doubt  that  the  greater  proportion 
(if  all  cases  of  middle-ear  catarrh  are  excited  through  the  action  of 
chronic  rhinitis.  The  change  within  the  Eustachian  tul)e  and  middle 
ear  is  not  only  due  to  the  direct  extension  of  the  catarrhal  inflani- 
niation  through  continuity  of  surface,  but  is  also  jiroduced  through 
tlu>  imjierfect  ventilation  of  the  tube  and  middle  ear.  This  rarefi- 
ciition  of  the  air  in  the  tul)e  and  middle-ear  chamber,  after  more  or 
less  prolonged  maintenance,  results  in  hyjiera-mia  of  the  mucous 
niinilii'.'ine  and  other  changes  which  are  designated  as  hyiiertrojihic 
c;itarrh  of  the  middle  ear.  This  condition  produces  varj'ing  degrees 
of  impairment  of  hearing,  tinnitus,  s<>nsation  of  fulness  in  the  ears. 
.■iut(ii)honia,  vertigo,  etc. 

The  eye  often  shows  changes  as  a  n'sult  of  chronic  rhinitis.  We 
find  as  the  result  of  the  inflammation  along  the  course  of  the  lacri'nial 
duct  various  changes  excited  within  the  canal.  \\'e  have  also  simple 
<'oiijunctivitis,  jihlyctenular  conjunctivitis,  and  keratitis. 

.\  numlx'r  of  apparently  serious  nervous  complications  result 
frussi  tlio  ititerfcrpnce  witli  nasal  n-^piration.  The  most  interesting 
of  the.se  is  the  dread  of  suffocation,  often  observed  in  nervous  females. 
I  have  often  had  patients  affecteil  with  hypertrophic  rhinitis  tell  me 
diat  it  was  impossible  to  assume  the  recumbent  position  at  night, 


782 


yoSK  AM)  Til  It  OAT. 


'm 


on  account  of  tlic  sensation  of  ini)M'nilinp  sufTocaiion.  Thoy  have 
tlistressinj;  dreams,  pressure  about  the  head,  impairment  of  memory, 
and  the  inalnhty  to  concentrate  thi-  mind,  supra^lrl)ital  neuralgia, 
sjiasms  of  tlie  mu.sch's  of  tlie  face,  epil('j)ti"  convulsions,  astiuna,  and 
spasm  of  the  larynx. 

There  is  no  doubt  that  changes  of  a  hyjH^rtroithic  character,  espe- 
cially about  the  middle  turbinate,  are  to  a  marked  ext«'nt  a  factor 
in  giving  rise  to  purulent  conditions  in  the  accessory  sums. 

Diagnosis.  The  diagnosis  is  usually  made  complete  by  the  grouping 
together  of  the  subji ctive  symi)toms  and  the  result  of  the  rhinoscopic 
examination.  H.sjH'cially  is  to  be  empha.siznl  the  imi)ortance  of 
making  use  of  cocaine  and  the  prolie  in  the  physical  examhiation. 
There  should  Ik-  no  difliculty  in  difTerentiating  this  con<lition  from 
other  affections  which  may  involve  the  nasal  chamlxTs.  From  .syph- 
ilitic infiltrati(m  and  gummatous  growth  they  can  Ik-  differentiated 
by  the  absence  of  other  lesions  of  syphilis,  the  history  of  infection, 
and  the  fact  that  infiltration  and  gummatous  dejM>sits  do  not  con- 
tract under  the  action  of  cocaine,  and  have  a  dense  feeling  when 
touched  with  the  probe;  from  na.sal  j)olypi  by  the  jjolyp  having 
a  grayish-blue  transparent  appearance,  iM'ing  mobile,  and  by  their 
pediculated  well-discerned  attachment  about  the  middle  turbhiate. 
Spurs  and  d(  flections  are  readily  differentiated  from  the  fact  that 
they  are  firm  .swellings  affecting  only  the  inner  walls  of  tl-.e  na.«ial 
cavity. 

Prognosis.  The  prognosis  is  usually  favorable,  although  at  times  it 
re(iuires  a  protracted  course  of  treatment.  The  severity  of  the  case 
and  the  amount  of  hypertrophy  In'ar  no  relation  to  the  time  nM|uin'd 
in  the  healing  process.  Often  cases  with  enormous  liypertrophy  will 
yield  rapidly,  with  relief  of  all  symptoms,  while  ca-ses  with  simple 
hyi>cnemia  will  try  both  the  patience  of  the  physician  and  the  indi- 
vidual affected.  Too  nnich  a.ssurance  should  not' be  given  to  the  relief 
of  symptoms  and  reflex  disturbances  apparently  due  to  the  chronic 
rhinitis,  as  such  conditions  may  be  influenced  by  other  i)atliological 
coiulitions  not  observable  at  once.  The  rapidity  of  result  is  often 
influenced  to  a  marked  extent  by  the  patie'it's  willingness  to  aid  and 
follow  all  directions  as  to  rules  of  liygiene. 

Treatment.  There  is  no  local  pathological  condition  within  the 
na.sal  chambers  that  retpiires  such  a  thorough  consideration,  both 
con.stitutional,  hygienic,  and  local,  as  does  the  therai)eutic  considera- 
tion of  chronic  rhinitis.  Without  a  thorough  correlation  of  the  two 
plans  of  treatment  it  is  absolutely  im{)ossible  to  bring  about  a  la.sting 
effect  as  the  result  of  treatment.  T'.e  hygienic  surrf)undings  shoulil 
be  carefully  iiupiireil  into,  and  wherein  they  are  defective  as  regards 
care  of  the  skin,  clothing  of  the  body,  aiiil  protection  of  the  feet, 
thev  .should  iie  rectified  when  possible  The  <|iet  i-.f  the  p;!'l''!ft 
should  be  c;ii, -fully  gone  over,  and  that  which  is  suitable  to  the  indi- 
vidual should  be  din'cted  anil  insi.sted  ui)on.  Fre(|uently  an  office 
worker  will  h^  following  a  dietary  suitable  onlv  for  an  athlete  or  n 


IXJLAMMATonr  DIHEASKS  OF  THE  I'PI'ER  AIR  PASSAdES.     78^ 

lalM)ror.  Fresh  air  in  sIccpiiiK  apartments,  dwellings,  and  ofiices 
should  he  re(|uired,  and  the  avoidanee  of  overcrowded  hadly-ventilated 
iialls  and  hmhus  of  jjeneral  asseinhlage.  Kxereise,  f;oo<l  hours,  mid 
corn-etion  of  hahits  of  excess  should  Im"  made  ohiigatory  when  eondi- 
lioiis  demand  them.  l'ro|H'r  medieation  to  meet  constitutional  dis- 
iiirhanees  that  are  din'ctly  or  indin-ctiy  niHuencing  the  nasal  changes 
should  Ik-  c(»nsidered.  Removal  from  unfavorable  occupation  or 
climatic  surnjujidings  is  not  always  possible,  but  when  feasible,  it 
-Imuld  be  done.  And,  lastly,  if  not  least  imjjortant,  is  the  correction 
of  any  disturln'd  condition  of  tlu"  alimentary  canal. 

The  local  tn-atinent,  which  plays  an  imjKirtant  role  in  the  restora- 
tion to  the  normal  of  a  chronic  rhinitis,  has  for  its  o'.ject  the  reduction 
of  hyiH'nemia,  the  removal  of  .structural  hyixTtorpiiy,  the  less«'ning 
uf  cellular  and  glandular  activity,  and  the  restoration  of  th*  normal 
iihysiological  functions  of  the  nasal  cavity.  In  the  milder  tyjx's  of 
liyi).Tamia  and  moderate  degret-  of  hyiwrtrophy  the  local  apjilication 
of  non-irritating  alkaline  .solulions,  to  which  is  added  some  antiseptic 
:i>:ent  in  conjunction  with  the  constitutional  care,  will  often  bring 
iltout  a  complete  resolution.  The  .solutions  which  are  most  applicable 
for  such  pur{)ose  are  iis  follows: 

Salil  blcarbonatti, 

Sodil  buntlii. 

.Sodii  cblorlill,  tA  82.00 
M.    Slg— Small  teupoonAil  to  ■  pint  of  water. 

Acldi  rarbol.,  30.00 

Sodil  1,1  nrb.,  2.00 

Sodll  L/iborat.,  3.00 

Glycerlnic.  4.0O 

A(|ii!e  destUlat.,  180.00 

M.    Sig.— ror  local  um. 

To  these  .solutions  may  Ix.-  a<lded,  acconling  as  the  condition  seems 
to  demand,  any  one  of  the  a-stringents,  as  nitrate  of  silver  in  1  jkt  cent. 
-nhition,  suli)hate  of  zinc  in  1  |)er  cent,  solution,  chloride  of  zinc  in 
1  nil-half  of  1  |)ercent.  solution,  and  sulphocarlMilate  of  zinc. 

These  solutions  are  introduced  into  the  nasal  chaml)ers either  by  the 

us<'  of  the  atomizer  or  by  one  <>{  thi-  various  modihcations  of  the  nasal 

douche,  as  the  Dessau  or  Bermingiiam  douche.     Due  care  should  be 

ilisc  ned  to  note  that  !)oth  nasjil  chambers  are  free  enough  to  permit 

ilic  return  of  fluid.    Thorough  care  and  caution  should  be  given  to 

'lie  us<'  of  sf>lutions  for  this  purpo.se,  and  I  cannot  too  strongly  con- 

'liiiii  the  indiscriminate  placing  into  patients'  hands  of  various  a)lu- 

'  II  HIS  with  imi)erfect  instructions  as  to  their  use  or  abuse.      It  is  always 

ctter  for  the  physician  when  possible  to  have  the  local  treatment 

lioniughly  within  his  care,  allowing  the  patient  t<i  use  only  a  mild 

ilkaline  solution,  solely  for  cleansing  pur}X).ses.     When'  a.stringents 

■'TV  u.sed  ill  jujueous  solution  it  is  !idvisah!e  there.ifter  to  spray  nut  the 

iosc  with  one  of  the  forms  of  refined  petroleum,  such  as  albolene  or 

li'iizoinol.     In.stead  of  an  astringent  solution,  one  might  accomplish 

ln'tter  results  after  cleansing  out  the  nasal  chambers  by  the  use  of  an 


rH4 


SOSE  ASD  Tim  OAT. 


f=r  f 

I! 


altfiaiivc,  with  a  vawoiiuitor  stimulant,  such  aa  the  nu'Uthol-cainphor- 
iodiiic  siilutiiiii. 

This  siiUitiiiri  is  not  'is  U-Mcticcnt  in  its  action  in  tnilil  hyiK-rtropliics, 
i>ut  is  cxcccclinjriy  aniccaiilc  and  pleasant  in  its  ininnMliutc  cH'ccts. 

Mori"  fici|ucntly  these  simple  measures  will  not  U'  attendeil  with 
tlie  desired  results,  ami  ot'ttiines  at  the  bejrinning  the  amount  of 
structural  clianj;*'  will  demonstrate  that  time  so  emijloyed  will  he 
w.isted,  and  that  the  only  method  l>y  which  results  can  Ix'nained  is 
thmunh  active  local  tn-atment.  \'ario\is  methods  have  In-en  sug- 
;;e>ted  for  the  purpose  of  reducing  the  hyiKTtrophies,  most  of  which 
are  through  the  use  of  agencies  (iroducinK  destruction  of  tissue.  The 
method  t<i  1'  employed,  the  amount  of  reaction  n-fpiired,  the  aRent 
to  Ih-  employed  and  the  success  attained  are  largely  the  result  of 
individual  experience  and  skill.  It  is  well  to  l)e  skilled  and  exjjerienced 
in  iill  the  various  agents  that  are  employed  for  this  puri)ose,  and  then 
to  u.s<'  that  agent  which  is  Ix'st  a|)|)lical)le  to  the  case  in  hand  and  that 
will  most  thoroughly  and  (luickly  accomplish  the  sought-for  result. 
The  methods  in  vogui'  an-  pres.Hure  through  .soft-rubl)er  splitits,  cau- 
terization, actual  or  chemical,  the  .snare,  hot  and  cold,  and  the  more  or 
less  complete"  removal  of  the  turhinal  hodies,  partial  or  complete  tur- 
binotomy. For  the  ti-chnique  of  oiM>rative  intervention  reference 
imist  Ix-  directed  to  the  chapter  upon  that  subject.  Wagner  calls 
attention  to  the  fact  that  the  use  of  flexible  metallic  tul)Os  worn  for  a 
short  period  for  many  days  woultl  bring  about  a  resolution  in  hyper- 
trophied  tissue.  In  my  observation  in  the  wearing  of  splints  for  the 
correction  of  deformities  of  the  .septum  I  have  been  impressed  with 
the  thoroughness  of  the  nMluction  of  the  liyp'rtDphy  in  the  turbinate, 
when  any  existed,  and  the  i)ennanency  of  this  action.  It  .seems  as 
though  this  woulil  then'fore  be  a  very  etHcient  if  rather  un|)leasant 
method  of  accomplishing  a  rapid  anil  radical  resolution.  I'llectrolysis 
is  also  suggested  as  a  mi-thod  to  lie  employed  in  the  reduction  of  hyper- 
tro[ihies  of  the  turbinal  tissue.  It  is  an  advant'igeous  method,  as  it 
is  altenile(l  with  little  or  no  local  reaction.  Its  chief  disJidvantagc  is 
the  slowness  with  which  results  are  obtained. 

The  chemical  cauterizing  agents  are  chromic  and  trichloracetic 
acid.  These  are  es|M'cially  applicable  when  the  hy]>ertrophy  is  uni- 
form and  not  very  tiiarkecl,  showing  no  tendency  to  form  tho.se  masses 
known  as  anterior  or  jujsterior  hyjK'rtrophies.  In  the  application 
of  these  agents  it  is  well  to  ha\'e  the  nasal  chainl)ers  as  free  from 
moisture  as  possible  ;'nd  to  make  the  points  of  application  over  a  limitei  I 
area,  sn  as  to  pin  down,  as  it  were,  the  mucons  membrane  to  the  ])eri- 
osteuni.  If  through  this  means  a  mnnlx-r  of  minute  points  of  cau- 
terization ap'  made  on  the  an-a  of  liyjx'rtrophy  there  will  be  a  gra<lual 
obliteration  <  tin  overdist ended  venous  channels  and  a  reduction 
of  i!ie  mtnsv  :-i'i!!;!!  foi'iieetive  ti^-ise  .•■.-;  the  result  of  the  adliC'^io': 
and  contnicti  111  of  these  points.  Latterly,  Dr.  N.  II.  Pierce,  of  Chi 
oatro,  has  .suggi  sted  the  sui)mucous  ii  c  of  chn  'iiiic  acid,  and  the  result- 
of  this  iiietho<;  of  application  are  highly  axtisfaetory.     I  have  founi 


IXFLAMM.iroHY  DIHISA.SES  OF  THE  UPl'KIi  AIH  PASSAuKS.     7ho 


the  iiicthod  fxtronioly  easy  in  tpchni(|ur,  and  ;itton(|('(l  with  unifurni 

;: I  icMilt.s.  Dr.  (joidstcin,  <>f  St.  Louis,  has  su^K'''*''''!  "  six-cial  trocar 

iiiil  canuia  and  cautery  cariicr  for  this  |iur})<>s«'.  Tlio  naivanocautcry 
I-  useful  in  the  same  class  of  cases  as  the  ctieniical  ajjents,  and  should 
!)<•  used  in  the  same  manner.  The  (i^ivanocautery  is  a  most 
vulualile  anient,  which  unfortunately  has  bi-en  much  abused.  The 
disfavor  into  which  the  Ralvanocautery  has  fallen  is,  no  doubt,  larpely 
duf  to  the  fact  that  through  the  faulty  methods  of  its  application 
marked  reaction-*  were  freciuently  excite(l  with  profound  constitutional 
disturbance.  This  was  due  to  the  method  which  was  in  vopue  some 
lew  years  ago  of  Roing  throuftli  the  nasal  <  !iatnl)ers  with  long  linear 
rMiiterizationsi'xtendingdown  to  the  turbinai  Ixmes.  If  a  very  finely 
|"iinted  electnxh-  is  used,  and  fnun  four  t<)  six  minute  but  dfH'|)  cau- 
iciizatious  are  made,  the  advantage  is  largely  in  favor  of  the  galvano- 
("lutery  over  the  chemical  agents.  The  galvanocautery  ia  less  painful 
in  ai)plication,  with  net  after-pain,  its  action  can  l)e  mon*  accurat^'ly 
LMUfred,  and  there  is  no  violent  pan)xysm  of  8ne«'zing  and  headache. 
In  favor  of  the  chemical  cautery  is  the  simplicity  of  its  application  and 
ilir  abisence  of  any  bleeding,  and  the  mild  course  of  the  healing  pro- 
iiss.  When  we  have  large  redun(hint  ma.sses  of  ti.ssue  forming  at  the 
interior  or  po.sterior  extremity  of  the  turbinates  or  hanging  from  the 
middle  turbinate  or  the  fr(H'  border  of  the  inferi-.r  turi)inate,  tiie  most 
•  tllcacious  and  most  resultful  method  of  [trocedure  is  their  removal 
with  the  hot  or  colil  .snare.  The  hot  .sn;ire  is  used  by  some  in  prefer- 
inif  to  the  cold  snare,  because  thnmgh  its  caut«'rization  it  is  suppo.sed 
ii>  occlude  the  venous  channels  and  prevent  hemorrhage.  The  objec- 
li'  11  to  its  use  is  the  fact  that  we  have  with  its  applic;ition  a  bunit  and 
\v(.und<'d  surface.  Through  the  introduction  of  the  suprarenal  extract 
;iiid  its  active  j)rinciple,  adrenalin,  we  need  have  little  fearof  annoying 
licMiorrhage  with  the  cold  snare,  and  as  its  use  leave.-^  a  perfectly  clean- 
lut  wound  which  heals  kindly.it  is  much  to  Im>  preferred  tothe  hot  snare. 
<  >ccasionally  we  find  large  pendulous  gn)Wths  of  iiy;»  rtr(i|)hieil 
lis-iiie  along  the  fn-e  border  of  the  inferior  turbinate  and  large  infil- 
tr.itcil  middle  turbinates,  the  former  filling  up  the  ii>li'rior  meatus  and 
tjif  latter  coming  in  contact  with  the  septum  or  m;  king  firm  pressure 
liiireon.  The  only  operative  intervention  that  will  .ffectually  reduce 
this  form  of  hyjiertrophy  is  by  partial  or  complete  excision  of  the  tur- 
i'inate.  Any  of  the  various  oj)erative  procedures  of  partial  excision, 
;i>  suggested  by  Kyle,  Hohnes  and  others,  isusually  attended  with  most 
s.itisfactory  results.  I  find  that  the  cutting  away  of  the  lower  bonh-r 
'!'  the  inferior  turbinate  bone  just  through  the  centre  of  the  ilownwani 
■  iirvc  and  extending  through  its  whole  length  in  an  antero-posterior 
iircction,  taking  away  as  it  <1(K's  all  the  redimdant  tissue  with  a  small 
n:irgin  of  bone,  results  in  the  formation  of  a  linear  cicatrix  along  the 
.';i.,lf  free  border  of  the  turbinate,  with  a  free  ivspiraw>ry  space  ami 
-ullicient  turbinai  ti.s.sue  left  to  ade(|uately  carry  out  the  physiological 
:  unctions  of  the  na.«al  chamber  operated  upon.  The  above-mentioned 
Iteration  can  be  performed  with  scissors,  saw,  or  conchotome. 

50 


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.\osf:  .i.\/j  TiinoM 


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ii  i  i 

I       : 
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IH 


Iroin  wh.'it  roiilts  I  Ii.i.f  .S4(ii  from  (■(unplcic  liirMnotoniy,  I  atii 
ratlicr  ..|)|mim.,|  In  its  appiicaiiii!:  as  a  suriri    il  proci-duiv  in  ai'iv  fnriri 


i>f  cliMiiic  rhinitis.     lit  tin-  few  ca; 


CS  III 


|)lct«> 


>f  th 

niv  I 


<•  iti- 
M'cn 


fcrior  Mirbiiiati  wliicii  I  have  s<H'ii  (Ik  patictit 
n-lifvcl  i.f  the  liy|H-rtn  i  hy  aixl  jjiv.-n  ,ihs<iliitr  I'rccil.ini  (i.,  f|„. 
n-spiratciry  I'lr  ■nt,  Imt  tiic  siifTcrinn  caiisr.!  I,v  the  pharviinitis  si<-ca 
r.-siiltiii>r  lia.«i  I..-.-I1  tiiaiiilul.lly  j;ivatcr  than  thr"  inconvcni'i'iicf  .■ausi-| 
l>y  til.  !.r.'vi(iiisly  cxisiinji  hyi-irtrnphy.  'ccasionally  we  liii'f  hirffc 
(Ifii-,  liy|..T(n.|.hifs  winch  have  liccn  vainly  attackcl  aK.-iii  and 
anaiii  liy  various  cautery  aj^i'iits,  ami  yet  they  "recur.  The  niethod  ol 
panial  exi-ision  Kiven  alnive  almost  always'^ives  complete  ivliel'  in 
thrs*  cases.  In  summing  up  the  treatineiit  of  chronic  rhinitis  1 
sliMiil.l  .sf!it4-  that  a  due  regard  nm.-t  1m'  >;iven  to  the  prohahie  c;,iisative 
l.-iclors.  and  tJiesc  should  he  n'liioved  when  |Mi.ssili!c.  Du-  attention 
shoulil  he  paid  to  the  -onstitutional  condition,  hahits  and  hyuienic 
•surroundin^rs  of  the  patient,  anil  that  local  treatment  in.s'tituteil 
which  will  hriiijt  a!M)iit  th'-  most  .satisfactorv  and  ifuickest  result. 
(»vero|M'rafive  treatment  shoiil  !  Ih-  cautioned"  af;:unst,  and  ine  local 
tntiiment    m.-*titnti-il  >houlil   Ih    ,|on(.  under  as  fhoroush  aseiisi>  as 

l)o.s>il)lc. 

Fibrinous  Rhinitis.     Fibrinous  ir  iweudomemnranous  rhiniti.s  may 
Im>  descrilM'd  as  an  acute  infl.tmmation   of  the  uasiil  mucous  inoii!- 
brane   allmded  with    the   formation   of    t   ch.ir.icteristie   e.tudation 
ujion  the  surface  of  th(.  mucous  iiKinbrah,        In  con.sidcriiifj  this  sul)- 
ject  one  must  r>-co>;nize  tl;e  fact  that  tin  n    kv  various  ty|><v  of  false 
deposits  in  the  nasal    chamlM'rs  which  aiv  due  t.>  ditfereiit  e.vcitant.-. 
but  which  :in'  often  cla-ssified  tojr-ther.     Kyle  ii;,s  well  divided  thes*- 
mto  thni'  ty|ies,    namely,  cn^upous  or  i)s<"'udomeml)ranous  rhinitis, 
tibrinopiastic  rhinitis,  and  diphtheritic  rhinitis.     AlthiMij;li  fibrimms 
rhinitis  is  apparently  a  well-defined  di.s<>ase  wliicli  imi.st  have  always 
attraited  the  attention  of  the  rhiiiolopist,  it  has  only  U-vu  within  ti-.c 
last  hfteen  years  that  it  has  be«"n  thoroughly  descrilMvl  and  its  clinical 
))osilion  to  a  certain  decree  definite!}  e.staliiished.'   This  eondition  i> 
markedly  a  disejise  of  child  life,  as  it  is  ob.scrved  in  the  pn"|W)nderatin}r 
projiortion  of  c.a.ses  in  children  und<'r  twelve  years  of  afrc.      It  mani- 
fests itself  in  two  types  of  m  ■mbniiioiis  exiid.ition.     In  the  one  tliere 
is  an  outpouring  i.f  an  albuminous   exudation  which  forms  a  mem 
brane  upon  the  surface  of  tlie  mueos.i  and  does  not  in\olve  its  .struc- 
ture.    Tliis  meml)r;me  can   Ik-  .s<'i)arateil   without   causing  bleedinjr. 
and  leaves  a  [HTfectly  inta.t  mucous  membrane.     In  the  .second  tyin- 
of  cases  the  e\uda»!on  is  of  a  highly  libriiions  coafrnlable  material, 
which  not  only  i.s  thrown  f)ut  upon  the  surface,  but  also  involves  the 
substaii'-e  of  the  mucous  membrane.     This  exuil;,le  a^  it  unilerp>es 
coajrulation  c  iitaiifrles  within  its  .subst.mce  leucocytes,  epithelial  dt'bris. 
and    imi.ierfectly  I'orjMed  ce!!^■      T  hi'-.u- ;!<-|>o-!t^   nu'v  eximd  ih^.m-'li 
out  one  or  l>oth  na.s.al  chamlx-rs,  forms  on  the  surface  of  turbina'ti'- 
and  septiiin,  is  detariinl  witii  ^rn-al  diftieuliy,  and  when  attempts  an 
m.ide  at  its  forcible  reminal  there  usually  follows  free  bleeding. 


^^mfm 


I.MLAM.^fATnny  IHSE.lSf:S  Of-  TIIK  I'Pl'fCR  Alii  J.USHAi.HS.     7S7 

Etiology.  Tho  piinly  cnuii  nis  ty|«-  "f  I'xuduU-  is  iiion'  fn-qiictitly 
tin'  iinxluct  of  Incal  irritatiuii  where  eell  re.^islaiiee  is  lowered.  Tlie 
irritatiiiii  may  lie  <lue  to  injury  or  to  llie  action  of  cuusticd  or  cautery. 
Ill  :ill  [irolciliility  iiiiiiiy  cases  'if  this  ty|x'  of  CAiiihiti  tn  .ihserved  in 
child  life  lire  due  to  iiiechanic;i  irril  tioii  Various  ciiemical  aircnls 
\vh(  II  inhaled,  os|<<'cially  if  there  is  ainady  a  solution  of  the  contin- 
iiity  of  the  mucous  membrane,  will  Iw  attended  \,ith  the  formation 
of  a  crouiHius  exi»datioii.  This  form  of  memhrane  is  .-«'n  iti  its 
purest  ty|M>  as  occasionally  followisij;  the  aj)|i'icaiioM  of  the  jjaivniio- 
.aiitery."    The  meiiihrane  thus  (K'currinn  si  it.self  as  a  grivish- 

white.    thick,   aihuniiiious,    semitranspaivnt    lirposit,   more   or    ie.-s 
adiuiciit  at  the  |<oiiit  of  injury.  Iiut  only  feehly  adiien-nt  over  the 
reiiiaiiuiijj  portion  of  th(>  niu<'o.si.  upon  which  it  n-sts.     Tiiis  tyjK-  of 
iiieir.hraiious  riiinitis  is  as  fre(iuently  ol)ser.ed   in   the  adult   as  in 
ciiiidhi'od.     The  etiology  of  the  true  tilirinous  dejMisit    as  occurrinc; 
in  tiie  nasal    ,'!ia.nlier  is  still  •».  suliject  of  considenitioii.     It  is  no 
<|oulit  a  distinctly  pr'anary  "niiditioii  ilue  to  tlie  activity  of  various 
fi:riiis  of  c(«'ci,  or  an  atteiiu.    it!  lonu  of  the  Klehs-LoeHior  Itacilnis. 
\arious  forms  of  cocci  hivc  Ix-tii  found  on  bacteriological  ob.s«'r\atioii 
li\  different  authors.     The  staphyli>cocci  j)yogenes,  the  stn-ptococci, 
\(Mi  llotTmair's  l.icillus,  the  pni-innococci.  and  the  niicroco<'cus  lan- 
(•(■nj.iius  an-  the  type  of  cocci  usually  obs«'n(Hl,  while    as  fn'(|uently 
ihere   lia-   Ix-eii   observed   a    Klebs-Loeftier   bacillus  of  low   vitality. 
Tlie  relaiionshi])  of  this  bacillus  of  a  wraiv  .lej^'ree  of  virulence  to 
i!;r  true  Klel):--I,oetil'  "  bacillus  of  diphtheria  has  n       lieeii  clearly 
ilitineii.     Wel.nowclii     ally  that  tht  fe  is  anotliei        <        librinou.s 
( Aud.-ition    if  the  na.sal  ch.imber,  na.sal  diphllseria,  nti   ;■      i  ^\    '»  the 
pn.-cnce  of  the  K!eb.s-Lo,>tHer  b.icillus,  which  in  it-    .<  'u!.    '  M.i^-al 
liistorv  is  entirely    lilTerent  from  the  condition  that      ■     .'av  lave 
■iinleriKiisideratioii    We  also  know  th;it  the  clini'-aMii-;:        ■■  '.   .i.^nous 
rhinitis  .•^eein-  to  1k'  the  same,  whatever  form  of  baciiUls  .    ,;fe.sent. 
We  know  <  iiuically  that  the  true  Klebs-Loettler  bacillus  produces  only 
one  type  of  di.sease  when  present  in  th.'  f.iuces,  and  the  streptococci 
another  tyjK  ,  which  are  in  their  clinical  a.spects  unlike.     It  remains 
tnr  the  bacteriologists  to  explain  t4(  us  why  the  dilTerent  tyiKs  of 
inicro-orp.'inisnis  produce  in  the  na.sal  chambers  a  clinically  id  "tical 
picture.     .Vccording  to  .Vbbott,  ( ultures  made  from  tlie  na.s;il    •liain- 
l)eis  of  a  patient  affected  with  this  form  of  disca.se  caused  iKaiti  in 
iruinea-pigs  within  forty-eigl  '  hours.     The  dejMisit  is  usually  lini'tid 
to  the  ;interior  portion  of  tin   nasal  chanilxT.s,  over  the  .surface  of  the 
M|ituiii.  and  inferior  tur'   nate.     It  may  be  bilateral  or  unilateral. 
I'hf  membrane  rarely  extends  iH'j'ond  the  liiniis  of  the  nasal  cham- 
bers.    It  is  also  very  intert'sting  to  observe  that  this  afTection  is  not 
Ncry  infectious.     It  seems  that  in  mo  t  of  the  cases  in  which  infection 
ha-  followed  after  expoxire  llie    TeMiitiiig  disea.'^e  i,a5  iM-pn  in  the 
t'orin  of  membnuious  rhinitis  rather  than  true  nsisal  or  fnucial  diph- 
liii'ria.    There  an*  s«'veral  cas<»s  of  f.i  icial   inferr;(>n  aiid  to  have 
•'(■(•urred  after  exposure  to  fibrinous  ihinitis.     ^r  the  numlx-r  of  cases 


7«8 


yOi>£  AXD  rilHOA  T. 


I 


that  I  havo  had  uiidor  my  (>l)s('rvati(tn  infection  of  otliors  has  I'ovcr 
ofcurrctl.  From  our  i)r('scnt  knowledge  of  tiiis  pon(htion,  and  .  <|h'- 
cially  on  account  of  the  fn'iiucncy  of  tlic  fin(hii);  of  the  Klelw-Loctficr 
l)acilhis,  it  is  prudent  and  advisajjlc  to  make  cultures  of  all  oai<c.s  and 
to  insist  upon  the  tliorouph  isolation  of  jjaticnts. 

Symptoms.  This  condition  is  frciiucntly  ushcrod  in  by  more  or 
less  ijronouncod  general  syinj)tonis.  Thcif  is  usually  a  chill  or  a 
chilly  sensation.  There  is  generally  a  feeling  of  malaise,  depression, 
loss  of  ap])etite,  thirst,  and  ni  children  extreme  irritahility.  The 
temiM'rature  at  the  onset  n..)j;es  from  iM»°  to  101°  F. :  after  the  sec 
Olid  day  the  tem|)eratun>  runs  ahout  100°.  \t  (tther  times  the  gen- 
eral symptoms  an-  insigniticant.  Then>  is  nasal  obstruction  in  the 
side  affected,  and  in  case  both  cavities  are  involved  it  is  complete. 
At  night  the  breathing  is  very  distressing.  There  is  a  seropurulent 
discharge  from  the  nose.  There  is  impairment  or  los.s  of  the  sen.se 
of  smell.  Frontal  headache  is  very  marked,  a.s  well  as  neuralgia 
along  the  course  of  the  tiiih  nerve.  In  littli!  ones  the  ntusal  obstruc- 
tion, the  mouth-breathing,  the  febrile  disturbance,  the  nasiil  dis- 
charge*, and  the  disturbed  rest  at  night  form  the  most  amioying 
symptoms.  On  examination  of  the  na.sal  cavity  the  characteristic 
appearance  of  the  condition  will  be  observed,  the  vestibule  of  the 
nose  will  be  noted  to  Ik'  inordinately  congested,  while  on  the  se])tuni 
and  over  the  turbinates  will  be  ob.served  a  distinct,  well-detined. 
grayish-white  membraiii',  which  is  very  tough,  fibrinous  in  character, 
and  which  can  only  be  separated  in  small  shn-ils,  such  separation 
being  followed  by  copious  bleeding.  The  swelling  of  the  mucosa  with 
the  su}jerim].osed  membranous  dei)osit  cai.sos  a  complete  and  abso- 
lute occlusion  of  the  nasal  chambers. 

Diagnosis.  The  diagnosis  is  usually  n>adily  made  from  the  history, 
.symptoms,  aiid  the  local  condition  observ-ed.  (tne  condition  witii 
which  this  disease  might  be  confounded  is  that  of  a  foreign  body  in 
the  nasal  chamber.  In  the  ca.se  of  a  foreign  body  the  mass  of  floccu- 
lent  exudation  which  simulates  croiijMius  exudation  can  readily  he 
removed,  and  the  foreign  body  may  be  recognize<l  on  insiK-ction  or 
by  the  use  of  a  prolw.  The  diffen-ntiation  from  true  nasal  diph- 
theria is  usually  nmde  without  difficulty.  In  na.sal  diphtheria  we 
have  marked  general  symptoms  attended  with  considerable  pms- 
tration.  In  fibrinous  rhinitis  the  symptoms  are  much  milder.  .\as;il 
diphtheria  is  always  attended  with  postna.sal  and  faucial  de|M>sit. 
with  a  profus(>  sanguinolent  seropurulent  discharge.  Fibrinorhinitis 
is  almost  never  attende.l  with  extension  to  the  pharynx  and  fauces, 
the  discharge  is  more  seropurulent  and  not  very  profuse,  and  then' 
is  absolute  blockage  of  the  nasal  chambers.  In  nasal  diphtheria  we 
may  h.ave  nephritis  and  j)aresis:  in  Hbrinous  neither  of  these  condi- 
tions. 

Pi'ognosis.  The  prognosis  is  extn>mely  favorable  as  to  life.  Chauveau 
reports  a  case  of  death,  but  it  was  apparently  due  to  a  secondary 
development  of  tulxTcular  meningitis  nither  than  to  the  membranous 


tSFLAMMATORY  JUSKAHES  Of  TUE  ViVEU  AIH  VAUSAUES.    789 


rhinitis.  Tlio  disoaso  follows  no  roRular  course,  and  has  an  indpfinitc 
duration.  In  favorahlo  cases  it  lasts  al)out  ten  days  or  two  weeks, 
at  tiie  end  of  which  time  there  is  a  complete  exfoliation  of  the  mem- 
brane with  a  gradual  n-solution  of  the  inflamed  nuicous  surface.  In 
more  unfavorable  cases  it  may  j>ersist  for  a  period  of  si'vend  weeks. 
Treatment.  The  constitutional  treatment,  which  stH'ins  to  be  the 
most  inii)ortant  and  resultful  in  this  disease,  ha.-s  lu'cn  generally  along 
the  line  which  has  been  followed  in  fibrino])la.stic  exudation  when 
occurring  elsewhere  ui)on  laucous  surfaces,  the  hrst  indication  being 
tlie  thorough  opening  of  the  bowels  through  the  medium  of  fractional 
doses  of  calomel  combined  with  bicarbonate  of  sodium,  followed  by  a 
.saline.  This  is  foUoweil  by  the  administration  of  the  tincture  of  the 
chloriile  of  iron  in  1  gramme  do.ses  every  four  hours.  The  calomel 
should  lie  repeated  fre<iuently  ei  ough  to  keep  the  bowels  in  good 
condition.  As  there  .sei-ms  to  be  strong  evidence  through  bacterio- 
logical investigation  that  many  of  these  cases  owe  their  existence  to 
the  presence  of  a  bacillus  identical  with  the  bacillus  of  faucial  diph- 
theria, it  would  Im^  advisable,  where  such  bacillus  is  found  after  culture 
experiments,  to  administer  from  2(K)0  to  4(KK)  units  of  antitoxin, 
according  to  the  age  of  the  patient,  and  to  repeat  the  dos?  according 
to  the  methods  adopted  in  the  treatment  of  faucial  dip'htheria.  Anti- 
toxin should,  in  all  ca.ses  where  the  Klebs-Loeffler  bacillus  is  found, 
give  a-i  radical  and  decided  results  as  it  does  in  faucial  diphtheria. 
.Vs  the  treatment  previou.sly  emjjloyed  lias  had  no  influence  what- 
ever upon  the  bettering  or  shortening  of  the  attack,  we  shall  look 
with  considerable  interest  for  the  action  of  antitoxin  in  this  disease. 
Patients  should  lie  isolatcnl.  and  this  should  be  thorough  until  the 
roult  of  culture  proves  the  non-existence  of  the  Klebs-Loeftier 
bacillus. 

Local  treatment  ha.s  ajiparently  accomplished  little  in  the  improve- 
ment or  shortening  of  the  attack.  Attempts  at  separation  of  the 
membrane  seem  unwise.  Clearing  of  the  na.sal  chambers  with  an 
alkaline  antisejjtic  spray  keeps  the  cavity  clean  and  lessens  absorp- 
tion. Kyle  reconnneniis  a  1.")  per  cent,  solution  of  chromic  acid.  I 
li;>ve  foui'd  the  best  results  to  follow  the  use  of  a  5  per  cent,  solution 
ot'  lactic  acid.  This  should  be  carefully  applied  to  raw  surfaces  with 
a  cotton-carrier  after  cleansing  of  the  na.sal  chambers. 

Atrophic  Rhinitis,  .\trophic  rhinitis  is  a  chronic  catarrhal  in- 
ilammation  of  the  nasal  chamber  liaving  an  uncertain  onset  and  an 
imletinite  duration,  being  attended  during  its  cour-e  with  increasing 
and  |)rogressive  destruction  of  the  glandular  and  epithelial  structure, 
a'l.l  the  formation  of  crusts  and  scales  within  the  nasal  chambers, 
wliicii  occasion  a  distinctive  odor,  terminating  in  a  true-  sclerosis  of 
tiic  na.sil  mucosa  and  atrophy  of  the  turbinal  os.seous  tissues. 

Before  entering  u])on  a  consideration  of  this  subject  we  shall  dev()te 
a  few  words  to  the  discussion  of  the  existence  of  two  distinct  diseases, 
namely,  oza'iia  and  atrophic  rhinitis.  Oza-na  is  simply  a  term,  as 
its  derivation  implies,  to  designate  the  existence  of  an  odor  issuing 


790 


yOSE  ASn  THROAT. 


\i 


from  tlip  nasal  chaiiibors,  and  can  Ix'  a])pli(Ml  witli  equal  force  to  any 
(li.si':i.se(l  condition  of  tlio  nasal  diainhcrs  which  is  attended  with  an 
unpleiusant  exhalation,  as  for  exaiupie,  to  nasal  sy|»hilitie  necrosis, 
toreign  bodies,  rhinolitiis.  and  sinus  diseases.  ( )z:i'na  in  itself  ex|)lains 
nothing:  it  simply  indicates  the  feature  which  is  most  unpleasant 
and  intolerable  in  certain  dise:used  conditions  of  the  niisal  chainlx-i-s. 
It  is,  in  fact,  a  term  which  by  some  authors  has  lurn  apolied  to 
tlistinguish  a  more  severe  type  of  atrophic  rhinitis,  or  this  disease 
in  the  most  active  stage  of  its  development,  wherein  the  crust  for- 
mation is  most  abundant  and  in  which  the  stench  is  the  mort  |)ro- 
nounced  symptom;  the  j)athe'  -^V'-il  changes  and  the  train  of  sub- 
jective and  objective  symptoms  are  the  :;ame  as  in  the  condititin 
which  is  more  generally  described  as  simj)  e  atrophic  rhinitis.  The 
odor  may  be  the  most  pronounced  and  distrcising  sym|)tom  in  atrophic 
rhinitis;  it  may  come  and  go,  it  may  b<'  m.irkedly  ii..inifested  at  one 
|)eriod  of  its  life-history,  and  almo.st  disa,)pear  at  another,  it  may  be 
i)ilateral  or  unilateral,  and  it  may  be  influenced  markedly  by  ( fforts 
at  cle.'inliness  and  through  the  use  of  reiaedial  agent.s.  Liuler  these 
circumstances  it  seems  rath(>r  illogical  to  designate  as  a  distinct 
disease  a  .syt!iptom  which  is  but  the  |)roduct  of  ii  well-known  and 
characteristic  disease  which  has  a  well-dotined  clinical  history  and 
produces  uniform  pathological  changes. 

Etiology,  'lucre  is  no  dise.i.se  ill  rhinologj-  in  which  speculation 
has  lM>en  s"  ramp.mt  in  the  eonsidi  ration  of  its  etiological  factors  as 
in  atro|)hic  rhinitis.  These  theories  have  all  been  made  along  sci;>n- 
tihe  lines,  advanced  by  numerous  authors  after  painstaking  care  and 
investigatioii :  i)ut,  unfortunately,  their  conclusions  are  very  diver- 
gent. .\o  doubt  this  marked  liiveigenci'  if  theories  is  largi'ly  due 
to  the  fact  that  no  one  lias  been  able  to  trace  a  given  case  from  the 
absolutely  normal  conijiiidn  into  the  developinent  of  and  through 
the  successive  stages  of  this  disease.  We  :u'e  at  the  present  time 
apparently  as  far  from  the  universal  aceeiitance  of  a  tenable  theory 
as  to  the  etiology  of  atrophic  rhinitis  as  in  the  beginning  of  the 
investigation.  TIk'  various  tlu'iuio  wi.icli  li.ive  been  advanced  to 
explain  the  origin  of  itrophie  rhinitis  are  of  interest,  and  are  here 
given 

1.  The  theory  has  been  ad\  anced  that  atrophic  ridnitis  is  a  secjueia 
t.'  and  an  advanced  form  of  hy|)ertrophie  rhinitis,  .\ecording  to 
■(';is  vi  w  tli'Ti"  is  fii-t  thi'  intrava.scular  connective-tissue  hyper- 
li-ojihy  ■ind  ceHular  intiltration.  fcilowed  by  coimective-tissuc  c.in- 
tniclioii.  resu  !in<r  in  more  or  less  de.-iruction  of  Uie  nutrient  arteriiil 
supply  to  the  !iiu<'osa  ami  .s-<eous  structure,  producing  an  atrophic 
chanire  within  the  boiii'  and  mucosa. 

2.  TIeit  the  condition  is  the  result  i>f  !in  anatomical  alteration  in 
the  osseous  framework  of  the  nasal  chambers — .a)  tli.at  tlu  eoiidition 
is  due  to  abnormal  widening;  (b)  that  it  is  the  result  of  abnorm;i! 
shortKc^s,  lihi  (■•  that  it  is  due  to  congenital  shortness  of  the  nasal 
fossa'  (Zaufal,  Ih  iimami,  Fraenkel.  Sauvage). 


I^i 


ISTLAMMATORr  DISEASES  OF  THE  UPPER  MB  PASSAGES.     791 
•<   Th.t    itrcnliie  rhinitis  is  the  result  of  a    mrulent  rhinitis  in 

'"■'f  Xs'a  result  of  suppurative  changes  in  tlxe  accessory  cavitk^ 

mmmmmm. 
sMmmmm 

"'''"••''^rf;:f.;;iiatt;r;ni^^^^^^^ 

r";;::;ji;J':\;h  iiiltloi/oft  and  subsequent  sclerose  of 

„.VH.osa  ana  atro,^.y  ..n.one  ^,;,,k.  who  a.lvocates  this  theory, 

ll.w.l-      Ik   K'IS   \1>'I  .li»r.>v.Tnl  a  l.ac'illlis      lUrli  In    nam 'i  "i 

,av,.  rise  to  the  evil  snu-ll.     Stra..a  f.-un-l  an  '"'*'^"^    '.^"J  J^^^ 


mt^si 


l'J-2 


yoat:  AXD  throat. 


jl.uioii  discovered  tlie  same  bacillus,  and  states  that  it  is  the  producer 
of  a  chronic  purulent  rhinitis  which  is  acconii)anied  by  fetor  and 
leails  to  turbinal  atrophy.  Abel,  in  reports  made  after  further  investi- 
gation, states  that  whatever  the  slape  in  which  the  |)rocess  is  observed, 
if  the  essential  features  of  the  disease  are  present  the  bacillus  is  found. 
By  absolute  healinjt,  that  i>.  the  disap[M-ar:uice  of  crust,  fetor,  and 
all  mucopurulent  disciiarKc,  the  bacilli  also  disappe;ir. 

The  exact  period  of  life  in  which  the  atrophic  changes  commence 
is  very  dilKcult  to  determine.  It  evidently  begins  early  in  chihi-life. 
This  proce-ss,  li'-"  other  chronic  inHammations  commencing  gradually 
without  marked  .symptoms,  does  not  attract  the  attention  of  the 
patient  until  the  process  being  well  advanced  distres.ses  the  parents 
on  account  of  the  offensive  odor.  It  has  been  ofwerved  ius  early  as  the 
fourth  year  of  life,  and  I  have  observed  well-advanced  ca.ses  :n  children 
;is  early  ;is  the  ninth,  tenth,  and  eleventh  year.  In  fact,  the  most  dis- 
agreeable ca.s<'s,  on  account  of  odor  and  well  advanced  in  atroi)hy. 
that  I  have  ever  witnessed  were  manifesteil  in  two  sisters  of  nine  and 
eleven  yi'ars.  It  is  peculiar  that  the  disease!  .seems  to  affect  the  female 
s<'x  more  than  the  male.  Whether  the  tact  that  women  seek  treat- 
ment more  fretiuently  than  men  for  Mich  disturbatice  explains  the 
preponderance  of  ciises  observed  in  wo;nen  over  men,  it  is  impossil)le 
to  state,  but  I  am  inclined  to  believe  that  it  is  numt>rically  more  fre- 
quent in  the  gentliT  sex.  In  my  ex[)erience  it  luus  lieen  overwhelm- 
ingly more  frecpiently  olxserved  in  women  tiian  in  men.  This  condi- 
tion, while  obtaining  among  all  classes  of  people,  is  no  doubt  observed 
more  fre(iuemiy  .imoiig  the  poorer  classes.  With  us  I  think  it  apjKvirs 
more  frwiuently  among  the  first  and  second  generations  of  the  foreign 
born. 

Symptoms.     ILsually  with    those    affected   with   atrophic  rhinitis 
we  obtain  a  history  of  a  long-existing  catarrh.     Freipiently  we  learn 
that  since  early  childhood  the  afflicted  individual  has  had  more  or 
less  discharge  from  the  nose,  which  was  i)urulent  in  ciiaracter  arnl 
attended  with  Tuore  or  less  excoriation  of  the  ahe  nasi  or  upper  lip. 
During  the  early  history  of  the  individual  the  general  health  wa> 
excellent,  but  as  the  disease  became  more  manifest  there  was  a  In- 
of  flesh,  impiiirment  of  appetite  and  develoimient  of  an;emia.     On 
iaspection  of  the  external  no.se,  changes  of  a  cliaracteristic  type  will 
l)e  observed    in   some   individuals,  while  others  manifest  no  change 
This  .tlteration  consists  in  .slight  spreading  and  sinking  of  the  nasii! 
bones,  which  give  an  undue  witlth  to  the  root  of  the  nose.     The  thro 
local  symptoms  which  characterize  the  disease  are  the  secretion,  tin 
odor,  and  the  .atrophic  changes.     The  .secretion  of  the  na.sal  chamber^ 
is  markedly  .altered  in   this  disease.     The  .source  of  thi>  secretion, 
whether  it  is  the  product  of  the  ctit.irrhal  changes  in  ttie  nuico.sa  or 
the  outpfinring  of  discharge  from  within  the  accessory  .sinuses,  whicl. 
.'iccmimlate  within  the  nasal  chambers,  is  still  a  disi)uted  ipiestion 
While  (irlmwald  ;ind  others  may  be  correct  in  their  contention  tii.ii 
fre(iuently  atrojiliic  rhinitis  and  .sinusitis  go  hand-in-haiid,  the  view 


JXFLAMMATOUY  VJHEASKS  OF  THE  ll'l'ER  AJll  PAHSAaKit.     7«J3 


\v(»ul<l  not  <'Xi)laiii  the  origin  of  the  idnitipiil  spcrotion  in  atro|)hic 
liiiiiitis  in  cases  wiiiTc  sinusitis  is  i^nown  not  to  exist.     Tl'is  seeretion 
vaiie:.  greatly  iiccording  to  the  stage  in  wiiicii  the  ilisease  is  oi)serve(l. 
Ill  llie  very  early  liistory  of  tiie  cases  it  is  inclined  to  he  more  Huid, 
aiitl  is  frecV/'ntry  ohserved  in  a  seniili(|uid  state,  filling  the  inferior 
iiicatMs,  wliii.'  over  the  inferior  and  niiildle  turbinates  it  forms  soft 
puitaceous   whitish   masses   which   sei)arate  themselves  easily   from 
the  underlying  mucous  mt  inhrane.     As  the  jjrocess  becomes  more 
ailviuiced  the  Huid  secretion  is  diininishe<l  and  the  crust  forms  more 
(ir  less  completely  over  the  whole  mucous  lining  of  the  njisal  chambers, 
("rusts  formed  iii  this  stage  are  of  a  reddish-brown  or  greenish  color, 
aiitl  scale-like,  firm,  and  tenacious  in  their  adiiercnce  to  the  mucosa. 
( )ft times  in  this  stiige  of  the  lesion  complete  mucous  casts  of  the  nasal 
chambers  can  Ix"  obtained  by  removing  the  crust  by  means  of  forceps. 
Alter  removing  crust  in  this  .-«tate,  and  gently  insiimating  the  j)robe 
above  and  b'lieath  the  middle  turbinate'  and  in  the  mucous  folds  in 
tlie  vertex  of  the  nose,  we  can  often  observe  more  or  less  liijuid  secre- 
tion.    In  the  nio.st  advanced  form,  when  atrophy  seems  (|uite  com- 
pletc,  diere  is  not  nmch  crust  formation,  what  little  forms  adhering 
ill  .-iiiall  ina.--ses  of  a  greenish-brown  color  over  the  (lej)res.«ions  or  on 
she  upper  surface  aiul  borders  of  wliat  remains  of  the  atrojjhied  tur- 
l)iiials.     Fetor  is  usually  present  in  most  cases  during  .some  period 
iif  the  existence  of  the  disease.     The  fetor  varies  not  only  in  different 
periods  of  the  same  ca.se,  but  also  in  different  ca.sps  as  to  the  degree 
of  its  intensity.     It  is  a  peculiar  odor,  which  is  quite  characteristic, 
iiid  i.nce  noted  is  never  forgotten.     The  odor  is  characterized  as  a 
iiiiwiy  rat-like  smell.     It  is  usually  most  intense  during  the  greatest 
iiciiviiy  of  the  crust-forming  period,  and  is  markedly  offensive  in 
tlin-r  cases  attended  with  large  jniltaceous  greeni.sh-vvhite  ma.s.«es. 
The  disagreeable  stench  is  the  mo.st  di.stn  .-ising  .symptom  to  the  poor 
siitf.  nrs,  ;ind  often  causes  .'ilmost  .social  ostracism  1"  young  girls  when 
.•<o  aftected.     The  odor  is  not  appreciated  by  the  patient  on  account  of 
tiic  destruction  of  their  own  olfactory  .sense.     Tlie  atrophic  changes 
cxtiiiiling  to  the  jiharynx  and  larynx  give  rise  to  excessive  dryness 
111  the  pharynx  and  the  formation  of  crusts  in  the  nasopharynx  which 
are  r;iised  and  exix'ctorated.    The  voice  is  hoarse,  and  may  be  aphonic 
Mil  Hii-'iii^  in  the  morning,  cletiring  up  -is  the  crusts  are  removed  and 
the  sivri'tion  <\<-ited.     An   irritative  cough   is  frequc'^tly  present. 
Ileiiiorrhage  from  the  nose  is  an  occasional  .symjitom.  due  to  the 
Liceration  of  the  nasal  mucosa  by  the  separation  of  the  crusts.     Nasal 
■  .li-trucion.  on  account  of  the  cavities  being  filled  up  with  crusts, 
■iiid  conse(|uent  mouth-bn>athing,  especially  at  night,  is  frecjuently  a 
-viiiptom.     FIead:iche.  frontal  in  tyjie,  is  usually  present,  and  mental 
iiiactinn  with  lielietiide.  and  more  or  less  imjiairment  of  the  memory, 
iiKiv  !"■  present.     Xervoiisiiess.  hysterical  manifestations,  and  melan- 
■liiilia   ari-   concomitant   symiitoms.   usually   brought    about    either 
through  ostracism  or  the  voluntary  shrinking  frnni  .social  intercourse 
liv  the  patient  on  account  of  the  consciousness  of  the  disagreeable 


(94 


yOSE  AXD  TllHOAT. 


odor  ciiuinatiiiR  from  tlio  lu.  :il  diaiiihors.  The  sense  of  snicll  is  almost 
always  impairctl  or  lost,  ("oiitrary  to  what  some  ol)s<'rver.<  state,  1 
believe  that  j>erforatioii  of  th<'  septum  is  uinisually  rare  in  atrophic 
rhinitis.  I  have  al.so  been  impressed  with  the  infrcMiueney  of  vatarrhal 
and  suppurative  ehaiifjes  within  the  middle  ear  in  individuals  affected 
with  this  di.sea.-<e.  and.  conversely.  J  have  noted  the  extreme  rarity  of 
atrophic  rhinitis  in  those  ai)plying  for  treatment  for  affections  of  tln^ 
tube  anil  the  middle  ear.  Certain  ocular  <lisorders  are  manifest  dis- 
turbances during  the  projjress  of  atr.jjihic  rhinitis.  Amonp  these  we 
may  note  tlie  various  forms  of  conjunctivitis,  blepharitis,  dacro<"Vstitis, 
and  anomalies  of  muscular  tension.  ( )ii  inspection  of  the  na.sal  cham- 
bers various  chanjres  will  be  observed  aKfctiiif;  the  soft  mucous  tissue 
according  to  tlie  state  in  which  the  di.sea.se  ha.s  advuucod.     .Vs  is  well 

Fig.  413. 


An  advauted  stage  of  alroiihy  v{  luuoHsa  and  bony  turbinBls,  a>  seen  in  atrophic  rhinitis. 

known  this  di.-;ease  usuallv  affects  both  nasal  cavities  and  produces  tiii^ 
chaiifr.'s  simuitane'iu.sly  in  both  chambeis:  occasionally  one  chamber 
will  be  affected,  and  at  a  later  period  the  other,  and  very  rarely  the 
di.sea.-<e  .-icems  to  involve  only  one  of  the  two  chambers.  <  hi  Hr>t 
inspecting  the  na.sal  chambers  they  will  be  observed  filled  with  tli( 
crusts  so  characteristic  of  the  disease,  and  these  tuust  be  thoroufrhly 
removed  Ix'fore  the  exact  condition  of  th(>  underlying  structure  ran 
be  determined.  One  is  immediately  impressed  with  the  extreme 
roominess  of  the  nasal  cavities.  In  tJi"  early  stages  of  'he  disease  tli'' 
mucous  iiK'niiirane  jiresents  a  )ale-reddeneil  appearance.  The  inferior 
turbinates  .<eem  somewhat  shrunken,  ami  the  middle  may  appe.i- 
somewhat  pendulous,  or  the  reverse  condition  may  Iw  present.  Hot' 
turbinates  may  appear  somewhat  shrunken  in  one  nasal  chambc 


ISFLAMMATORY  DISEASE.S  OF  THE  UPPER  AIR  PASSAGES.     795 

tlic  mucous  incinhrauc  apparently  drawn  tiplitly  over  tlu'  surface 

of  the  turbinates,  wliile  in  the  other  cavity  one  of  the  turbinals  may 

seem  to  i)e  hypertro|)liie(l,  while  tiie  other  is  contracted.     In  a  more 

advanced  form  the  turbinals  are  considerably  reduced  in  size,  tiie 

mucous  membrane  contracted  down  firmly  on  the  osseovis  framework, 

and  of  a  pinkish-white,  sclerosed  appearance.     In  this  state  there  is 

considerable  space  between  the  turbinals  and  the  septum.     In  the 

more  advanced  stapes  the  cicatrization  ot  the  Tuucosa  is  complete,  and 

tiie  inferior  turbinate  ha.s  underRoue  such  complete  atrophy  as  to 

iippear  only  as  a  more  or  less  prominent  ridge  on  the  outer  wall  of  the 

nasal  chamber,  while  the  middle  turbinate  appears  as  a  very  thin  plate, 

much  shortened  in  its  vertical  dimensions.     In  the  advanced  state 

the  atroi)hv  of  .soft  and  osseous  tissues  has  been  .so  complete  that  a 

view  of  the  pharvnx  can  re.adily  be  obtained  by  anterior  rhinoscopy, 

XI  that  the  upper  surface  of  t lie  soft  jialate,  with  its  movements  in 

(lcf;lutiti(m  and  phcmation,  the  mouth  of  the  Kustachian  tub<',  and  the 

post  pharv-nx  can  be  clearly  observed. 

The  diagnosis  of  atrophic  rhinitis  should  be  accomplished  without 
much  ilitiiculty.  There  is  hardly  any  other  affection  of  the  nasal 
(•ii.imbers  which  presents  such  a  clear  and  characteristic  chain  tif 
symptoms.  Krom  a  syphilitic  caries  or  necrosis  it  may  be  readily 
differentiated  by  the  presence  of  exposed  or  necro.sed  bone  in  syph- 
ilis, which  is  never  present  in  atrophic  rhinitis,  by  the  difference  in 
liic  odor,  and  by  the  evidences  of  constitutional  impairment  noted 
ill  the  sy])hilitic  and  not  observable  in  atrophic  rhinitis;  from  a 
toreigii  bodv— in  this  condition  we  have  the  sudden  on.set,  the  obstruc- 
tion, usually  unilateral,  and  the  ])resence  of  the  objc-l,  detected  by 
inspection  through  the  sjM-culum  or  by  the  use  of  the  probe. 

Prognosis.     When  one  considers  the  vast  amount  of  therai)eutical 
material  that  has  been  brought  to  bear  U])oii  this  disease,  and  with 
what  avidity  each  new  agent  is  hailed,  we  cannot  but  be  impressed 
with  the  great  stubbornness  of  the  di.sease  and  how  futile  all  efforts 
so  far  have  Iweii  in  bringing  about  a  cure  of  the  di.sea.se.     I  have 
never  seen  a  cured  case  of  atroi)hic  rhinitis.     I  have  seen  ca.ses  of 
atrophic  rhinitis  that  have  apparently  nm  their  course,  with  large 
patulous  cavities,  atid  freedom  from  odor  or  crusts.     These  are  spent 
(Vises,  not  cured  cases.     I  would  therefore  state  that  atrojjhic  rhinitis 
ill  I  lie  present  knowledge  of  our  therajieutic  resources  is  not  a  curable 
lisease:    but    under   carefully  carried  out    C(mstitutional    and    local 
ni'atment  it  is  su.sceptible  of  improvement,  with  a  lessening  of  the 
iitivity  of  its  destructive  jjrogress,   with  amelioration,  or  even  a 
"iiijiiete  abeyance  of  its  most  unpleasant  ami  annoying  syniptom.s. 
Treatment.     Whatever  line  of  local   treatment   is  in.stituted  it   is 
ilisiiiutely  necessary  that  cleanliness  form  the  primary  and  essential 
ature  (if  this  treatment.     Thorough  cleansing  of  the  nasal  cham- 
'Ts  once  or  twice  daily  with  an  alkaline  antiseptic  wash  introduced 
ly  anterior  and  jwsterior  injection  until  the  solution  C(mies  through 
irar  and  free  from  crusts  or  secretion  is  very  important.     The  solii- 


7!'<? 


yoSE  AMf  TIIHOAT. 


tiniis  arc  iiitidilucfd  (interiorly  l)y  any  of  the  various  f(»riiis  of  iia«;il 
iloiu'iii's,  pr('fcral)ly  by  those  exerting  only  a  moderate  (le>;ree  of 
pressure,  ami  posteriorly  Wy  the  postnasal  syriiipe.  i'atients  shoulil 
l)e  tlioroujilily  iusiructed  in  the  use  of  these  nu-chanicai  deviees  and 
in  the  danjrer  ineurred  hy  forcihly  l)lowin>j  of  the  nose  durinn  the 
use  of  the  douche.  As  the  (juantity  of  solution  which  is  to  1h'  used 
is  larjje  it  is  wise  to  select  some  solution  which  will  accomplish  good 
results  without  iH'inj;  very  expensive.  I  know  of  nothing  that  t'(|uals 
a  normal  saline  .solution.  This  can  Im-  prepared  each  time  hy  adilijig 
a  teas|)oonful  of  salt  to  a  litre  of  hoiled  water,  or  by  using  the  tablet 
of  nasal  phusma  before  referred  to.  Another  solution  which  is  also 
verv  erticacious  is  one  composed  of  one  teas|)0()nful  of  a  10  per  cent, 
solution  of  permanganate  of  potash  to  the  pint  of  warm  water.  Ht^ric 
acid  may  \yc  used  in  the  strength  of  Id  to  .'{()  grammes  to  a  litre  of 
water.  In  the  early  stages  of  the  cleansing  it  will  In?  nece.ssarv  to 
aiil  the  action  of  the  solution,  on  account  df  the  densitj-  and  tirnmess 
of  the  crust,  by  the  u.se  of  cotton-covered  probes.  Daily  or  every 
alternaf'-day  the  patient  should  be  carefully  cleansed  by  the  attendant 
jihysician,  and  he  should  go  over  the  whole  nuicous  surface  as  care- 
fully as  possible  with  a  cotton-protected  prolx",  removing  all  crust 
and  pus  from  within  the  folds  and  duplicatures  of  the  mucous  ineiii- 
brane.  Due  caution  should  be  observed  in  using  instruments  for 
douching  and  sprays,  to  see  that  they  are  as  sim|)ly  contrived  an 
jMissible,  that  they  are  aseptically  constructed,  and  that  tliey  admit 
of  sterilization. 

Various  forms  of  local  treatment  have  been  suggested,  mechanical 
and  medicinal,  to  meet  the  various  theories  that  have  been  suggested 
as  to  its  etiological  factors.  Cleanliness  and  active  irritation  through 
till'  medium  of  irritative  drugs  is  suggested  by  those  Ix'lieving  it  the 
seciind  stage  of  a  purulent  catarrh.  Those  accei)ting  the  histological 
changes  believe  in  curetting,  galvanocautery,  and  vibrato-massage, 
(irimwald  and  his  adl'.erents  resort  to  the  opening  uj)  of  disea.sed 
sinuses.  Bayer  ami  those  acceptinp  the  trophoneurotic  idea  resort 
to  interstitial  electrolysis.  Indeed,  excellent  results  are  c'aiined  hy 
those  resorting  to  the  u.se  of  eli'ctrolysis  in  the  treatment  of  this 
disease,  and  as  its  application  is  so  readily  made  I  should  strongly 
ailvise  its  use.  While  the  bacteriologist  has  suggested  the  various 
active  germicidal  agents,  formaldehyde  and  bichloride  solutions, 
among  the  various  local  mechanical  agents  that  have  been  suggested 
are  t.-nnpons  ((!ottstein\  use  of  curettes,  and  the  action  of  electricity. 
There  is  no  doubt  that  the  (lotlstein  tam|)on  is  a  valuable  agent  in 
the  treatment  of  tiiis  condition,  especially  in  that  class  of  cases  i:i 
which  from  various  cin'umstances  frequent  irrigation  cannot  be  eiii- 
plo\e,l.  The  tampon  is  readily  made  by  the  ]>ati<'nt  out  of  absorbed' 
coMiiM.  and  is  easily  introduced  and  removed  from  the  na.sal  cham- 
ber, riie  mass  should  be  large  enough  to  tit  well  into  the  na^:ii 
chamber,  and  should  be  nearly  ;is  long  as  tiie  little  finger.  It  should  !  '■ 
well  greased  with  a  neutral  non-irritating  oil,  or,  better  still,  witli  i 


(■': 


m 


IXHAMMAroKY  l>I.St:.lSES  UF  Tilt:  ll'fEIt  AIR  VASS.UlES.     7:,7 

■>5  or  50  n.T  cent,  solution  «f  ichthyol.     Whcr.'  inoriiinR  or  .  vciiiiiR 
rlrausiug  is  tl.oruunl.ly  rcs,.rt.Ml  f.  it  is  ..i.ly  lu'C-ssiry  t..  w.  ar  th.- 
lan.iH.n  fr.-in  tl.r.'.-  t..  f..ur  hours  .hiily  m  ••acli  imsal  chamlM'r.      Il.e 
,M>  ',f  il.is  ajtn.t  will  ih.1  Lriiijl  about  rt'solutum:  but  witl.  thonrngli 
HcaiisiiiK  an.l  tlu-  us.-  of  tl..-  taiupoi.  iiMMlicat.-d  witl.  ichtliyol  th.-rt> 
will  bo  a  u.arkca  diniiiiutioii  in  cnisi  formation  an.l  Icsscnui},'  ol  ti.e 
olTcnsivc  odor.     I  can  sc<-  no  reason  for  tin-  us*-  ot   il.c  (urrtt.^  or 
.nlvanocautm-  lus  pa.t  of  tiu'  routine  treatment  m  this  aiunent,  nor 
do  the  advocati's  of  vibratory  or  interstitial  massajre  seem  to  assert 
■,nv  result  from  their  treatment.     This  method  ot  vil)ratory  ma.s.s.,iie, 
oriL'inally  instituted  by  Braim.  is  still  stron^rly  a.lvccated  by  many 
of  his  adherents.     It  may  be  used  l)y  han.'.  or  motor.     In  this  eom.try 
SImrley,  Price-Brown,  and  Bishop  claim  excUent  r-sii  ts  fn.m  its 
„>.■      -Vn'oiiR  the  local  reiiu'dies  that  an-  mow  Immiik  ised.  :uid  which 
seeminL'lv  exert  more  or  less  intiuence  for  g(.o.l  in  this  type  ot  catarrh. 
nnv  be  m.-nlioned  .ormaUlehyde.  xO.ich  may  be  .'.ed  m  the  stren^Mh 
of  i  to  r)0(K),  praduallv  increasiiiK  the  strenpth  as  it  becomes  beaiable 
t,i  the  patient.     Stearate  of  zinc,  to  which  is  adtl.'d  1  pramme  o 
pnwdere.l  nitrate  of  si'ver  to  the  ;{->  K'"-  insuttiated  into  the  cleansed 
insd   chambers,  shonl.l   not   Ik>   used   more  fre.|uently   than  every 
il,ird  dav.     Both  of  these  age;its  are  stimulatinp  ami  cau.se  more  or 
l,s-;  oain'     Mentliol  is  extensively  used  alone  or  in  combination  with 
,Mu>phor'or  io,line  in  oily  s..lution.     Uliile  I  believe  this  a  pood 
protective  and  an  exceedinply  [.lea.sant  apeiit  after  thorough  cleans- 
iM.r  of  the  nasal  chambers,  nev.'rtheless  I  cannot  vi(>w  its  use  but 
as^'iidini;  and  abetting  th.-  progress  of  thedi.sea.se,  and  therehm- won d 
a,lvis,.  stronglv  against  it.     In   ichthyol    we  have  an  agent   which, 
^vhen  iudi'.iouilv  u.sed  in  connection  with  thorough  cleansing,  or  in 
roun.vtion  with  cleansing  and  tamp-.i-'ng.  gives  results  whicii  are 
,:,r  superior  to  those  attainable  by  any  o^her  form  ot  treatment  with 
.  liieli  we  an-  -4  present  co.r  .Tsant.     Th  •  ichthy..l  should  at  hrst  be 
u-e,l  in  l.^  p-r  cent,  solution,  rapidly  increased  ie  strength  until  it 
r.|,  l.e  l)orne  in  7.5  per  cent,  solution,  or  to  the  full  strength  of  the 
■  \ni"     The  drug  should  be  thon-ugiily  in.stilled  into  every  portion 
,,t  the  n:«al  clwunber  that  can  be  n-ach-d  by  the  dttendant.  at  least 
.very  sen  i.d  dav,     Somers.  of  I'hila,leii)hia,  claims  great  succos  in 
ihe  i(-sseiiing  of  crust  formation  and  diminution  of  odor  by  the  use 
.1  iusuiflatioii  of  a  -.'.i  per  cent,  powder  of  citric  acid  and  sugar  of 
:nilk     Careful  examination  should  be  made  iii  all  case:,  tor  di.seases 
;  eommuuicating  sinuses.     The  antitoxin  of  diphtheria  ha.s  been 
,i-e.l  ii,  treating  this  di.sea.se  without  any  permanent  results.     In  the 
Miimagement  of  all  ca.ses  of  atrophic  rhinitis  there  is  one  feature  that 
-hould  stronglv  impress  itself  upon  the  therapeutist,  and  that  is  the 
•iiaiiifest  nc'd  of  radical  constitutional  treatment.     I  have  never  seen 
case  of  :;;roi  hie  rhinitis  in  which  the  individual  possessing  it  did 
•lot   impress  n,e  as  one  wh(.  w:i.s  constituti(mally  below  par.     The 
aI.oI,.  hvgienic  >urroundings  nee<l  careful  overlooking  and  correcting 
vheiiever  at  f.'^ilt.    They  should  be  housed,  fed,  bathed,  and  clothed 


;iH 


.vo.s/-  .i.\7*  r/ntoA  T. 


I 


itvi 


t  m 


Ml 


,jf 


:i.«i  well  as  is  coiisistoiit  witli  thfir  al)ilit>  to  provitlu.  TIhv  ^lioiitil. 
Uiilfss  iiccfssity  ftH'l)i(l,  live  as  i  iicli  mil-ttf-doors  as  |M>ssil>lc.  ( )rc-a- 
sioiial  cliaiijro  of  cliiiiatc  ami  surnmmiiiijts  cxi  rt  a  ilccidcil  hcricficial 
iiithu'iic)'.  Tlif  cnrn'ctioM  m  ilisurtliTfil  conilitiiins  <<i  tlic  aliiacntarv 
canal  is  vrry  in'tciit  fur  jjimmI,  csiii'cially  of  tlir  li.ihil  of  rniis!  mitioii, 
wiiicii  is  so  prt'vali'iit  aiiioiij;  this  class  of  patients.  It  will  also  Im- 
foiiml  that  thcsi'  patients  improve  more  rapiilly  under  a  treatment 
that  includes  some  of  the  following  coii.'-titutiohal  a/."'nts:  iron,  iodine, 
arsenic,  cod-liver  oil.  or  the  hypopliosphites. 

Hay  Fever  or  Vasomotor  Oatarrh. 

Hay  fever  is  characterized  as  a  |K'culiar  form  of  catarrhal  in- 
flammation of  the  mucous  membrane  of  the  nasal  passa^>s, 
occurrinp  with  a  dejtree  of  ]M'riodicity.  The  most  fn^piently 
occiirrinp  tyiM-  of  ixTiidic  viusomotor  catarrh  is  that  which  I'xists 
durinn  the  tloweriiiji  of  certain  plants,  such  as  tiie  rajiwivd,  the 
grasses,  and  the  j;olden  rod,  which  in  our  climate  usually  takes 
place  in  the  month  of  .XuRust,  this  form  Iwinjr  c<immonly  designated 
as  hay  fever,  .\nother  ty|M'  makes  it.self  manifest  during  the  latter 
part  of  May  and  .lune  in  this  climate,  this  form  Ix-ing  commonly 
di'signateil  as  rose-cold,  .\nother  type  makes  it>elf  manifest  during 
any  [period  of  the  year,  in  winter  as  well  as  summer,  app.-irently  due 
to  various  .sources  of  external  irritation,  and  i-  designated  as  [mt- 
emiial  vasomotor  c.itarrh.  Hay  fever  first  attracted  the  attention 
of  medical  world  through  the  fthle  description  of  this  condition  liy 
John  Hostock.  in  ISIK.  Tlir  Kinilition  had  lK>en  recognized  for 
.-ievend  centniie.-;  iii>\ious  to  Hostock'^  descrit)tion.  Thosr  to  whom 
nc  are  ind<!>ie  1  f.n  our  present  knowledge  of  this  diseas"  an>  Phoehu-^, 
Helmlioit/.  iiiiu,  Hlackley.  Weyman,  Meani.  Marsh.  Daly,  Hack, 
Roe    John  .Mackenzie,  and  I'/ishop. 

Etiology.  It  is  generally  accepted  that  there  is  essential  to  the 
development  of  visomotiT  catarrh  the  pn-seiuc  of  three  factors, 
which  are  cl.issiiied  as.  lu'-^t.  a  neurotic  temperatiieiu :  secondly, 
a  hyiK'nesthetic  condition  of  the  terminal  tilaments  of  the  sensmv 
iicr\c>.  usually  hiougiit  ahout  hy  some  local  change;  and  thirdK'. 
the  pn  •-;<;(■('  of  M.iiii'  sutiice  of  local  irritation.  It  is  a  well-known  l";Ht 
tliai  ili(i>  •  who  sulTer  from  the  various  tyfx's  of  va.somotor  disturhanci's 
.show  by  their  very  presence,  their  .nctions.  their  (|uick,  nervtms  wav-, 
the  existence  of  the  nervous  teii:iM'rament.  iIk  neurotic  iiabit.  Tho-e 
atTeetetl  witii  the  .•ulmetit  belong  to  tliat  class  of  individuals  who  arc 
intense  in  lli'ir  natures  and  given  to  mental  ralhcr  than  [)hysicil 
:icti'iity.  The  jicriodicity  of  the  attack  points  al.so  strongly  to  ;  - 
'it'r\ous  character.  It  is  more  common  among  the  In-tter  class,  amoi ;.' 
those  who  live  more  or  less  luxuriously.  It  is  distinctly  hereditar- . 
.•uid  oiten  afflicts  many  members  of  the  same  family.  It  is  also  pnn  - 
'■  I!'  among  'hose  who  evidence  a  lowered  nerve  activity,  as  i  ■ 
n,  ill  .stliemc,  although  not  as  common  as  among  those  who  shiw   i 


ISHAMMATilRY  lilSKASKS  OF  TJIK  I'l'rEH  AIH  PASSAUES. 

iliHii'i'  111  iiiaikcil  1KTVOU.X  activitv.     TIk 


7{»9 


srivat  iirrvoiH  strain  aii<!  mental  im-ssiirc  ( 


>.•«•  who  an-  siihjcpt  to  the 


ii'iifs  II 


>minoii  to  the  <'iiviroii 


fa  jm-at  fity  arc  iiiiicli  iiuin-  fn'(|u..tit  sufrcr.>>,  fmn,  tl 


i.ila.lv  than  thiis<'  who  Icuil  the  cv 


ili'nt        vilhiRc  and  coiintrv  life.     .\ 


•Ml  and  unexciting  existciK 


•«'  inci- 

,f    ,      ,.,  ,  ,,      ,  iW  wH'nw  to  Ik- cxenii.t.     It 

atfiM't-  ihildr...,  of  tni.l.r  ag.-  as  well  as  the  age,!.  altho.J,  n.oir 
i.nval.nt  dunng  nnddle  adult  life.  The  hy,H.m.nsitiven..s«  of  the 
|«ii|iljer.d  nerve  Imngs  u;.  the  eonsiderafioi,  of  the  various  lorn! 
p..th..log,,a|  d.sturl.anees  whirl,  nmy  l,y  their  existence  give  origin 
tn  the  hy|M-rsi.,.s.t.v..  condition.  The  (|uestion  of  the  existenc..  of 
ccrtani  an-as  of  hy|H.rsensifive  tissue  which  can  Ik-  located  with 
.•xactness  ,n  tho.se  who  an-  susceptible  to  or  suffer  from  v,i.so,notor 
catarrh  cannot  In-  doubted:  l.ut  that  the«.  an-as  an-  constant  and  are 
'■Nit.d  to  certan,  regions  of  the  nasal  cavities  is  not  dci.K.iistral.le. 

I    has  also  Ik.,.,,  del non.st rated  that  there  are  many  local  patf gical 

•liMMges  ,,,   themtsal  chamlK-rs  which.  I,y  the  irritation  of  the  fija- 
.1..  .It.  o(  the  .s,.„.sory  nenes  distril.ute.l  throughout  the  na.sal  cavi- 
i-v  ungmate  reflex  .hsturl.ances  which  aid   in  the  ,,ro,luction  and 
...nntenance  of  vasomotor  catarrh.     Drs.  Daly.  M.k-,  llosworth.  and 
link  «^.r..  tl...  stro„g..st  and  most  ardent  ndvocates  of  this  local 
•M  -'111  ol  vason.otor  catarrh.     Among  th...  intrana.sal  conditions  which 
may  he  mentioned  as  pro.jucing  local  irritation  are  acute  and  chn.nic 
c.-.  arrh,  liy,K.rtrophic  catarrh.  hy,K.rtrophy  of  tlie  mid.ile  turl  t.ate 
p..lv,...  growths  of  various  kin.ls.  spurs  and  deflections  of  the  seZ,,; 
.uiil  di.s<.ases  of  the  communicating  sinuses.     The  pn-s^-nce  of  one  of 
M  lM,^r,  v...r...ty  .  f  irritatmg  agents  ,nay  he  tl„.  <.xternal  exciting  cause 
'"■  ••^m  Ik.  n„  douht  that  there  n.u.st  Ik>  son,e  .source  of  external 
"itaiiun  to  tur,...h.  as  ,t  were,  the  stimulus  to  the  alreadv  irritated 
i.n.cosa  and  th.  susceptihle  a.i.l  over-charge.l  nervous  svs te, ,  s 

-M  csseiitial  that  the  so..r"e  of  local  irritation  should  "he  the  .sa„,e 
in  .III  (.ises.  The  source  of  irritation  may  Ik-  the  odors  of  animals 
ynmis  drugs,  a.s  ammonia,  ipecac,  salicylic  acid,  the  , last  of  the 
"  .Is.  exposure  to  the  direct  rays  of  the  sun.  the  cKlor  of  roses  an.l  the 
1-1  -n  ol  various  plant.s.     I,  is  ,,uite  noticeable  that  a  p,.rennia  frm 

■     'Mia.  k  e>  s  experiments  in  the  causation  of  hav  fever  the  ,,ollen 

..;.     .IS  IS  exciting  cause  l.us  fn-en  almost  uni^.-rsallv  accepted 

'      .  at   t  ...se  ,l,sea,ses  are  more  pn-valent  during  the  pLriod 

'""  I.  the  pollen    of    eertam    flowers  and  plants  are  being   ,li>- 

n   lated  strengthens  greatly  the  theory  that' the.se  variou,    t.ll e  s 

'■  the  direct  exciting  cau.se  of  most  of  the  c;,.ses  of  vasomotor  ca  arr 

Mer, ni""-;"'';'"^  *'"'  '"'"'  '-'''"'"^i'''"  ^-'-"S-  and  /ie  «,ur  o      f 
,,,!'•'  '•'•';P"':^'V'-l.v»re  inpnnlucingparoxvsms  of  vaso 
t     catarrh  .    i.s  ,,,„te  impossible  to  state.     There  is  no  doubt    hat 

'"  ui   t,e  t,,„pora,nent.     \ery  rarely  do  we  find  anv  natholoeicl 
■  '^...ge  m  tliese  cases  in  the  nasal  chamber,  other  than  the  disteSd, 


MICROCOPY   RiSOlUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No    2) 


u; 

|2.8 

m 

Ui, 

Hi 

1^ 

IIIIIM 

Hi 

%am 

b 

■  40 

12.0 

.8 


1.6 


A     /IPPLIEDJNA^GE  _lnc 

^a—  ■■  '16)    *82    ■  030G   -  Phone 


ii'j- 


800 


yO.SE  AM)  Til  no  AT. 


relaxed,  and  palo  turhinal  tissiio,  witli  tlio  outpnurinfr  of  clear,  watery 
secretion,  the  relief  of  which  is  in  no  way  hronjiht  ahont  by  local 
treatment.  Only  occasionally  can  these  patients  mention  any  source 
of  irritation  or  any  condition  that  seems  to  excite  an  exacerbation. 
When  such  local  source  of  irritation  is  given  it  is  generally  some 
unusual  excitement  which  imiires.ses  u|)on  one  the  jjecnliar  nervou.s 
character  of  the  whole  disturbance.  The  type  (»f  nervous  condition 
which  is  usually  present  in  p<M-emiial  vasomotor  catarrh  is  that  of 
exhausted  nerve  energy,  neurasthenia.  In  the  disea.se  of  hay  fever 
and  the  various  disturbances  of  this  class  we  note  one  pathological 
feature  which  is  ever  present,  and  from  whose  pres(>nce  most  if  not  all 
of  the  sym])toms  originate:  that  condition  is  a  vasomotor  paresis. 

According  to  Hishoj)  and  others  the  central  disturbance  is  excited 
by  an  increase  of  uric  acid  in  the  blood,  brought  about  by  either  an 
excessive  ])roduct  of  the  acid  or  a  dimini.shed  excretion  of  the  same. 
This  ])erversion  of  nerve  function,  which  leads  to  disturbances  along 
the  course  of  the  na.sal  and  bronchial  sympathetic,  may  not  i)e  as 
nuich  due  to  increa.se  of  uric  acid  in  the  blood  as  to  other  excretory 
elements  which  accumulate  at  times  in  excessive  ([uantities  in  the 
blood.  The  condition  of  uricacidirmia  lias  al.so  been  mentioned  by 
numerous  other  authorities,  and  treatment  directed  along  this  hne 
seems  to  be  attended  with  marked  improvement  in  many  ca.ses. 

Symptoms.  The  j«  culiar  characteristic  of  hay  fever  and  rose-cold 
is  the  periodicity  of  the  symptoms,  the  persistence  during  a  certain 
interval,  and  the  usual  abrupt  and  comi)iete  subsidence.  The  attacks 
occur  with  marked  jx'riodicity,  the  ])ati('nt  being  usually  able  to  tell 
to  the  exact  day  when  the  invasion  is  to  be  expected.  The  attacks 
usually  become  mon'  .severe  with  each  recurrence,  and  after  a  few- 
years  it  is  not  only  the  upper  respiratory  track  that  is  involved.  i)ut 
to  this  may  be  added  an  invasion  of  the  bronchia!  mucous  membrane. 
It  is  also  to  be  note(l  that  after  several  years  of  successive  inv;ision  the 
attacks  do  not  terminate  .Ml)ruptly  with  the  onset  of  frost,  but  grad- 
ually subside,  while  slight  local  irritation  might  provoke  a  full  recur- 
rence. The  attack  is  ushered  in  by  a  sensation  of  dryne.ss,  fulness, 
and  itching  in  the  nose  at  the  vault  of  the  pharynx  and  at  the  imier 
canthus  of  the  eye.  The  above-described  symptoms  last  but  for  a 
few  hours,  when  they  are  followed  by  violent  |)aroxysnis  of  sneezing, 
which  rei)eat  ihemselves  again  and  jigain  throughout  the  day.  Ia- 
posure  to  direct  sunlight  or  dust  product's  a  paroxysm  of  sneezintr 
almost  instantaneously.  There  is  intense  itching  of  the  con.jm.ctiv:e, 
increased  lacrymation,  and  considerable  photophobia.  The  na>al 
nuico>,i  is  swollen,  the  na.sal  cavities  being  partly  or  comjjletelv  ob- 
structed wi'  "  ■■    ■ 


P 


rge,  more  or  loss  acrid  in  cl 


lar- 


■ter.     There  is  fre(|uently  a  dist'e.ssing  c<(ugh,  especially  at  nigh 
riiere  is  congestion  of  the  eyes,  with  more  or  less  putfine.ssof  the  eyt 
'  neural; 


lid 


and 


dgic  I 


)ains  in  the  e\ei)alls.     There  is  fre(|uently  marke. 


distress  over  the  whole  head,  or  the  ))aiii  may  be  localized  only  ov 
the  frontal  region,  producing  a  seasation  of  great  distention  tliereit 


JM-LAMMATOIir  VIJSEAHES  OF  THE  UPPER  AIR  PASSAGES.    801 

lividt'iiccs  of  tubal  catarrh  arc  not  wanting,  as  is  frwiuently  shown 
l)V  itcliins  or  soreness  alonji;  tlie  course  of  tlie  Eustachian  tube,  a  feeUng 
oi  fulness'or  pressure  in  the  ears,  and  more  or  less  iini)airnient  of  tlie 
licarinj;.     Tlie   amount   of   constitutional   symptoms   (lei)encls   to   a 
certain  degree  upon  the  severity  of  tlie  attack.     Tliere  is  usually 
>ii,,iv  or  less  irritability  of  the  temper  and  other  manifesiations  of 
extreme  disturbanees  of  the  general  nervous  system.     The  i>atient 
becomes  pale,  anil  there  is  a  general  lowering  of  the  physical  tone,  as 
shown  bv  lack  of  vigor,  incapacity  for  mental  activity,  inii)airment 
of  the  memory,  lassitude,  loss  of  appetite,  and  marked  disturbances 
of  the  digestive  functions.     The  attacks  of  sneezing  and  discomfort 
generally  subside  during  the  night.     There  is  occasionally  a  slight 
elevation  of  temi)erature  in  the  evening,  with  the  excretion  of  a  scanty 
highly-colored  urine.     The  patients  freciuently  complain  of  more  or 
less  chilline.ss.      There  may  be,  to    add  to  the  patient's  discomfort, 
a  general  hypersensitive  condition  of  the  scalp  or  areas  here  and 
there  over  the  general  cutaneous  surface.     The  local  appearance  of 
the  nasal  mucosa  shows  more  or  less  turgescence  of  the  tissue  over 
tlie  turbinates,  which  may  be  so  great  as  to  make  a  complete  obstruc- 
tion of  tl'.e  nasal  chanibeVs,  or  it  may  be  only  partial,  giving  rise  to 
alternate  relaxation  and  obstruction.     This  swollen  mucosa  in  receiit 
cases  presents  the  bright-red  appearance  of  the  ordinary  hypertrophic 
rhmitis,  but  in  cases  of  long  staiuling  the  membrane  has  a  sodden, 
i)ale   appearance.      The    membrane  is  usually    extremely    sensitive 
throughout  to  the  use  of  the  probe.     The  congest'  I  mucosa  is  usually 
somewhat  more  resilient  than  simple  hypertropiiic  tissue,  and  does 
not  indent  so  easilv  at  the  touch  of  the  probe.     After  several  years  of 
successive  invasion  of  the  hay  fever,  wherein  only  the  nasal  and  ocular 
manifestations  are  i^resent,  "we  have  added  to  these  symptoms  from 
the  bronchial  mucosa  in  the  form  of  asthmatic    paroxysms.     The 
severity  of  the  asthmatic  seizures  varies  in  proportion  to  the  other 
sympt(")ms.      At   each   following    invasion    the    asthmatic    feature 
iiecomes  more   pronounced.     The  asthma  of   hay  fever  exists  by 
da>  MS  well  as  bv  night,  and   may  persist    after  the  subsidence  of 
tlie  n:isai  symptoms,  so  that  the  patient  becomes  a  confirmed  .osth- 

in;itic.  .  It 

Diagnosis.  The  peculiar  periodicity,  the  invasion  at  the  period  ot 
the  vear  when  hav  fever  is  persistent,  and  the  peculiar  train  of  symp- 
toms makes  tli(<  lUagnosis  a  very  simple  matter.  When  to  this  we 
liave  added  the  nervous  symptoms  and  the  nsthmatic  attacks,  the 
diasjjnosis  is  extremelv  clear. 

Prognosis.  The  prognosis,  so  far  as  life  is  concerned,  is  favorable. 
W  hen  Msthma  hi's  supervened  the  lot  of  the  sufferer  is  a  very  unhappy 
one  indeed.  The  conditions  spontaneously  disappear,  and  there 
Mcms  to  be  a  tendencv  for  its  sul)sidence  with  age.  Relief  can  usually 
he  obtained  if  the  means  of  the  sufferer  will  i)ermit.  Treatment  is 
more  successful  in  relieving  the  attacks  and  producing  j)ermanent 
riiip-  thaii  was  formerly  the  case. 

.51 


802 


XOUK  ASU  THROAT. 


Treatment.  In  discussing  tho  treatment  of  ha>  fever  we  shall  first 
taive  up  the  consideration  of  the  treatment  i)et\veen  the  attactcs, 
((()  the  preventive,  i';)  tiie  constitutional,  (r)  the  local;  s<'eoiid,  the 
treatment  of  the  attack,  {<i)  constitutional,  ih)  local. 

During  the  interval  of  the  attack  the  various  etioloj  cal  factors 
should  be  thoroughly  considered,  <'liminated  if  possible,  or  their 
jxitency  diminished.  The  general  hygienic  surroundings  of  the  patient, 
ills  sanitation,  as  well  as  his  physical  regimen,  shouhl  be  carefully 
considered  and  regulated.  We  often  find  that  those  who  are  affected 
with  iiay  fever  are  individuals  who  spend  many  hours  of  the  day  in 
batlly  ventilated  and  imperfect i*  lighted  office  buildings,  subjectetl 
to  intense  nervous  tension  or  work  that  retiuires  a  high  degree  of 
mental  activity.  These  same  individuals  usually  take  no  ujKMi-air 
exerci.se,  and  frecjuently  spend  the  evenings  in  diversihed  but  con- 
tinuous mental  strain.  These  people  must  be  taught  to  live  ration- 
ally. They  nmst  work  under  better  hygienic  surroundings,  they 
must  diminish  the  hours  of  strain,  they  nmst  take  active  exercise  in 
the  open  air,  and  h:n  <■  a  more  rational  and  suitable  diet  prescribeil, 
to  which  they  mu^  ulhere.  As  long  as  there  is  evidence  of  a  defi- 
cient elimination  of  the  products  of  imperfect  digestion,  or  tiie  accu- 
mulatiitn  of  those  ch(>mical  elements  in  the  i)loo(l,  only  present  when 
the  relations  between  assimilation  and  elimination  are  iint  normal, 
the  patient  should  be  kept  on  a  liciuid  diet  or  a  very  rigid  diet,  of 
wliich  liijuiils  form  the  i)redoniinant  part.  I  usually  find  it  expedient 
to  give  a  dessertspoonful  of  the  effervescing  phosphate  of  .soda  night 
and  morning,  to  be  increased  or  diminished  according  to  its  action 
on  the  bowels.  It  is  usually  well,  also,  to  admini.ster  three  or  four 
tim(>s  daily  a  five-gniin  tablet  of  the  effervescing  citrate  of  lithia  in 
a  glass  of  wjiter.  ('old  bathing,  cold  sponging,  and  the  cold  bag  t() 
the  spine,  especially  in  tho.se  showing  vasomotor  disturbances,  are 
especially  api)licable.  The  marked  neurasthenia  should  have  the 
l)enefit  of  the  rest  cure,  .\mong  constitutional  remedies  certain  tonics, 
alteratives,  and  nervines  are  found  of  special  value.  These  drugs 
may  be  used  singly  or  s(>verai  in  combination.  Among  the  tonics 
are  iron  (Hlaud's  pill)  and  strychnine:  among  the  alteratives  arsenic, 
and  among  the  nervines  are  be'latlonna  and  phosphorus.  The  coni- 
|)lete  cessation  from  occupation,  removal  of  the  apparent  source  of 
the  local  irritation,  and  chanp  ■  of  environment,  habits  of  life,  and 
location  are  the  most  potent  agents  to  bring  about  relief  from  the 
paroxysms.  Some  people  .seem  to  feel  the  greatest  benefit  from  a 
sea  voyage  or  the  abiding  on  an  i.sland  in  the  .'<ea  so  distant  that  the 
influence  of  breezes  from  th{>  mainland  are  lost.  Others  get  the 
greatest  practical  Ix'iiefit  from  going  to  the  northern  mountains  and 
the  lake  regions  of  Canada.  The  White  Mountains  have  one  or  more 
imnume  places.  During  the  interval  in  the  attacks  the  nas.al  cham- 
bers should  be  placed  in  order  should  there  be  the  slightest  local 
pathological  change.  Hypertrophies,  polypi,  deflections,  and  other 
local  disturbances  should  i>e  removed  or  corrected. 


jyFL.iMMATORY  DISEASES  OF  THE  UI'PEli  AIR  PASSAGES.    803 


'riiKATMKNT  OF  THK  AiiAcK.  Th«'  l)cst  trpatinpiit  for  tho  attack  is 
t((  send  tli(>  patient  at  once  to  (tii(>  of  the  itimiuiic  places,  tliere  to  re- 
main until  the  occurrence  of  frost  at  his  [jlace  of  habitation.  The  ini- 
nume  place  from  which  I  havef;ain<'(l  the  Rreatest  a(lvant".jie  is  Beth- 
lehem, in  the  White  .Mountains.  If  the  patient  is  obliged  to  remain 
at  his  lionie,  then  fjreat  relief  can  he  assured  him  hy  ap|)ropriate  pen- 
erai  and  local  treatment.  Bishop  jjives  duriii}?  the  attack  teasixxinful 
doses  of  Ilorsford's  acid  phosphate  two  or  three  times  daily.  He 
claims  tliat  it  lessens  the  uric-acid  coiulition  of  the  blood  by  lesseninjj 
its  solvency  and  aidhig  its  elimination.  He  and  others  claim  luost 
posiiive  results  from  thi.'-'  line  of  treatment.  Dilute  hydrochloric  acid 
or  the  nitrotnuriatic  acid  mif^ht  be  substituted  for  the  Horsfcrd's  acid 
l)liosphaie.  Tlie  diet  should  be  regulated,  the  digestion  corrected, 
and  the  amount  of  work  iliminished.  Among  constitutional  renie- 
tlies  those  that  t.)ne  up  the  nervous  system  should  be  administered, 
such  its  iron,  strychnine,  and  phosphorus.  Among  all  the  remedies 
that  have  In-en  heretofore  suggested  for  the  constitutional  treatment 
of  hay  fever  during  the  attacks,  I  know  ot  no  drug  whose  action  is 
so  constant,  so  consistent  and  uniformly  successful  as  suprarenal 
extract.  The  suprarenal  extract  should  be  given  in  doses  of  three 
to  five-grain  tablets,  or  the  powder  in  capsules  every  two  to  three 
hours.  The  drug  can  be  pushed  until  there  is  noted  a  feeling  of 
vertigo,  nausea,  chest  constriction,  some  slight  nervous  excitement, 
and  increased  activity  of  the  heart.  I  have  noted  this  mild  toxic 
action  of  the  drug  in  those  with  high  nervous  organization  much 
earlier  than  in  those  of  more  robust  natures.  It  is  in  the  local  appli- 
cation more  than  in  the  constitutional  administration  that  the  drug 
slinws  its  distinctive  usefulness.  Locally  the  drug  should  be  used 
in  aciueous  solution  of  the  dry  powder,  prepared  according  to  the 
foi  inula  suggested  by  Ingals.  Previous  to  the  use  of  the  drug  the 
nasal  cavities  should  be  well  sprayed  out  or  douched  gently  with  a 
solution  of  biborate  and  bicarbonate  of  soda,  with  a  few  drops  of 
carbolic  acid,  and  then  a  pledget  of  cotton  introduced  into  each  nasal 
chamber  saturated  with  the  a((Ueous  solution  of  the  extract,  anil  there 
allowed  to  remain  for  several  minutes.  The  drug  can  be  used  also 
by  atoniization  of  the  same  sf)lution.     This  may  be  repeated  several 

ti s  daily.     This  internal  and  local  administration  of  the  suprarenal 

extract  will  not  always  give  absolute  certain  results,  but  it  will  give 
relief  and  more  relief  tlian  almost  any  ag(>nt  I  know  of,  and,  so  far  as 
we  are  aware  of,  with  no  unpleasant  after-effects.  Many  have  used 
this  agent  with  the  same  results  that  I  here  speak  of,  and  are  as  warm 
in  its  praises.  I  may  mention  Drs.  Bates,  Bean,  Douglas,  Louis  S. 
Soniers.  Henry  L.  Swain,  K.  \V.  Wright.  S.  Solis  Cohen,  anrl  Mullen. 
1  here  is  .some  peculiar  property  in  the  adrenalin  solution  that  causes 
1  t(i  occasionally  give  rise  to  a  paroxysm  similar  to  hay  fever,  and 
I  would  therefore  strongly  advise  against  its  use  to  meet  the  indi- 
c.itions  here  outlined.  Cocaine  has  [>revious!y  been  extensively  used 
to  give  relief  from  the  na.sal  stenosis.     The  effect  from  this  drug  is 


804 


yOUE  ASD  THROAT. 


I 


only  transitory,  possesses  no  doprpc  of  permanency  of  action,  antl  is 
very  prone  to  give  rise  to  the  liai)ituai  use  of  the  drug.  Dr.  E.  W. 
Wriglit,  wiio  lays  great  stress  upon  the  hypersensitive  condition  of 
the  na.sal  mucosa  as  the  important  factor  in  many  cases,  suggests  a 
frictional  massage  of  the  mucous  memijrane  of  the  nose,  in  order  to 
increase  its  resisting  powers,  so  that  it  can  withstand  the  irritation 
and  excitation  from  the  impact  of  the  pollen  of  plants.  His  method  is 
to  resort  to  gentle  massage  of  the  nmcous  membrane  with  a  cotton- 
covered  probe.  At  the  meeting  of  the  Section  of  Laryngolop,  tnd 
Otology  of  the  American  Medical  A.ssociation  in  .June,  1900.  Dr.  H.  H. 
Curtis  read  a  pajM-r  upon  the  subject  "The  Immunizing  Cure  of  Hay 
Fever."  In  this  paper  Dr.  Curtis  stated  that  he  had,  through  previous 
suggestions  in  the  treatment  of  cases,  thought  of  the  i)ossibility  of  im- 
numizing  in  hay  fever  by  the  admi.iistration  of  a  tincture  or  fluid  ex- 
tract made  from  the  flowers  and  pollen  of  the  ragweed.  The  Huid 
f  'ract  and  tincture  of  ambrosia  artemisia'folia  should'  l>e  given  in 
two  to  ten-drop  doses  in  water  three  times  daily.  A  solution  ui  tea- 
spoonful  doses  is  also  prejjared.  There  have  been  reported  a  number 
of  successes  as  well  as  almost  an  eijual  numlx'r  of  failures  after  its 
use.     Further  use  will  either  prove  its  fallaciousness  or  its  value. 

Bhinorrhoea. 

This  is  an  obscure  and  curious  affection  which  is  exceedingly  rare, 
and  is  characterized  by  the  escape  of  u  profuse,  thin,  watery 
discharge  from  the  nose. 

lij  the  consideration  of  rhinorrh(ea  we  arc  impressed  with  the  fact 
that  then>  are  two  distinct  types  of  this  condition,  one  being  attended 
with  the  ilischarge  of  a  Huid  from  the  nasal  cavities,  which  has  its 
■origin  in  the  arachnoid  space,  atul  the  other  with  the  e,sca]X>  of  a  similar 
fluid,  but  which  is  secreted  from  tjie  nasal  mucosa.  St.  Clair  Thomson 
hi  his  able  thesis  entitled  "The  Cerebro-si)inal  Fluid,  Its  Spontaneous 
Escai)e  fro  II  the  Nose,"  has  added  greatly  to  our  knowledge  of  the 
former  condition.  Cases  have  also  been  reported  suice.  Dr.  Thom- 
son has  collated  in  his  work  eight  undoubted  cases  similar  to  his  own. 
and  twelve  cases  probably  of  the  .  ame  character.  Most  of  the.se  cases 
ha-l  been  classed  by  various  authors  as  ordinary  cases  of  rhinorrluea. 

Etiology.  The  facto'-  which  play  a  rule  in  the  production  of  th;it 
class  of  cases  which  are  clearly  attended  with  the  escape  of  cerebro- 
spinal fluid  is  somewhat  obscure,  nevertheless  it  is  extremely  sugges- 
tive how  fre([uently  there  were  evidences  of  "crebral  symptoms  and 
retinal  changes.  Out  of  21  cases,  17  cases  exhibited  cerebral  symp- 
ton>s,  and  N  ca-^cs  showed  retinal  changes  (ThomsonV  reports!. 
Fracture  of  the  skull  involving  the  anterior  cerebnil  fossa  is  occ- 
sionally  attended  with  the  escape  of  a  clear,  limpid  fluid  from  the 
nasal  fossa.  The  nasal  for  r.  of  this  disease  is  somewhat  obscure  as  tn 
its  etiologv.  In  most  cases  there  seems  to  he  a  well-marked  neuroti' 
temperament  which  usually  manifests  itself  by  .some  disturbance  of  the 


ISFLAMMATOny  inSEAHE^  OF  THE  UPPER  AIR  PASSAGES.     805 

syinpathotic.  It  is  supposed  to  bo  due  to  the  impairment  of  the  inhib- 
itory influence  of  the  trifacial  or  to  stimulation  of  the  sympathetic. 

Symptoms.  The  affection  is  characterized  by  its  chief  .symptom, 
which  is  the  discharge  of  a  clear  watery  fluid  from  the  nose.  The 
ilischarjie  may  be  bilateral  or  unilateral.  When  bilateral  it  indicates 
more  frecjuently  the  nasal  type,  when  unilateral  the  cerebro-spinal 
type.  The  fluid  may  be  bland  and  non-irritative  in  character,  or  it 
may  be  acrid,  exciting  excoriation  of  the  ahe  and  the  upper  lip.  The 
amount  of  secretion  may  vary  from  a  few  ounces  to  a  pint  in  twenty- 
four  hours.  The  di.^charge  may  be  continuous  in  its  How  during  the 
twenty-four  hours,  during  the  working  hours  escaping  from  the  nose, 
and  (luring  sleep  p:«ssuig  into  the  pharynx;  or  it  may  be  intermittent, 
ceasing  entirely  while  the  patient  is  asleep.  When  the  discharge 
escapes  j)osteriorly  into  the  pharynx  during  sleep  we  may  have  cough- 
ing and  spasm  of  the  glottis.  The  discharge  u  \y  occur  at  periodic 
intervals,  or,  while  for  the  most  part  continunis,  there  may  be  inter- 
vals (if  a  few  days  wherein  it  ceases.  The  attack,  when  occurring 
at  periodic  intervals  during  the  day,  is  usually  preceded  by  more  or 
less  formication,  itching,  or  paroxysms  of  sneezing,  which  subside  as 
the  flow  is  established  In  the  periodic  or  nji.sal  type  the  attack  lasts 
(iiily  a  few  hours,  recurs  at  regular  or  irregular  intervals,  and  the 
amount  of  discharge  is  variable.  In  the  continuous  tyjx>  the  dis- 
charge is  persistent  through  many  months  or  years,  and  is  very 
constant  as  to  the  amoimt.  In  na.sal  hydror-ha>a  the  discharge  has 
no  distinct  point  of  exit:  it  seems  to  be  an  oozing  from  the  general 
mucous  surface.  In  cerebro-spinal  rhinorrha'a  the  discharge  is  noted 
as  issuing  between  the  middle  turbinate  and  i.he  .septum,  high  up. 
1  Aaminations  of  the  na.sal  chambers  show  very  little  alteration  in 
tlie  mucosa.  The  mucous  membrane  may  be  a  little  paler  than 
normal,  and  in  the  advanced  cases  the  middle  turbinate  may  appear 
waterlogged.     Occasiomdly  mucofs  jxilypi  are  found. 

Diagnosis.  The  diagnosis  of  tl  i  affection  is  easily  n^ade  through 
its  characteristic  symptoms,  the  How  of  a  clear,  limpid,  watery  fluid 
from  the  nasal  chainb(>rs.  The  important  feature  of  the  diagnosis  is 
the  (litToreiitiati(m  of  the  purely  nasal  from  the  cerebn  .spinal  rhinor- 
rhiea,  and  is  as  follows: 


yai^t  Hhinorrhira. 
I'Ih'   IIdw  is  usiiitlly  periodic,  preceded   by 

riic  (lisdiarKP  Is  not  contlnuoii" 
It  iistiHlIy  ceases  at  night. 
Arnouiu    of    (Iis<'harKe    iliirinff    twenty-fojir 
h'.ur>i  and  at  dillerent  i>erl(xls  of  the  day  is  vari- 

ill.r 

Tlio  dtscharKe  usually  issues  from  both  nasal 


Crrftyro-tpinal  Rhinorrhcea. 
The  flow  is  continuous.    It  is  attended  with 
no  symptoms. 

l>ocs  not  cease  during  sleep. 
Amount  of  disc'liarge  during  the  day  and  at 
different  periods  of  the  day  is  constant. 

n  is  always  unilateral. 


The  iiandkcrchiefs  moistened  with  the  secre- 
tii'ii,  after  dryiug  are  stiff. 

ciu'inicn!  rxamiiiation  ri'vpaU  thp  prpjernff  .f 
iiinriu  and  albumin,  and  it  does  not  redu(>e 
I  VhliUK's  solution. 


The  handkerchiefs  moistened  with  the  dis- 
charge dr>'  sofl. 

rhnmiral  tix»n*.:nati.^n  rpvpftlis  tl  p  abispnrp  of 
mucin  ;  prntelds  arc  practically  at  tent,  and  it 
reduces  Fohling's  solution. 


■J^-f; 


806 


yOSE  AM)  THROAT. 


! 


[ 


PrognosiB  is  ralhor  unfavorable  as  to  improvenicnt  or  euro. 

Treatment.  It  is  very  iiiiportaiit  in  all  cases  of  nasal  rhinorrhiva 
to  make  a  careful  differentiation  as  to  the  possible  origin  of  the  Huid, 
as  it  has  an  important  bearing  uj)on  the  therapeutic  measures  to  Ik* 
adopted.  In  the  eerebro-.'spinal  type,  as  indicated  by  St.  Clair  Thom- 
son, all  forms  of  local  treatment  are  absolutely  useless.  In  rhinor- 
rluea  of  a  purely  nasal  type,  jtartial  relief  may  be  obtained  through 
the  use  of  cocaine,  atropine  in  a(iueous  .^^olution,  as  reconunended  by 
F.  Kerper,  and  sujjrarenal  extract.  A  thorough  study  of  the  case 
from  an  etiological  point  of  view,  so  as  to  enable  one  to  apply  that 
general  therapeutic  resource  which  may  be  of  value  in  the  individu;'' 
case,  is  absolutely  essential. 

Influenza. 

Influenza  is  an  inflanunation  affecting  the  mucous  membrane  of  the 
whole  upper  respiratory  tract  and  the  bronchial  nmcosa,  with  more 
or  less  well-marki'd  systemic  symptoms,  evidently  due  to  the  action 
of  a  sjjecitic  bacillus.  This  disease  is  mildly  c<mtagious,  as  it  is 
frecpiently  noticed  that  it  spreads  throughout  all  the  members  of  a 
household  when  one  member  becomes  affected.  Influenza  respects 
neither  age,  sex,  nor  social  condition.  It  is  conuiion  to  all  latitudes, 
although  more  prevalent  and  more  active  in  the  temjjerate  and 
collier  zones. 

Etiology.  From  the  fact  that  influenza  is  more  prevalent  during 
the  fall  and  spring  of  the  year,  it  has  been  stated  that  its  prevalence 
at  these  times  was  due  to  the  changes  which  were  taking  place  in 
th(>  atmo.-<pliere  at  these  .>*easons.  Its  |)revaleiice  at  thes(>  j)eriods  is 
probably  more  rationally  explained  b  the  lowered  bodily  tone  inci- 
dent to  exposure,  which  renders  the  muco.sie  susceptible  to  the  inva- 
sion of  the  specific  bacillus  of  influenza.  Numerous  bacilli  have  been 
described  as  the  active  agent  in  the  production  of  the  pathological 
condition  known  as  influenza.  The  bacillus  de.'^cribed  by  Pfeiffer  is 
the  one  generally  accepted  as  the  exciting  etiological  factor. 

Symptoms.  The  invasion  of  influenza  is  usually  marked  by  very 
decided  constitutional  symj)toms.  There  is  usually  a  very  decided 
chill  or  chilly  sen.sition,  which  is  followed  by  a  rapid  elevation  of  the 
temperature.  There  is  marked  prostration  aiul  bodily  weakness. 
Loss  of  ap{)etite.  often  intense  frontal  headache,  intense  muscular 
soreness,  and  ])ain  in  the  extremities.  The  muscular  soreness  may 
attack  any  group  of  muscles,  but  most  frecjuently  affects  those  of  the 
back  and  neck.  The  1emperat\ire  ranges  from  100°  to  10;{°  F., 
and  is  fre<iuently  irregular  in  its  tyi)e.  Tli(>re  is  usually  manifest<'d 
an  intense  catarrhal  infl.iiTimalion  of  the  whole  up])er  respiratory 
and  bronchial  tract,  with  the  array  of  symptoms  incident  thereto. 
Thus  we  have  the  usual  syniptotiis  attending  a  coryza,  more  or 
lesj  soreness  in  the  pharynx,  with  ))ainful  deglutition  and  hoarse- 
ness of  the  voice.  The  outpouring  nf  secretion,  estal)lishe<l  shortly 
aftei  the  invasion,  is  usually  very  copious  and  of  a  mucopurulent 


lyPLAMMATORY  DISEASES  OF  THE  UPPER  AIR  PASSAGES.    807 


i'liaractpr.  Cough  is  a  very  persistent  and  distressing  symptom. 
More  or  less  i)iiiii  about  the  chest  vvalls  is  common.  Puin  aiui  discom- 
t'ort  in  tiie  pharynx  and  larynx  are  fre<iuently  out  of  uU  pnjportion 
tc  Lie  amount  of  intiammation  evident  upon  inspection.  There 
is  not  (mly  a  marked  degree  of  actual  physical  depri'ssion  in  many 
cases:  but  this  is  often  added  to  and  intensified  by  the  mental  depres- 
sion and  the  disturbance  of  the  central  nervous  syst«'m.  Physical 
examination  will  reveal  the  usual  changes  which  we  have  learned  to 
note  as  being  present  in  acute  inflammatory  disturbances  of  the  upiH>r 
air  tract.  In  the  chest  we  will  f.nd  the  usual  evidences  of  an  acute 
bronchial  catarrh. 

Prognosis.  This  dise:i.-*e  usually  runs  its  course  in  'ibout  ten  days 
or  two  weeks,  and  if  due  care  is  exercised  in  its  management  it  most 
fre(|uently  terminates  in  complete  n'covery.  It  is  a  most  serious 
condition  when  affecting  the  very  young  or  the  aged,  as  ttie  intense 
.'tdynatiiia  is  prone  to  be  followed  by  exhaustion  ni  the  physical  power; 
or  the  exteii  ion  of  the  inflannnation  into  the  capillary  bronchi  is  apt 
In  lie  followed  by  catarrhal  pneumonia,  either  of  which  conditions 
may  prove  fatal.  Complications  are  very  common  in  this  affection, 
and  when  occurrhig  they  add  to  its  complexity  and  its  gravity. 

Complications.  ()net)f  the  most  fre(|ueiit  complications  in  hitluenza 
is  the  invasion  of  the  auditory  tract.  We  may  have  tubal  catarrh, 
sinii)le  or  exudative  catarrh  of  the  middle  ear,  sui)purative  otitis,  and 
mastoiditis.  The  simi)le  and  exudate  catarrh  are  the  most  frequent 
complications  in  connection  with  the  ears,  and  their  characteristic 
symptoms,  usually  intensified  in  this  disea.se,  add  greatly  to  the 
mental  depression.  The  acces.sory  sinuses  are  freciuently  affected. 
Tiiere  is  no  doubt  that  sinusitis  is  frequently  dependent  on  a  l)re- 
vioiisly  existing  attac'  of  influenza.  The  antrum  of  Highmore,  the 
etlimoidal  and  th'-  :■  i  '■uises  are  the  cavities  most  freijuently 
atTected.     Periton^^  ;•  ss  is  a  complication  that   occasionally 

l)re.scnts  it.self,  altno-  (*>ink  it  is  present  as  a  complication  only 

in  those  who  are  su'ijecc  lo  attacks  of  suppurative  tonsillitis.  (Edema 
of  the  glottis  is  rarely  a  complication.  In  simie  epidemics  there  is  a 
iiiarkeil  proneness  to  hypertrophy  of  the  lingual  and  submaxillary 
glands,  which  enlargement  almost  always  subsides  without  supi)ura- 
tion.  Pneumonia  of  the  catarrhal  type  is  a  frequent  complication 
of  n'":lected  cases  and  in  the  very  young  and  aged.  \'arious  nervous 
liheiiomena  may  be  present  as  complications,  as  evidenced  by  marked 
iMcntal  depression,  hypera'sthesia  and  neuralgia  affecting  various 
branches  of  the  trifacial  nerve.  The  diagno.sis  of  this  condition  is 
readily  differentiated  from  acute  rhinitis  through  the  marked  depres- 
sion, the  i>romin('nt  nervous  symptoms,  the  involvement  of  the  lower 
n>spiratory  tract,  and  the  protracted  course.  In  acute  rhinitis  the 
involvement  of  the  pharynx,  larynx,  and  louver  respiratory  tract 
when  it  takes  place  is  in  sef|uence  and  not  synchronous. 

Treatment.     It  is  .ibsolutely  essential    that  patient*  sufferii-.g  from 
this  maladv  should  be  confined  to  the  bed.     Under  no  circumstances 


808 


NOSE  AND  TUROA  T. 


should  thpy  bo  allovvod  to  inuvp  about  in  the  ojien  nor  ovon  within 
tlu'ir  rooms.  All  avoidance  of  Ixxlily  exertion  and  absolute  n>st  is 
essential  to  prevent  unfavorable  eoinplicatimi-  and  to  avoid  exhaust- 
ing the  patients  physieal  streiiKth.  The  i)atient  should  be  placed 
upon  a  hinhly  nutritious  liijuitl  diet.  The  bowels  should  Im'  well 
oiM-ned  by  fractional  doses  of  calomel.  Bromide  of  ijuinine  or  sulphate 
of  cinchonidiiKC  should  be  given  in  small  doses  until  the  temiwrature 
has  returned  to  the  normal.  Should  there  Ih'  evidence  of  much 
prostration,  strychnine  in  appropriate  dosage,  and  alcoholic  stimulants 
should  b(«  administered.  The  convalescence  should  be  a.ssured  Iw'fore 
the  patient  is  allowed  to  assume  his  usual  vocation.  Should  cough 
prove  a  distressing  symptom  it  should  be  relieved  by  ai)[)ropriate 
treatment  directed  to  that  portion  of  the  air-tract  from  the  patho- 
logical disturbance  of  which  it  seems  to  issue,  as  well  as  by  the 
internal  administration  of  codeia,  heroin,  or  (yanide  of  potiish. 
Complications  should  be  carefully  watched  for,  and  when  occurruig 
should  be  appropriately  treated. - 


Asthma. 

In  the  discussion  of  the  general  c  )ndition  known  as  -isthma  we 
intend,  under  this  heading,  to  consider  the  subject  only  in  so  far 
as  it  is  a  respiratory  reflex,  and  to  enumerate  the  conditions  in  the 
upper  tract  which  may  give  ri.se  to  it.  Asthma  is  a  morbid  con- 
dition, in  many  of  its  features  closely  allied  to  that  of  hay  fever. 
Its  primal  causative  element  is  at  our  present  vvTiting  a.s  far  from 
solution  as  is  the  cause  of  hay  fever.  Many  authors  accept  a  some- 
what similar  schematic  etiological  chain  for  bronchial  asthma  that 
they  have  constructed  for  hay  fever,  namely,  first,  an  inflamed 
hyiM-rsensitive  or  irritable  condition  of  the  bronchial  nuicosa;  second, 
a  (listurbei!  or  diseased  condition  of  some  other  system  or  organ  how- 
ever remote;  and  third,  a  neurotic  condition  which  pennits  of  the 
linking  of  the  two  other  conditions  through  the  vasomotor  system. 
This  theory  permits  not  only  an  explanation  of  the  occurrence  of  the 
nasal  reflex  asthma,  but  also  of  all  other  types  wliich  seem  to  be  of  a 
reflex  character;  it  in  no  wise  attempts  to  explain  asthma  due  ti> 
cardiac  and  l)ronchial  disease-.  The  attacks  of  asthma,  as  is  well 
known,  consist  of  well-marked  paroxysms  ot  difficult  breathing, 
usually  coming  on  at  night,  and  of  variable  duration.  The  difficult 
breathing  is  excited  either  by  a  vasomot'-r  paresis  resulting  in  a 
dilatation  of  the  bloodvessel,  or  by  a  spa'  ,  of  the  nuiscular  fibres  in 
the  small  hronciiioles,  either  of  which  phenomenon  results  in  a  narrow- 
ing of  the  calibre  of  the  bronchial  tubes  affectecl. 

Morbid  Conditions  of  the  Upper  Air-tract  Which  Excite  Asthmatic 
Paroxysms.  Tiic  most  characteristic  and  typical  nasal  condition 
which  excites  ])an)xysms  of  asthma  is  hay  fever  and  the  allied  types 
of  vasomotor  catarrh.  In  many  cases  of  hay  fever,  with  its  amuiai 
recurreiice,   the  asthmatic  symptoms  become  the  most  prominent 


INFLAMMATORY  DISEASES  OF  THE  UI'l'EB  Alii  PASSAGES.    809 


t'caturp  of  tin-  ens*'.     Nasal  polypus  is  stated  by  many  authors  to  he 
one  of  the  most  p(»t('iit  patholo^rical  fhaiiKcs  witlnii  the  nasal  chanilHT 
exciting  by  reflex  disturbanees  paroxysms  of  astliina.     It  is  difhcult 
to  explain  why  the  smaller  growths  eause  this  disturbanie  rather  than 
the  large  ones,  unless  it  be  that  the  smaller  ones  irritate  the  mueosa, 
while  the  larger  ones  obtund  its  sensibility  tl  ough  pressure,  (irowths 
(il  other  types  apjwaring  in  the  nasal  ehanibers  may  exeite  the  eon- 
liitioii  under  consideration.     The  condition  known  ,s  hypertrophy  of 
the  inferior  turbinate  is  also  an  infrecjuent  etiological  factor  in  asth- 
matic attacks.     A  similar  condition  of  hyjKTtrophy  of  the  middle 
turbinate,  whether  it  be  a  simple  hypertrophy  or  what  is  freciueiitly 
called  an  (edematous  degeneration  or  myxomatous  ethmoiditis,   is 
one  f)f  the  pathological  changes  in  the  nasal  cavity  said  to  occa!<ion 
asthmatic  paroxysms.     Among  oth'-r  changes  within  the  na.'^al  cham- 
bers which  may  be  mentioin'il  as  causing   asthma  are  spurs  and  de- 
flections of  the  septum  ami  purulent  diseases  of  the  sinuses  comnmni- 
cating  with  the  nasal  chambeis.     xVmoiig  thos<'  diseases  of  the  pliarynx 
wiiich  have  been  eimmerated  as  pla\ing  an  etiological  role  may  be 
mentioned  adenoids,  nas'  pharyngeal  growths,  enlarged  uvuhe,  and 
liypertroi)hied  tonsils.  In  considering  the  relationshij)  betwwn  known 
existing  pathological  changes  in  the  upper  air-tract  and  asthma,  it 
is  well  *o  bear  in  mind  the  fact  that  however  marked  the  local  changes 
from  the  normal  may  be,  and  how  much  the  asthmatic  paroxysms 
may  appear  d<  pendent  upon  the  local  condition,  there  may  be  between 
t'l'iM  no  pathogenic   relationship  whatever.     This  fact  it    is  well  to 
bear  in  mind  in  consideringoiK'rative  treatment  of  diseased  conditions 
of  the  upper  air-tract  for  the  purpose  of  relieving  the  asthmatic  con- 
dition, in  order  not  to  subject  yourself  to  embarrassing  failure  and  your 
patient  to  keen  (lisai)pointments.     It  is  well  to  state  the  probability 
of  the  relationship  of  cause  and  effect  between  the  local  morbid  change 
ai'd  the  asthmatic  condition,  and    the  probable  relief  that  will  be 
afforded  to  the  one  by  the  removal  of  the  other;  no  further  in  the 
l)romise  should  one  go.     I  have  very  little  faith  in  the  extreme  view 
taken  by  Hosworth  and  others  that   in  a  large  percentage  f^f  cases 
asthma  is  due  to  some  form  of  intranasal  disease.     There  is  no  doubt 
tiiat  in  some  asthmatics  certain  forms  of  na.«al  disease  which  may  co- 
exist may  be  the  local  excitant,  and  their  removal  may  be  attended 
with  relief  which  may  be  more  or  less  permanent.     Usually,  however, 
ill  order  to  make  the  reliof  permanent,  it  is  neces.sary  to  correct  the 
constitutional  condition,  which  is  ecpially  at  fault.  Ie.«t  some  local  irri- 
tation elsewh( -e  after  a  time  cause  a  r'^'-urrence  of  the  asthma.     I 
have  seen  the  removal  of  minor  pathoh  „'ical   changes  in   the  mse 
atteiidei"  with   subsidence   of   asthmatic  attacks,  and,  on  the  otlier 
liaml,  I  nave  seen  the  removal  of  spurs,  correction  of  deflections,  and 
niiioval  of  polypi  in  asthmatics  accompanied  with  no  result  so  far  as 
tlie  asthma  was  concerned. 

Treatment.     The  local  treatment    should  be   the  removal  of  any 
condition  in  the  upper  respiratory  tract  which  is  pathological  and 


»10 


yuHE  AND  THROAT. 


\ 


! 


i 


lujiy  fairly  Ik-  ropardod  as  a  poxailjlc  reflex  exciUiiit  of  the  asthmatic 
state,  'riiere  shoulil  i)e  iiistituteil,  at  the  same  time  as  the  loeal  treat- 
ment is  heiiij;  worked  out,  that  fonii  of  eoiistitutioiml  treatment  whieh 
will  aid  in  the  relief  of  the  pan)xysms  and  restore  the  gtuierul  system 
to  the  normal  state. 

Acute  LaryngitiB. 

Aeute  laryngitis  is  an  aeute  inllanimation  of  the  mucous  mem- 
brane of  the  larynx.  Acute  hiflammatioii  of  the  larynx  is  not  so 
common  an  affection  as  simila'-  catarrhal  inllammation  of  the  nose  and 
pharynx;  hut.  on  account  oi  the  alteration  in  function  that  it  calls 
forth,  the  sufferers  from  this  condition  seek  medical  assistance 
(luicker  than  those  suffering  from  iia.sal  or  pharynj;eal  inlianuna- 
tion. 

Etiology.  Exposure  to  cold  an<l  wet,  the  ordimr  I'onilitioiis  that 
are  |)roductive  of  cold-catchiiifi,  are  potent  in  tlinr  mtluence  in  pro- 
tluciii};  acute  inflanunation  nf  the  larynx.  The  form  of  exposure 
attf'ix'i'd  with  the  playing  of  a  ilraught  of  air  upon  the  head  or  neck 
is  the  most  common  exciting  cause  of  acute  laryngitis.  Acute  attacks 
are  also  common  among  those  who  profcet  their  throats  with  nmf- 
fiers,  l)o;is,  and  collarettes.  The  laryngitis  produced  is  not  .so  much 
due  to  the  simple  wearing  of  these  forms  of  dress  as  it  is  the  result  of 
the  loosening  of  them  when  the  neck  becom<'s  warm  ami  the  su<lden 
chilling  tims  produceil  while  the  neck  is  over-<'X|)o.sed.  There  is  also 
no  doubt  that  certain  individuals  seem  to  develop  a  proneness  to 
acute  laryns^itis  whenever  subjected  to  undue  exjMtsure,  while  others 
terminate  their  acute  colds  with  an  acute  laryngitis.  The  spring 
and  fall  seem  to  be  the  seasons  in  which  this  condition  is  most  fre- 
(jaently  developed.  Those  who  are  ex^^osed  much  to  the  inclement 
weather  without  proper  protection  are  also  j  redis])o>ed  to  attacks. 
The  excessive  use  of  alcoholic  drinks  .«eem:  also  to  1m'  productive  of 
this  condition.  Inordinate  use  of  the  voice,  especially  in  a  manner 
that  the  individual  has  not  been  accustomed  to  exercise  it,  as  well 
as  its  continued  and  excessive  use,  as  in  exhortation,  cheering,  and 
louil  calling,  act  as  exciting  causes.  This  is  also  observed  in  over- 
exertion of  the  voice  in  addn^sing  large  audiences,  and  the  improper 


use  of  it  in  singing  and 


in   nil 


I  <; 


c  speaking.     Irregularities  in  the 


gastro-intestinal  tract  act  ofttimes  as  a  predispi ■•■iiig  cause.  The 
various  exanthemata  are  often  accompanic'l  by  an  acute  laryngeal 
mflammation,  such  as  influenza,  measles,  variola,  and  more  rarely 
scarlet  and  typhoid  fever.  Prolonged  exi)osure  to  ba<l  atmospheric 
surroundings  a.'nl  the  breathing  of  impure  air,  the  result  of  over- 
crowding ami  ba<l  ven'iii-tion,  or  of  ;in  atmospliere  containing  vapors 
of  chemicals,  such  as  iodine,  chlorine,  bromine,  sulphuric  nr  nitric 
acid,  are  j)otent  f.acfors  of  a  semitraumatic  nature.  Direct  mechani- 
cal injury  from  excessive  cougliing.  entrance  of  foreign  bodies,  and 
surgical  manipulations  jir. .ducc  laryngeal  inflammation..  .Mlacksarr 
frequently  due  to  exten.sioii  of  inllanimation  from  the  ])harynx  above 


ISFLAMMATORY  DISEASEH  OF  TUE      "I'KR  AIR  PASSAaES.    jjH 


or  friiin  tlic  trachea  IHow.  There  is  a  riiarke<|  predis<pi>sitioii  to 
thew  attacks  in  jxTstiis  sufferiii>?  fnuii  olisl ructions  in  the  lasul 
ehanil)ers.  Men  are  inure  fre«(uently  affected  than  woniou,  anil  ..Julta 
more  fre(,iiently  tlian  chil(in>n. 

Symptonu.  In  descriliing  the  syrnptoins  of  acute  hiryngitis  it  would 
Im'  extremely  dillicult,  on  account  of  the  varied  ty|M's,  to  define  it 
in  more  than  a  jjeneral  way,  and  then  afterward  inon-  can'lully 
enuineratc  the  syinptmns  peculiar  to  the  distinctive  ty|M's.  The 
const  it  ulional  syni|)toins  are  usually  very  mild  in  the  average  case 
of  acute  laryngitis,  the  patient  simply  feeling  slight  general  uncasi 
ness,  with  constipation.  In  some  of  the  more  severe  inflammation, 
there  may  he  a  slight  fehrih  reaction  with  the  usual  constitution 
m:iiiirestatioiis  that  present  themselves  under  such  conditions.  I'sually 
the  hrst  evidence  that  one  h;us  of  impending  inflammation  is  a  feeling 
of  pressure  or  uncoml'ortaMe  sensation  in  the  larynx,  which  grad- 
ually hccoiiics  magnified  into  a  feeling  of  s)reness.  There  is  often 
a  peculiar  niw  s<'nsation  in  the  larynx,  ai  i  he  !nsi»ired  air  is  dis- 
tinctly felt  as  it  j)as,ses  over  the  inflamed  sur*'-  "c.  There  is  fretiuently 
a  sensation  of  rawness  <ir  heat  felt  extending  from  the  u])per  border 
of  the  hirynx  to  tin'  middle  of  the  sterman.  When  there  is  marked 
(•;  ngestion  of  the  epiglottis  or  arytenoid  we  have  jijiinful  deglutition. 
The  tickling  or  dryness  of  the  throat  at  first  cans-  s  the  patient  to 
m.ike  fn'(|uent  efforts  at  hemming,  which  is  later  on  followed  hy 
fre(|uent  coughing.  As  the  s«'cretion  becomes  established  the  cough- 
ing becomes  ;.iore  frei|uent  and  annoying.  The  cough  is  of  a  peculiar 
iH'llowing,  metallic  character.  The  cough  varies  gn-atly  in  its  char- 
acter, fre,(uency,  and  the  rapidity  of  its  subsidence,  accorduig  to  the 
region  of  the  larynx  affecteil  and  the  intensity  of  the  inflammation. 
I  h.ive  usually  ol)s«»rved  that  the  cough  is  njost  distressing  when  the 
infi.inimation  extends  to  the  subconlal  portion  of  the  larynx.  The 
c  III  itions  which  intensify  the  cough  are  exces.sive  congestion  of  th^ 
larynx,  excessive  .swelling  or  an  n'dematous  condition  of  tlie  e;  "'- 
glottis  and  arytenoids,  exces.sive  secretion  of  a  liquid  rharact(>r,  '"■ 
the  paroxysmal  cough  excited  by  crust  formation.  Tl  ^  'ici  varie 
greatly  iti  the  extent  of  its  involvement  hi  different  'acks  and 
according  to  the  extent  and  seat  of  the  intlamiuation.  Thus,  when 
the  upper  portioti  of  the  larynx  is  involved  the  voice  may  not  be 
affected,  or  only  moderately  altered,  although  it  usually  varies  from 
a  moderate  hoarseness  to  coni])lete  aphonia.  When  the  free  edges 
of  the  cords  are  congested,  or  the  whole  vocal  region  and  the  false 
cords  inflamed,  the  voice  is  usually  intensely  hoarse.  Swelling  in 
the  iiiterarytdioid  region  is  attended  with  hoarsene.ss  or  complete 
aphonia,  dependent  on  the  amount  of  .swelling.  Paresis  of  the  crico- 
arytenoid internus.  or  arytenoideus  transversus,  which  sometimes 
occurs,  is  attended  with  comjjleto  aphonia.  (Vu.st  formations  attend- 
••int  u|)on  laryngitis  sicca  are  .K'companied  by  alternating  aphonia  iv  d 
hoarsene.--.  The  amount  of  the  inlerfeicnce  ^^itll  respiration  is  in 
the  great  majority  of  cases  only  slight  and  practically  not  noticed 


-^'\W 


812 


SUSi:  AXD  rilROA'l'. 


by  tlio  patient,  yet  in  certain  forms,  as  in  the  laryngitis  sicca,  tlic 
hyixiglottic  funn,  and  in  the  acute  laryngitis  of  children,  it  may  not 
(uily  become  distressing  to  the  patient,  but  actually  endanger  the 
life  of  the  affected  one.  At  first  there  is  an  intense  feeling  of  dryness 
in  the  larynx,  but  this  after  a  ju-riod  of  a  few  hours  gives  rise  t() 
the  outpouring  of  at  first  a  semimucous  secretiiin  which  gradually 
undergoes  a  change  to  a  mucous  and  nmcopurulent.  This  discharge 
is  for  a  few  hours  abundant,  but  lessens  rapidly  as  its  licjuid  elements 
diminish  in  cpiantity.  The  secretion  is  at  times  discolored  with  little 
masses  of  coagulated  blood  or  streaks  of  free  blood.  The  laryngo- 
scopic  picture  obtained  in  tlu'  more  frecjuent  simple  acute  laryngitis 
differs  greatly  as  to  the  seat  of  the  inthunmation  and  tlie  degree  of 
its  intensity.  The  whole  nmcous  meml)rane  of  the  larynx  may  vary 
from  a  pinkish  red  to  a  most  intense  scarlet  red,  and  the  vocal  cords 
may  participate  in  this  inHannnation  in  the  same  degree  as  the  rest 
of  the  nmcous  membrane  or  appear  only  slightly  discolored.  Again 
the  vocal  bands  may  show  vivid  redne-s,  while  "the  remainder  of  the 
larynx  is  only  moderately  intiamed,  or  they  may  show  only  an  intense 
red  line  of  inHannnation  along  their  free  borders,  while" the  rest  of 
the  cords  appear  normal.  The  superior  surface  of  the  cords  may 
show  areas  of  epithelial  deimilation,  and  this  condition  may  be  mani- 
fest on  the  surface  of  the  fals(>  cords,  aryepiglottidean  folds,  and 
lateral  walls  of  the  larynx— superficial  ulcerations.  These  surfaces 
are  said  to  give  rise  to  iKvnorrhage.  There  may  be  swelling  in  the 
interarj'tenoid  region  preventing  the  coaptation  of  the  cords,  while 
intiltration  in  the  muscles  themselver*  may  bring  about  the  same 
condition.  The  arytenoid  region  as  well  as  the  aryepiglottidean  folds 
may  not  only  be  deeply  congested,  but  also  (pdematous. 

Rheumatic  Laryngitis.  Hheum;itic  or  gouty  laryngitis  is  that  ty])e 
of  laryngitis  that  occurs  after  exposure  in  one  who  is  of  the  gouty 
or  rheumatic  diathesis.  It  differs  only  from  the  simple  acute  laryn- 
giti;*  ill  that  the  predisposing  cause  is  the  (iresence  in  the  circulation 
of  irritating  materials,  which  are  being  formed  in  excess  or  are  not 
being  excreted  in  normal  (piantities.  In  this  form  of  laryngitis  the 
throat  .soreness  and  pain  o:;  speaking  are  very  inten.'<e  and  more 
pronounced  than  in  the  simple  variety.  The  throat  soreness  is  in- 
creaseil  during  deglutition,  and  there  is  marked  tenderness  on  pressure. 
The  voice  is  usually  very  hoarse  and  often  aphonic.  The  p;itient 
is  depressed,  with  gre.at  lassitude.  There  is  a  marked  indisposition 
to  work  and  to  m;d<e  :iny  conlimious  nient;il  effort.  The  jjatieiit 
grows  extremely  anxious  as  to  his  condition.  There  is  an  almost 
constant  nervous  clearing  of  the  throat.  The  laryngoscopic  picture 
iiuws  a  slightly  more  jiunctated  condition  of  iiitlannnation  tlmn 
in  the  simple  Ijuyngitis.     There  is  p;iiii  on  p;ilpation  over  the  larynx. 

Laryngitis  sicca  acuta  is  ;i  sp<'cial  tyiw  of  l.-iryngitis  which  is  cliar- 
actei-izeil  by  the  peculiar  tendency  wjiich  the  .secretion  has  to  form 
gr,'iyi-ii-wliirc  III  |iiip\Mii>ii  cnists.  The  milainmation  is  tnore  intense 
in   the  cordal   and  subcordal   region.     The  crusts,   which  form  on 


[M.ATt-:    XX  IV 


F-K. 


T  y|Pf-.  I.I    A.  uu-  CaUiMh; 


il    L.:n\  iKjm 


ATH   XX\' 


n 


1-  ,,|       1        A.    I.I.-     c    .,1,11  1  l..ii       I    .11  \  il.irn-  i    i.|       .-■        I  1,'in.  .M  h.,.|  1    ..I  \  ll.|ltl~ 

1-,,|        H         (,,.,l.l.il      1     I     r..ii..  1    .nvn.nt!-      sv  :  I  i  i        (':.■    ii\.|.- .      -t       M.-       lill.Mli.il 

..\IM,    I--|,....-         M.|       i        P.,.    Ii^,|.-|  |,M..     1    .1.  V  i.,li- 


IMLAMM.ITOHY  DISEAHES  OF  THE  Ul'Pi      MR  I'AHiiAUES.    813 

a.rount  ..f  tlic  .lotifioiu}  in  watery  clomonts  in  the  socrotion   a.lluTO 
„i,itc  liniilv  to  tlu'  c.nls,  intcnirytciioi.l  r("};i..iis,  iMi.l  to  the  suln-on  al 
,;,„tioMs  ..}■  tin-  larvnx.    Tlu-  c.nls  ar.>  usually  not  very  niarkc.  y 
intlamcl,  althoufih  the  intorarytcnoi.l  aii.l  subconlal  irjiions  trcqufntly 
slu.w   coiisidc'ral)!.-   iractivc   chanp's.     Tl.o   voice   is   usually   quite 
aDlionie  wiieii  the  patient  awakens  in  the  iiiorniiig,  l.ecoining  almost 
n'.nnal  as  the  crusts  are  removed  by  rasping  and  e.)U<,dimK.  to  become 
.'laduallv  hoarser  or  aphonic  within  a  few  hours  as  tlu'  -nists  relorm. 
(■•ou-diink  is  verv  annoviug.  and  d(>pendent  uix.n  the  a  nount  of  ob- 
struction produce,!  I)v'tlie  incrustation;  the  breath.nr  may  b<  more 
or  less  impaired.     CoafTula  of  blood  may  be  occasionally  noted  m  the 
,.xp,.,-toration,  as  w.-l'  as  free  blood.     On  inspecti<.n  the  larynx  will 
|„.  „l,^,., ,,..!  to  l)e  sli^dltlv  redder,  the  vocal  region  will  be  noted  to 
|„,  „u„v  or  less  covered  with  grayish-white  or  l)r.Ayiiish  crusts   and 
ti„.  same  condition  will  be  obs.-rved  in  the  subcordal  region.     This 
(undition  is  observed  more  fre<iuently  among  females,  and  especially 
ai,„,iig  those  wli(.  suffer  with  atroi)hic  changes  m  thr  nose,     llie 
condition  resolves  within  a  few  days  or  passes  into  the  chronic  stage. 
Laryngitis  Hiemorrhagica.      (I'late  .\X\„  Fig.  2.)      This  condition 
cm  hardlv  be  classified  as  an  in<lividual  form  of  laryngitis,  as  1  con- 
sider it  simply  as  an  incident  in  certain  degrees  of  mHammatioii  of  the 
i-,ivn\      In  the  laryngitis  sicca  during  the  separation  ol  the  crust 
we'  may  have  a  littU'  denudation  of  the  epithelium,  with  slight  show- 
in-  of  l)lo.)d  or  coagula.     Also,  in  the  s(>vere  types  of  .«iinple   aryngitis 
where  there  is  localiz(>d  necrosis  and  d<-nud..tion  of  epithelu-m  with 
ll,c  superficial  reduction,  we  may  have  slight  bleeding.    Those  laryn- 
•n-il  inllammations  seenungly  attended  with  marked  bimlmg,  varying 
|,„,n  a  teaspoonful  or  more  of  free  blood,  are  not  m  my  opinion 
hemorrhages    from    the    larvng(>al    mucous    membrane,   but   rather 
blcMMJing  In.m  the  inilmonary  tissue.     Several  of  such  cases  winch  1 
have  had  und<-r  careful  ob.seryation  have  borne  out  my  expectation 
bv  disi)laving  at   a  later  period  unmistakable  signs  of  pulmonary 
tuluMculoiis      Tnless  there  is  a  l<.cal  lesion  in  the  larynx  sufficient  to 
account  for  the  amount  of  blood  lost,  I  should  advise  physical  exami- 
nation of  the  chest  and  bacteriological  study  of  the  sjuita  or  blood. 
Catarrhal  Epiglottitis,  or  Angina  Epiglottidea.     (Plate  X.\I\  .,  lig.  4.) 
This  yariety  of  laryngeal  inflammation  is  characteriz«>d  by  intense 
•  onp'stionof  the  epiglottis,  which  in  severe  types  of   mllainmatioii 
,,ccasionaIlv  shows  aivas   of    localized    .e.lema.     The  dilhculty   and 
pain   in   swallowing    in    inilamm;ition  of  the  epiglottis  is  the  most 

pronoun 1  and  ilistressing  symptom. 

We  note  also  a  profuse  secretion  of  mucus  and  the  sensation  of  the 
pivsence  of  a  foreism  body.  The  voice  is  only  a  little  rough  or  (piite 
normal.  Inspection  shows  the  ei)iglottis  somewhat  thickened  anl 
inleiiseiy  conii<>sted.  while  fre<ii!ently  along  its  tree  border  will  be 
note(l  little  areas  of  (edema. 

Laryngitis  Hypoglottica.  This  \ariely  of  laryngitis  is  ha|.].ily  not 
,1  very  common  tyjie  of  laryngeal  inflammation.     It  usually  com- 


814 


SOSE  A  XI)  Til  no  AT. 


il 


Fig.  416. 


moiicfs  with  the  syniptom.s  of  a  spvcre  acuto  laryngitis,  cli  iracterized 
b}'  iiiarisctl  (listurl)aiir('  of  tliu  voice,  severe  couj^h,  ami  iinpainiient 
of  tiie  respiration.  The  interference  with  free  respiration  speedily 
becomes  tiie  most  pronounced  .symptom,  the  breathinj;  becoming 
more  and  more  involved,  the  stridor  being  both  in.spiratory  and  ex- 
piratory. This  stenosis  rarely  becomes  so  .severe  in  simple  laryngitis 
liyi)oglottica  in  the  adult  as  to  demand  operative  intervention.  The 
cough  is  decidedly  croupy  in  character.  In  childhood  the  condition 
is  indeed  a  much  more  serious  affair.  The  initial  symptoms  are  the 
same  as  in  the  adult,  although,  on  account  of  the  relatively  .smaller 
calibre  of  the  child's  larynx,  the  symptoms  of  sten"-!is  are  more  rapid 
in  their  developtnent.  The  stenosis  is  charact'  izetl  by  laryngeal 
stridor  which  is  both  inspiratory  and  expiratory,  by  intense  dyspiuKa, 
marked  cvanosis,  and  extreme  anxiety.  The  pul.se  become-s  rapid 
and  thready  and  the  whole  appearance  is  that  of  a  child  with  laryngeal 
diphtheria.  The  .stenosis  is  followed  after  a  tinu;  by  gradual  relaxa- 
tion and  recovery,  or  becoming  more  intense,  unless  relieved  by  tra- 
cheotomy or  intubation,  terminates  in  death 
through  asphyxia.  The  laryngoscopic  investi- 
gation of  laryngitis  hypoglottica  shows  the 
upper  and  midille  regions  of  the  larynx  entirely 
free  or  only  moderately  inflamed,  while  the  vocal 
cords  may  be  moderately  injected  or  show  no 
change. 

It  is  entirely  in  the  subcordal  region  of  the  larynx 
that  the  pathological  changes  are  noted.  \'\mn 
deep  respirati(Hi  two  deeply  congested  immobile 
swellings  will  be  noted  just  lx>low  the  vocal 
bands,  nearly  filling  up  the  lumen  of  the  larv'nx.  From  the  sul?- 
jective  symptoms  alone  it  is  rxtremely  difficult  to  differentiate  the 
condition  from  laryngeal  (edema,  laryngeal  diphtheria,  and  other 
conditions  giving  rise  to  stenosis.  In  the  adult  the  ditTerentiation 
from  periclKmdritisard  (edema  is  somewhat  difficult.  In  children, 
v.-here  the  laryngoscopic  picture  is  difficult  to  obtain,  the  difT(>rentiation 
betwfM-n  diphtheria  and  hypoglottic  inf"  immation  is  at  times  ex- 
tr(>rnely  difficult.  The  differentiation  can  only  lie  made  positive 
through  the  laryngeal  mirror  showing  the  characteristic  hypoglottic 
swelling  or  the  false  membrane  and  the  results  of  bacteriological 
examination.  I  have  long  .«ince  been  of  the  opinion  that  in  many  of 
those  cases  in  children  wherein  we  have  api)arently  laryngeal  diph- 
theria, and  in  which  cultures  show  the  non-existence  of  the  Klehs- 
Loeffler  bacillus  we  have  this  condition  pre.sent. 

Acute  Laryngitis  in  Childhood.  Pseudocroup.  In  children  where  the 
inflammation  involves  only  the  supracordal  portion  of  the  larynx. 
we  have  a  train  of  symptoms  identical  with  those  that  occur  in  the 
.adult  with  the  sntite  <li<i<^as<>.  There  is  hoarseness  of  the  voice,  a 
high,  metallic.  Iaryng(>al  cough,  and  a  slight  stridor  in  breathing  at 
night.     .At  other  tinu>s,  and  always  in  children  of  a  strumous  type, 


Laryngitis  hypertro- 
phies acuta  in  a  child 
live  years  old. 


lyFLAMM.iTORY  DISEASES  OF  THE  Ul'l'Ell  AIU  PASSAdES.    815 


the  laryngeal  affoction  assumes  a  more  serious  phase  and  is  charac- 
terized by  nocturnal  paroxysms  of  intense  dyspncua.  In  this  form, 
which  is  conmionly  desij^nated  iis  false  croup,  tiie  child  during  the 
first  day  or  so  may  manifest  the  usual  symptoms  of  a  cold  with  slight 
hoars'  less,  a  metallic  cough,  and  a  mild  febrile  disturbance.  Tliey 
dispiav  during  the  day  their  usual  brightness  of  spirit,  showing  no 
premonition  of  the  impending  disturbance  whi( '.  may  occur  during 
the  night.  On  th(>  tirst  or  second  night  after  first  displayuig  an  irri- 
tation of  the  upper  air-tract  the  attack  of  paroxysmal  ditticult  breath- 
ing manifests  iti-elf.  After  a  <iuiet  sleep  varying  from  one  to  several 
hours,  the  little  one's  respiration  will  become  audible  with  a  slight 
res|)iratory  str  dor.  After  this  condition  lasts  for  u  few  moments  the 
child  becomes  restless  and  is  at  last  awakened  by  tlie  inter  se  desire 
for  air,  with  a  high-pitched  respiratory  stridor.  The  breathing  be- 
comes exceedingly  embarrassed,  the  stridor  more  marked,  the  cough 
sharj)  and  shrill,  the  face  anxious  and  cyanosed,  the  pulse  rapid,  and 
the  fact>  and  head  bedewed  with  perspiration.  After  a  few  moments 
tiie  paroxysm  relaxes  slightly,  the  breathing  becomes  easier,  though 
.still  audible,  and  the  voice  clearer.  In  from  fifteen  minutes  to  an 
hour  the  relaxation  is  complete  and  the  littie  one  falls  into  a  quiet 
slumber  which  may  continue  until  morning,  or  from  which  it  may 
be  aroiised  by  another  paroxysm.  During  the  succeeding  day  the 
condition  is  about  the  same  as  the  day  preceding  the  paroxysms, 
although  the  patient  is  usually  "droopy,"  somewhat  hoarser,  and  the 
cough  more  frequent.  Paroxysms  may  occur  on  the  second  or  third 
night,  or  the  attack  may  resolve  after  the  first  or  second  nocturnal 
])aroxysm.  The  laryngeal  picture  in  pseudocroup  is  difficult  to 
obtain  at  the  time  or  immediately  after  the  p.'iroxysm  of  difficul* 
breathing,  on  account  of  the  tender  age  of  the  patient.  Stiirk,  Mol- 
denhaur,  Dehio,  Rauchfuss,  Krieg,  and  Rosenberg  claim  that  the 
disturbance  is  due  to  a  subcordal  swelling  of  the  nmcous  membrane 
of  the  larynx,  practically  a  laryngitis  hypoglottica  acuta.  (Jottstein, 
Schroetter,  Jurasz,  and  Schech  state  that  while  there  may  be  a  slight 
infiltration  of  the  nmcosa  they  cannot  believe  that  this  condition  is 
attended  with  the  swelling  which  is  present  in  laryngitis  hypoglottica. 
The  last  mentioned  observers  believe  the  nocturnal  paroxysms  to  be 
spastic  in  character,  excited  through  irritation  from  dried  .secretion. 
This  condition  can  be  differentiated  from  laryngeal  diphtheria  by 
mild  subjective  symptoms,  by  the  amelioration  of  the  syuiptoms 
during  the  daytime,  by  the  peculiar  nocturnal  paroxysms,  and  by 
the  history  of  previous  attacks,  while  in  diphtheria  we  have  the 
jicrsistence  of  the  .symptoms  with  a  progressive  increase  in  their 
^(•verity  rather  than  amelioration,  by  the  prostration,  and  through 
ili('  larytigeal  examinations  and  culture  results. 

The  diagnosis  of  laryngitis  can  be  frecpiently  made  without  any 
difficulty  through  the  objective  and  subjective  sym])toms  presented 
liy  the  patient,  but  the  seat  and  character  of  the  inflammation  can 
only  be  determined  through  inspection  by  means  of  the  laryngoscope. 


«16 


SOSE  AM)  TIlliOAT. 


At  tiiiK's  one  will  find  it  cxtrciiicly  diflicuit  to  examine  the  larynxes 
of  little  ones;  l)ut  care  and  patience  will  often  enahle  us  to  accom- 
plish wonders  even  with  them. 

Prognosis.  The  simple*  acute  laryngitis  usually  Rives  a  most  favorable 
prognosis.  I'nder  |)r(iper  treatment  and  can*  all  cases  should  resolve. 
Many  cases,  even  without  medical  attention,  within  a  lew  days  or  a 
week  make  a  complete  return  to  the  normal.  The  laryngitis  hypoglot- 
tica  }iiv<'~  rise  to  j^rave  anxiety,  and  in  children  it  may  Ik-  atten(le(| 
with  fatal  i.'^sue.  Due  care  must  be  exercis(>d  in  treating  these  con- 
ilitions  to  see  that  the  resolution  is  complete,  other\vise  they  lapse 
into  a  chronic  state. 

Treatment.  Prophylaxis  in  re'jard  to  proper  care  of  the  skin, 
bathing,  and  unnecessary  protection  to  the  neck,  should  be  thor- 
oughly in.stilled  into  patients.  Constitutional  treatment  as  directed 
in  aciite  coryza  is  often  efKcacious  in  breaking  or  lessening  the  .sever- 
ity of  an  acute  laryngitis,  liest  for  the  voice  is  ab.solutely  es.s«'ntial, 
and  should  be  insi.sted  upon  when  the  voice  is  at  all  changed.  When 
the  cough  is  annoying  it  can  be  allayed  by  the  administration  of 
codeia  in  O.O'.i  doses,  or  heroin  in  0.01  do.ses  every  four  or  six  hours. 
Often  administration  of  one-drop  do.ses  of  tincture  of  actmite  for 
every  half-hour  until  six  doses  are  taken  have  an  exceedingly  bene- 
ficial result.  Where  there  is  exce.s,sive  irritability  from  dryness  of 
the  larynx  the  0.01  grain  tablet  of  pilocarpine  acts  very  well.  Rest 
in  bed,  even  in  the  milder  cases,  brings  about  a  quicker  resolution, 
ail''  in  the  more  severe  cas(>s  is  to  be  insisted  upon.  The  bowels 
should  be  kept  well  open.  Cold  compresses  to  the  neck  should  1h' 
employed  when  nmch  soreness  and  discomfort  are  present.  When 
tlien>  is  congestion  and  swelling  of  the  epiglottis  and  arv'tenoids  and 
aryepiglottidean  folds  the  ingestion  of  milk  as  hot  as  can  be  borne 
gives  great  relief.  Instead  of  cold  applications,  counter-irritation  in 
the  form  of  mustard  pa.-^tes  or  tincture  of  iodine  applied  from  the 
upper  border  of  the  larynx  to  the  middle  of  the  sternum  gives  great 
relief.  The  diet  of  the  patient  is  to  be  regulated:  it  is  wise  to  ]mt 
them  on  a  liinite(l  li((uiil  diet.  The  temperature  of  the  room  should 
be  kept  at  a  medium  of  about  70°  F.,  and  it  is  well  to  keep  the 
atmosphere  moist  by  the  generation  of  steam,  especially  during  the 
early  stages  of  the  inflammation.  The  desired  effect  of  steam  can 
also  be  accomplish(>(l  by  the  inhalation  of  compound  tincture  ot 
l)enzoin,  of  which  a  teaspoonful  is  added  to  a  pint  of  boiling  water. 
The  use  of  oily  solutions  and  the  insufflation  of  powders  in  the  larynx 
are  thoroughly  bad,  and  I  am  sure  do  more  harm  than  good.  li 
mere  is  evident  constitutional  disturbance  present,  which  may  have 
some  inffu"nce  on  the  production  and  maintenance  of  the  laryngitn 
it  should  be  actively  treated.  Therefore  rheumatic  and  gouty  condi- 
tions, gastro-intestinal  disturbances,  syphilis,  acute  exanthemata, 
diseases  of  the  he.art,  etc.,  .'ihould  be  a!)propriately  looked  after 
\\  henever  the  laryngitis  is  due  to  irritation  from  dust,  chemicals,  etc., 
the  patient  should  be  removed  absolutely  from  these  sources  of  irri- 


ISFLAMMATOliY  DISEASES  OF  THE  UPPER  AIR  PASSAGES.    %n 


tatirin.  Local  tmitmont  forms  an  essential  featuro  in  the  relief  and 
restoration  of  many  eas«vs  of  laryngitis.  At  present  there  is  a  differ- 
ence of  opinion  as  to  the  b«'st  and  most  non-irritating  method  of 
mukiiiK  these  topical  applications.  Some  use  them  through  the 
medium  of  the  spray,  others  with  a  syriiige,  and  still  others  by  means 
of  the  laryngeal  applicator.  When  one  pos.s«'sses  the  necessarj'  skill 
and  the  extreme  nicety  of  manipulation  to  make  application  with 
<'xactiiess  and  gentleiie.-is  of  touch,  there  is  no  ((uestion  of  the  .su{X'- 
riority  of  din-ct  to[)ical  applications  over  the  spray  or  th(>  syringe. 
In  the  early  stages  of  acute  active  congestion,  (edema,  or  hypoglottic 
inliltration  the  use  of  a  few  drops  of  the  .^^olution  of  suprarenal  extract 
or  the  adrenalin,  repeated  once  or  twice  daily,  les.sens  greatly  the 
(ideiiia,  .swelling,  and  congestion  of  the  mucou:-"  membrane.  The  u.se 
of  alkaline  sprays  to  tl  nose,  pharynx,  and  larynx  should  not  be 
overlooked,  and  whenever  there  is  ol).structive  dlsea-se  of  the  na.'^al 
ihambers  present  appropriate  treatment  should  be  instituted  to 
relieve  it.  Topical  application  should  not  be  re.sorted  to  until  secre- 
tion is  established.  The  local  aj)plication  of  the  mineral  salts  is 
(Specially  etHcacious  in  bringing  about  resolution.  The  silver  salts, 
on  account  of  their  mild  astringent  and  germicidal  action,  are  the 
most  favored  lately,  especially  i)rotargol.  The  sulphate  and  chloride 
ot  zinc  are  also  used  to  meet  the  same  indications  in  1  to  .3  per  cent, 
solutions.  I  pn'fer  the  silver  salts  in  a  1  per  cent,  solution,  or  the 
pnitargol  in  1  fK-r  cent,  solution  applied  every  day.  Where  dys- 
plionia  is  a  very  (listr>'ssing  .symptom,  especially  li"  "tlie  patient  is  a 
public  speaker,  singer,  or  one  whose  vocation  requires  the  fre(iuent 
use  of  the  voice,  I  find  that  resolution  is  materially  aided  by  the  use 
of  the  continuous  current  applied  to  the  larynx.  In  the  acute  larj'n- 
!litis  of  children  care  should  be  exerci.sed  in  proper  clothing,  bathing, 
rciiulation  of  the  diet,  and  building  up  of  the  general  health.  These 
children  usually  flourish  under  the  administration  of  iron,  arsenic, 
.iiid  (■od-liver  oil.  When  acute  attacks  occur  the  child  should  be 
kept  in  a  well-warmed  room  in  which  .steam  is  admitted  or  lime  is 
;i!lnw(»d  to  .slack.  It  should  be  given  a  calomel  purge  in  small  divided 
ili)-;es.  Internally  it  should  be  given  one-(iuarter  drop  doses  of 
aconite  with  a  stinmlant  expectorant  every  two  hours,  as: 


Holt  recommends- 


siK  — Teaspoonful  evei^-  twenty  rain      s  until  improvement  taken  place. 

Internal  applications  in  the  form  of  .stinmlant  embrocations  ap- 
lilicd  to  the  chest  and  neck  act  very  well.  I  prefer  the  official  soaj) 
liniment  for  this  purpose.     When  the  paroxysm  of  difficult  breathing 

52 


Amnintiia;  limmidi, 

1.00 

Ainniniiiic  carbon, 

1  00 

Tinotiir.eaconlttl, 

.50 

(flycerinBE, 

8.00 

AquiE. 

ad    62.00 

Chloral. 

5.00 

Potassii  liniraidi, 

».00 

Amtnotii.i'  bromidi, 

30O 

.\i](ife(>innan]omi. 

fii.UO 

818 


XOSE  A.\D  Til  HO  AT 


Faulty  a|>|iriixiiimiiiiii  uf  the 
Vftcul  oord»4  HN  otti'it  nbHi'rv»1  la 
ohnmie    hypertrophiu    iHryiiKltls. 

|('OAKI.Er.< 


is  coiaiiiK  on,  as  iiidiciitod  by  tin-  stridulims  hrcafhiii)?,  if  the  litflo  one 
is  a\vai<«'nt'(l  ami  n'vcii  tlraujilits  of  wanii  milk  llu-  attacks  will  !)«•  con- 
siilcrahly  aiiH'lioratcd  if  not  itrokcn  up.  SlioiiM  stenosis  he  very  in- 
tciist'  it  may  In-  ncctssary  to  resort  to  intul)a;ioii.  In  laryngitis  liy|»o- 
^lotti(■a  the  jieiieral  plan  of  treatment  as  outlined  aiiove  should  l)e 
carrieil  out.  In  this  ea.-<e  the  adrenalin,  external  application  of  cold, 
and  depletion  \)\  tiie  bowels  are  especially  ellicacious.  The  us«'  (if 
a  s|)ray  of  a  1  i)er  cent,  solution  of  chloride  of  zinc  or  of  a  2  per  cent. 
solution  of  protarjrol  is  exceedingly  iH-neticial,  es|>ecially  when  taken 
in  with  ileep  inspirations.  Should  breathing  iM'come  markedly  em- 
barrassed it  will  Ix'  nece.s.sary  to  resort  to 
tracheotomy  or  intubation.  Local  applica- 
tion in  rheumatic  laryngitis  is  not  advisa- 

^ ^k  I  ^« V__        Chronic  Laryngitis.    Chronic  laiyngitis 
"^•*^^M  I  IBBkZ?rr-     is  a  chronic  intlammation  of  the  mucous 

membrane  characterized  by  alteration  in 
the  voice  and  tlu*  s<'cn'tion. 

Etiology.  Tiiere  is  no  doubt  that  the 
larger  proportion  of  c;i,ses  of  chronic  laryn- 
gitis are  due  to  fre(|uent  neglected  attacks 
of  acute  laryngitis  which,  through  the  im- 
perfect restoration  to  the  normal  condition,  leave  after  each  attack  a 
certain  amount  of  n^sidual  ctmgestion  and  inflammatitm  which,  added 
to  l)y  recurring  attacks,  terminates  in  pronounced  permanent  changes 
in  the  form  of  congestive  hyperplasia  or  hypertrophy.  ( )bstructive  di.s- 
pa.sps  of  the  nasal  chambers,  causing  mouth-breathing,  chronic  nasal 
catarrh,  di.sea.ses  of  the  nasal  sinuses,  and  chronic  changes  within  the 
na.sopharynx  are  all  pnxluctive  of  chronic  laryngeal  changes.  There  is 
no  doubt  that  changes  within  the  faucial  as  well  as  in  the  lingual  ton- 
sillar tis.sues  act  as  exciting  .uases.  Ofttimes  inflamma'  w  and  en- 
largement of  the  uvula  are  secondary  to  chronic  changes  in  me  pharynx 
or  larynx,  nevertheless  there  are  times  when  the  engorgement  and  en- 
largement of  the  u\ula  urecedes  the  laryngitis,  and  its  removal  aids 
materially  in  bringing  ^:  .out  resolution. "  The  i«<rsistent  and  ctmtinu- 
ous  misuse  of  the  voice,  and  the  effort  to  produce  artificially  a  singing 
voice  of  greater  range  than  the  individual  pos.se.s.ses,  is  frecpiently  fol- 
lowed by  chronic  laryngeal  changes.  This  is  observed  in  preachers. 
pul)lic  speakers,  street  criers,  singers,  actors,  and  indiscreet  young 
people  who  think  they  po.ssess  voices  of  great  merit.  Persistent  and 
continuous  exposure  to  an  atmosphere  wtiich  is  deleterious,  as  working 
in  rooms  surcharged  with  steam,  <lust.  lime,  or  human  emanations, 
excessive  use  of  the  voice  in  overheated  rooms,  and  injurious  habits, 
as  the  addictiim  to  the  excessiv"  u.se  of  condiments,  alcohol,  and 
tobacco,  are  all  conducive  to  the  production  of  chronic  laryngeal 
inflammation.  Most  of  the  acute  infectious  diseases  are  attended 
with  inore  or  less  laryngeal  involvomcnt  which,  if  not  brought  to 
resolution,  may  pa.«s  into  the  chronic  state;  the  chronic  infectious 


/\FLA.MMATOKr  Dt.SK.lSES  OF  TIIE  ll'I'EH  AlJi  l-ASSAdFU.    8iy 

<lis.-as.-s,  surl,  as  tulKTouIcsisan.l  sy,,},ilis,  ..ro  almost  always  att.-n.icd 
Willi  chinin,.  arytiKcal  iiillanirnatiuns.  I  n.i.si.l.  r  it  wisr  in  all  cl.n.iiic 
larynural  iiitlaminati..Ms  to  .■xarniii..  can-fullv  for  tiii..Ti'ulosis  and 
Mpliilis.  DiaLrtrs.  >:out,  and  ti.c  iithaiMJc  conditions  coexist  with 
j""l  a|.|.aivnily  Millncncc  tlu-  .•l.anjr.'s  which  p,  to  n.ak.^  m.  chronic 
laryn^ntis.  I',|,id,.nnc  nifiucnza,  from  its  marked  proncnc-s  to  attVct 
Ih"  upper  air-tract,  especially  the  larynx,  can  he  considered  an  a<-tivo 
lactor  III  causing  chronic  larviiKitis. 

Symptoms.     Ordinarily  thc^se  alTect.-d   with  chronic  Ijirvncitis  do 
not  comp  am  mud.  of  the  sul.jcctiv.-  sensations.     There  mav  l.<-  n.,t..d 
;i  sli^'lit  dryness  or  a  leelmjt  as  th(.uKh  .something  foni^n  were  in  the 
larynx  causing  the  patient  to  make  fre(|uent  and  nn.re  or  less  vioh'iit 
attenipt.s  to  clear  the  throat;  occa.«ionallv  there  is  dy.sphaeia      In 
son...  individuals  the  fre.,uent  clearinR  of  the  throat,  known  as  •'■hem- 
ming,    is  often  so  eoiitinuoas  and  fn-(iuent  a,^  to  hecomo  distn-ssinc 
an,|  ncrvo-lestroymK  to  tho.se  forced  toa.ssociate  with  one  so  atTectod 
It  IS  the  alteration  and  impairment  of  the  voi'r  that  are  most  dis- 
tressing to  the  {)atient.     Th(.  voice  varies  greatly  in  different  cases  as 
to  the  amount  of  change  present.     In  some  ca.ses  it  is  only  slightly 
alten'd  trom  time  to  time,  in  others  verv  hoarse,  and  still   ,gain  it 
may  he  entirely  aphonic.     The  voice  may  he  clear  on  arising  in  the 
niorning,  to  Ixcome  hoarse  as  it  is  subject  to  more  use:  or  tiie  reverse 
may  he  th<'  case,  that  is.  the  patient  awakens  very  hoarse  to  find 
that  within  a  short  time  the  voice  becomes  dear  and  .strong      In 
public  speakers  and  singers  the  ordinary  conversational  voice  may 
sliow  only  slight  alteration  f)r  no  change  whatever  from  the  normal 
.vet  when  such  a  jx^rson  attemj)ts  to  address  an  au<lience,  using  the 
voice  m  Its  higher  registers,  he  finds  that  the  muscles  quickly  tire 
he  becomes  conscious  of  an  irritation  and  a  tickling  in  the  larvnx' 
and  his  voice  either  l)reaks  or  becomes  weak,   hoarse,  and  c^ften 
aph<.mc.     The  efTort  if  {x-rsisted  in  is  followed  by  more  irritation 
which  is  often  attended  by  distressing  paroxv.sms' of  coughing      In 
singers  the  alteration  is  noticed  more  deci.lediv  than  in  others,  as  a 
more  .Idicate  and  intricate  functioning  of  the  larvnx  is  necessary 
tor  tli.>  production  of  the  singing  voice.     At  first  singers  notice  a  shor^- 
'■m"K  of  their  register,  that  is,  tne  inabilitv  to  sing  certain  m.tes  in 
'  !.■  upper  r(>gister  which  before  thev  could  .strike  with  ease      They 
■ilso  n;.te  th(>  (|uick  tiring  of  the  voice.     If  thev  do  not  take  timely 
naming,  and  still  {)ersist  in  singing,  the  voice  Womes  hoarse  after 
;-linrt  eftorts,  breaks,  and  many  notes  in  the  regi.ster  become  weaker 
n.e  attempt  to  force  the  mu^^cular  stmctures  under  unfavorable 
'-nditDns   pads  to  a  feeling  (,f  .soreness  or  even  actual  i)ain  in  the 
innx.     I  he  degree  of  hoarseness   is  dependent   upon   either  the 
"nount  of  inhltration  of  the  vocal  cords,  the  false  bands,  the  swdling 
ni  (he  arytenoid  region,  the  degree  of  paresis,  or  the  amount  of  .secre- 
'"ti.     ( f,ugh  IS  not  an  essential  feature  of  chronic  lar\-n<riti«  u^tiallv 
■uw  being  present  when,  through  exertion,  there  is  excited  an  irri- 
ation  m  the  larynx.    The  amount  of  secretion  varies  greatly     It  is 


«2<) 


SOSE  AXD  THROAT. 


usujilly  iiKMlcTuto  iiiul  is  tlirown  out  in  little  jK»arl-liko  iikwhom  or 
slirctl-iikt'  ^tramls  of  clear  mucus.  LaryiiRoscupic  itis|M'ctioii  shows 
tlic  laryiifjeal  nuicous  surface  swollen  and  conKesleil.  The  amount 
of  redness  and  swi'llinj;  is  subject  to  great  variation.  The  redness 
may  U*  as  intense  as  is  often  >)bs«'rved  in  the  most  acute  forms  of 
acute  laryngitis,  a  saturated  ri>d,  .s«'ldom,  however,  involving  the  whole 
mucous  surfac  Most  freijuerUly  it  varies  from  u  delicate  ros<'  tint 
to  a  dirty  grayish-red.  .\t  times  the  nmcosa  shows  a  dark  bluish- 
red  appearaiii-e,  with  enlargement  of  the  veins.  The  fal.se  cords, 
the  nuK'ous  membrane  over  the  arytenoids,  and  the  subglottic  region 
fre(|ueiitly  show  the  most  malK<>(l  congestive  changes,  as  is  evidenced 
by  the  murkrd  redness  of  these  parts.  The  vocal  bands  show  most 
frequently  a  slight  off-coloring,  a  sii;  '  ,inkish-gray  discoloration, 
again  a  want  of  lustn\  with  the  showing  it  several  transvers*-  mark- 
ings of  minute  capillaries,  and  still  aga.n  i  briglit-red  slight  linear 
injection  along  the  free  bonier  of  the  cords.  'I  hen'  is  usually  i.iore 
or  less  swelling  of  the  nnicous  membrane  dependent  upon  the  activity 
as  well  as  the  duration  of  the  chronic  laryngitis.  In  acute  laryngitis 
there  is  only  a  round-celled  intiltration,  whereas  in  chronic  laryngitis 
this  condition  has  passed  to  one  of  actual  hypertrophy.  This  liypcr- 
trophy  may  expend  its  force  on  one  of  the  layers,  or  may  affect  all  the 
layers  of  the  nmcosa.  The  epiglottis  is  frecpiently  thickened,  stiff. 
and  almost  innnobile,  while  tortuous  veins  are  noted  toward  its  ba.-^e. 
On  account  of  this  immobility  of  the  epiglottis  it  is  at  times  difficult 
to  obtain  an  insjx'ction  of  the  interior  of  the  larynx.  The  aryepi- 
gluttidean  folds  and  tin-  false  cords  .are  prone  to  hypertrophic  changes. 
The  swollen  false  bands  frequently  extend  to  the  middle  line,  coming 
in  conlact  during  jilionatinn  ;it  the  .'interior  ihird  or  throughout  their 
whole  length,  thus  obsiiiriiig  complett'ly  the  true  cords.  In  i-nst'  of 
only  a  partial  covering  of  the  true  bands  we  have  only  a  dampening 
of  the  voice.  Wlu'ii  the  cords  are  entirely  covered  by  the  false  bands 
i'XteiMliiig  comjiletely  to  the  middle  jine,  they  may  either  interfere 
with  llie  function  of  the  voice  by  preventing  the  cords  coming  into 
apposition,  or  may  take  the  place  of  the  true  cords  an<l  functionate 
for  them,  producing  a  raw  hoarse  voice.  Tlie  most  rrei[uent  changes 
are  observed,  however,  in  the  region  of  the  arytenoid,  either  along 
the  anterior  portion  or  in  the  interarytenuid  s{)ace  The  redness  and 
swelling  over  the  arytenoids  and  the  posterior  wall  are  always  nm- 
noiinced.  The  normal  delicate  outline  of  the  .'irvtenoid  is  lost  in  the 
infiltnition  which  takes  place  in  the  mucous  membrane  over  tin 
cartilage.  The  processus  vocalis  and  imniedintely  neighboring  por- 
tions of  the  vocal  bands  are  congested  and  soniewli.-it  thickened, 
while  the  interarvfenoid  region  is  not  only  congested,  bul  thrown 
into  irregular  folds,  indicating  a  piling  up  of  epithelial  cells  if  not  ai; 
actual  hypertrophy  of  the  papillary  and  .stibnmcous  layers.  The-' 
alterations  ,'ire  .'it  first  characterized  by  a  tired  sensation  in  thethroaf. 
witii  slight  hoarseness  on  speaking.  Slight  des(|uamation  of  the  epi 
thelinm  here  and    ''ere  on  the  mucous  .surface  gives  rise  to  catarrh:  1 


r\l  I.AMMATOHY  DISEASES  Of  THE  UPPER  Alii  PAssAUES. 


821 


ulnrs  whicli  usimlly  In-ill  kin<lly  with  or  witlmut  treatment.  The 
aiiK.iint  ul  se<Teliuii  is  Mlijjhtly  in  exeest*  of  the  normal,  and  may  he 
tliih,  fluid-like  in  character,  or  .show  u  tendency  t(»  form  in  crust.-*. 
a.ihiTiiiK  to  the  .xurface  of  the  coni  or  mucosji  in  the  subcordal  portion 
of  the  larynx.  On  ohservatioii  tin-  mucus  is  s<'e!i  in  little  ln-atl-iike 
forii.ations  a.lherin,;  to  the  upp«'r  surface  and  to  the  free  edjres  of 
the  cords,  simulating  very  clos«-ly  singers'  nodes,  while  at  other  times 
It  shows  in  very  tmi  irand-iike  forms  running  from  one  hand  to  the 
other,  r.-iresis  of  tiie  voc.il  hands  is  very  common  in  chronic  iaryn- 
jlitis,  showing  itself  most  frecjuently  in  tlu'  thyro-aryteiioidei  inte'rni 
and  tlie  tnuisversus. 

The  diagnosii  is  made  throuRh  the  examination  with  the  laryngo- 
sc(.|M',  and  thi.s.  with  the  usual  sulijective  and  characteristic  local 
ihaiifies,  should  ofTer  no  ol).stacle  to  its  n'coRniti((n.  Marked  con- 
jrisiioii  of  one  or  Loth  vocal  hands,  or  considerable  thickening  of 
the  same,  should  arous*'  the  suspicion  of  possible  constitutional  di.s- 
Uirb.inces.  as  of  tuln-tculosis  or  syphili.s.  .Marked  thickening  in  the 
interaryteiKiid  n'gion  or  about  the  processus  vocalis  may  warrant 
the  diaftnosis  of  pachydermia.  In  making  a  diagnosis  care  sh.)uld 
he  exercised  in  carefully  examining  the  nose,  na.sopharynx,  pharynx, 
and  '  ings  in  order  to  .show  the  iM)ssible  corelatioiLship  U'tween  dis- 
eaM'd  conditions  in  these  parts,  if  found,  and  the  laryngitis. 

PrognosU.  The  condition  under  consideration  is  uniier  ordinary 
circumstances  not  fraught  with  much  danger  to  the  average  indi- 
\iilua!  so  fur  as  his  loiigevity  is  concerned.  Laryngitis  of  this  type 
may  exist  for  years  without  showing  much  alteration,  except  that 
due  to  occasional  acute  exacerbations.  For  those  whose  vocations 
are  ile|M'ndent  on  the  use  of  the  voice,  this  condition  is  indeed  a 
MTi'  problem  and  its  relief  es.'^ential.  Ordinarily  a  thorough  appre- 
ciation of  the  factors  entering  into  its  etiology,  their  remcval,  and  a 
c.ireful  meeting  of  indications  will  usually  bVing  about  a  complete 
resolution.     The  courw  of  treatment  is  freiir  -ntly  a  prolonged  one. 

Treatment.  First  of  all,  a  thorough  appn'ciaiion  of  the  po.ssible 
•  tii'logic.al  factors  must  be  taken  into  wmsideration,  and  means  under- 
i.ikeii  to  rem  .ve  these  must  be  instituted  at  once.  If  there  is  disease 
"t  fh(  nose  f,  i-a.sopharynx,  such  as  hypcrtrofjhies,  di&v  ■ -e  of  the 
-iinises.  deHecied  .'X'ptum,  adenoids,  disea.sed  ton.siIs,  or  enlarged 
uvula  Irci^'-nent  should  l)e  adoptci!  to  restore  these  parts  to  the 
ncirnia!.  CdiL-^iitutional  conditions  which  may  have  an  influence  in 
inamtair.:!)^'  the  laryuf-itis  should  be  corrected,  and  habits  that  may 
prejuilice  i  ..provenieiit  should  he  broken  up.  Ofttimes  a  change  o'f 
'•lunate  from  the  s«"ishore  to  the  mountains  or  from  the  mountains 
'o  the  seashore  works  great  benefit.  A  few  months  s|.ent  at  o»'-  of 
'lie  well-conducted  sulphur  springs  where  a  rigid  regimen  is  caniivl 
ut  olfen  produces  extreme  benefit.  Great  care  should  be  e'r>rcised 
in  fh(>  use  of  the  voire.  SingefF.  actors,  and  public  sppakc^^  should 
"■  counst^led  to  abstain  from  the  u.«ie  of  the  voice  in  singing  or  in 
l"ud  .speakmg.     It  is  much  better  if  these  individuals  use  the  voice 


d^yW'.'wm^m^.' 


.-.K^-^T^-- 


822 


NOSE  AND  TimOA: 


as  little  as  pcissiblc,  and  then  in  a  whisjier.  Local  treatments  are  of 
value  only  in  that  they  supplement  ami  assist  the  restoration  to  th(> 
normal  after  the  removal  of  the  cause.  The  medicament  may  1k> 
ai)plied  throufih  the  medium  (if  the  syringe,  the  spray,  or  by  a  cotton 
covered  ajiplicator.  I'nless  one  possesses  the  necessary  manipulative 
dext(>rity  to  make  the  laryngeal  application  gently  and  accurately, 
it  is  much  better  for  the  operator  and  the  patient  to  make  use  of 
the  spray  or  the  syringe.  When  wishing  to  reach  the  supraglottic 
regions  in  the  use  of  the  spray  or  atomizer  it  is  best  for  the  patient 
to  have  the  tongue  held  out  well  and  at  the  same  time  to  sound  a 
high  note.  If  it  is  desirable  to  reach  the  subcordal  region  the  tongue 
should  be  held  well  forward  while  the  patient  makes  deep  insj)ira- 
tions  at  each  time  the  s])ray  or  solution  is  injected.  The  mineral 
astringents  are  far  preferable  for  local  use  to  th(>  veg<'table.  I  have 
no  hesitancy  in  de|)recating  the  use  of  powders  in  any  form  in  the 
larynx.  The  mineral  astringents  .should  be  used  in  acjueous  solution, 
and  these  |)rcferably  at  a  temperature  of  about  100°  F.  In  most 
text-books  the  astringents  are  recommended  in  too  strong  a  solution. 
Even  a  1  per  cent,  solution  of  silver  often  causes  considerable  smart- 
ing that  may  last  for  hours.  The  astringent  applications  or  .solu- 
tions for  spraying  that  I  ])refer  are:  ])rotargol,  I  per  cent,  solution; 
argenti  nitratis,  1  to  2  per  cent,  .solution;  zinci  chloridi,  0.5  to  1  per 
cent,  .solution;  zinc  sulphate,  1  to  3  per  cent,  solution.  The  above 
solutions  should  be  used  lo  more  frequently  than  every  other  day, 
and  one  may  be  interchanged  for  the  other  from  time  to  time  during 
th<'  treatment.  It  will  also  be  noted  that  as  the  case  j)rogres.ses  it 
will  be  necessary  to  increase  the  strength  of  the  particular  drug  which 
is  being  used.  Whenever  there  is  considerable  induration  ami  thick- 
ening of  tissues  against  whi<'h  there  is  desired  more  intense  action, 
I  prefer  eith(  the  use  of  puif  crystals  of  chromic  acid  or  the  galvano- 
cautery  burner. 

Laryngitis  Hjrpoglottica  Chronica.  This  form  of  laryngitis  is  char- 
acterized by  an  infiltration  of  the  mucosa  and  .submucosa  of  the 
subcordal  portion  of  the  larynx.  Laryngitis 
hypoglottica  is  not  a  very  connncii  affection. 
It  seems  to  Le  more  prevalent  in  Continental 
Europe,  and  especially  among  the  natives  of 
eastern  and  southeastern  l-lurope. 

Etiology.     It  is  said  to  be  due  to  ex])osure  to 
cold  and  to  follow  .severe  types  of  chronic  laryn- 
gitis,  and    from    unresolved   acute   hyjioglottic 
infiltrations.     It  is  more  freiiuently  .secondary 
to  constitutional  affections.       It  is  sometimes  a 
sefpiela  of  typhoid  fever:  it   may  be  secondary  to  pulmonary  tuber- 
culosis, or  a    local    manifestation  of   syphilis,   scrofula,    and   rhuio- 
scleroma. 

Symptoms.     The   thickening  and  rigidity  of  the    opiglotli.-  wiiirh 
fretjuently  coexist  with  subglottic  swelling  ofttimes  makes  e.xamina- 


Fl.i.  418. 


,>A^vfAi 


IXI'LAMMATORY  DISEASES  OF  THE  UPPER  AIR  PASSAGES.     823 

tioii  of  the  larj'nx  extremely  difficult.  The  voice  is  always  altered, 
markedly  hoarse,  or  complete  ai)honia  exists.  The  most  marked 
.symijtoni  is  the  difficulty  in  breathing.  The  interference  is  at  first 
only  noticeable  when  moving  al)out  and  making  exertion;  later  it 
becomes  more  intense,  so  that  it  is  pronounced  even  when  at  rest, 
and  is  attended  with  both  an  inspiratory  and  an  expiratory  stridor. 
.\t  night  the  breathing  is  freijuently  markedly  impaired,  and  when 
tough  secretion  collects  tlu>re  may  be  paroxy.sms  of  extreme  distress; 
as  time  passes  the  obstruction  becomes  greater  and  the  stenosis  more 
pronounced.  On  inspection  just  below  the  vocal  bands  two  reddish 
or  pinkish  maj.ses  extending  inward  and  obstructing  the  calibr>'  of 
the  larynx  are  observed.  These  mas.ses  may  nearl\-  meet  in  the  middle 
line,  allowing  only  a  very  small  space  through  which  air  gains  access 
to  the  lungs,  or  they  may  show  somewhat  of  a  cleft,  es})ecially  at  the 
posterior  border.  The  mobility  of  the  vocal  bands  is  usually  imi)aire(i 
Cougli  i'-  present,  and  is  fretjuently  of  an  extremely  distressing  tyix-. 

Diagnosis.  The  diagnosis  is  not  usually  difficult.  The  character- 
istic picture  seen  in  the  laryngoscope  is  almost  pathognomonic.  It 
must  be  differentiated  from  iM'richondritis  or  abscess,  from  both  of 
which  it  can  be  diagnosed  [jy  the  denseness  of  the  liypoglottic  swell- 
ing, the  freedom  from  high  fever,  and  the  absence  of  tenderness  on 
external  pressure. 

The  prognosis  is  uncertain  both  as  to  restoration  of  function  and 
as  to  lif(>.  Very  freipiently  the  ca,«e  terminates  fatally  unless  opera- 
tive intervention  is  carried  out.  Thn'e  of  such  ca.«es,  under  my  care, 
iliat  refused  the  benefit  of  oj>erative  relief  died  from  suffocation. 
Those  of  the  tuliercuiar  tj-pe  are  the  most  serious,  those  due  to  expo- 
sure and  sj'philis  are  the  most  favorable. 

Treatment.  Internal  treatment  should  be  administered  along  the 
line  of  the  con.stitutional  condition  which  seems  to  be  the  etiological 
factor.  In  doubtful  cases  it  seems  to  be  prudent  to  administer  the 
iodide  of  potash.  Those  who  have  had  great  exi)erience  in  treating 
tills  condition  advise,  when  the  embarrassment  to  breathing  is  not 
^ncat,  the  local  ai)plication  of  silver  in  caustic  solution,  scarification, 
and  the  ai)plication  of  the  galvanocaufery.  I  would  be  extremely 
cautious  in  advising  the  use  of  the  two  latter.  The  course  I  have 
usually  pin-sued  and  which  is  advised  by  Sokolowski  is  the  early 
piTrormance  of  tracheotomy,  laryngofissure,  and  excision  of  as  much 
of  the  hypertrophied  ti.'Jsue  as  possible.  After  tlie  healing  of  the 
Inryngofi.ssure  Schroetter's  bougies  are  used,  or,  as  I  prefer,  the  intu- 
bation tube,  until  the  space  is  sufficiently  dilated  to  jK-rmit  dispens- 
ing with  the  tracheotomy. tube,  .\fter  the  tracheal  tube  is  removed 
it  iu'comes  necessary  to  occasionally  introduce  the  bougies  or  intu- 
liation  tube  throughout  (piite  a  long  period. 

Chronic  Dry  Lar]mgitis.  This  is  a  form  of  chronic  laryngitis,  also 
••ailed  laryngitis  sicca,  which  is  characterized  by  a  secretion  deficient 
ill  wafer  elements,  which  .secretion  tends  to  ailhere  to  the  mucosa  and 
form  crusts. 


824 


NOSI-:  AND  THROAT. 


I  n 


Etiology.  This  form  of  laryngitis  frciniciitiy  ensues  after  ;i  nej;- 
lected  attack  of  acute  larynptis  sicca.  It  is  more  fre(iueiitly  tlie 
result  of  the  extensiim  of  the  atroj)hic  form  of  nasal  catarrh  anil 
atrophic  pharyngitis.  The  invoi\Mnent  of  the  larynx  is  not  always 
a  necessary  se((uence  of  the  advanced  form  of  atrophic  rhinitis,  for 
we  freijuently  find  very  old  atrophic  cases,  with  marked  ilestruction 
of  the  soft  tissues  in  the  nose  without  change  of  any  character  in 
the  larynx.  Nor  is  the  laryngitis  sicca  always  due  to  a  direct  exten- 
sion by  continuity  of  surface,  although  this  method  is  no  doubt  a 
fretpient  ini'thod  of  its  extension,  for  it  may  he  due  to  the  circulatory 
changes  produced  by  the  mechanical  irritation  of  an  atmosphere 
which  is  thoroughly  unfit  for  laryngeal  resjjiration — i.e.,  an  atmo- 
sphere clHlled  and  deficient  in  moisture.  Radical  operativ.>  work  in 
tilt!  luLsal  chambers,  ius  complete  turbinectomies,  results  in  producing 
this  condition.  I  have  seen  the  nu)st  e.xcjuisite  ca.ses  (tf  laryngitis 
sicca  produced  in  this  way.  The  condition  excited  is  a  change  in 
the  mucosa  and  the  submucos:i,  with  atrophy  of  the  glandular  hiyer 
leading  to  the  production  of  an  altered  secretion,  from  which  the 
mf)isture  is  further  reduced  by  the  inspired  air. 

Symptoms.  The  accumulation  of  secretion  takes  place  in  these 
ctises  chiefly  while  the  larynx  is  not  b'  ing  used  and  when  the  patient 
is  at  rest.  On  awakening  in  the  morning  the  larvnx  is  usually  quite 
choked  up  with  crusts,  which  become  loos(>n(<(l  with  the  restoration 
of  secretion.  This  usually  takes  ])lace  with  the  performance  of  the 
toilet  and  the  exercise  incident  thereto.  At  fin-^t  the  patient  is  (juite 
aphonic,  and  there  may  be  paroxysms  of  laryngeal  spasm  on  account 
of  the  separating  crusts  being  caught  between  and  irritating  the  vocal 
bands.  .\s  the  crusts  are  removed  the  voice  becomes  clearer  and 
may  become  almost  free  from  hoarseness,  to  remain  so  throughout 
the  day,  or  become  hoarse  again  after  a  .  w  hours,  due  to  fresh  crust 
formation,  clearing  uj)  again  with  the  c(;ughing  out  of  the  freshly 
formed  crusts.  In  other  cases  the  voice  remains  of  alternating 
degrees  of  hoarseness  and  aphonia  throughout  the  day,  depending 
upon  the  freedom  from  crusts  in  the  larynx.  Coughing  is  a  very 
persistent  symptom,  and  is  usually  very  distressing  at  night.  Violent 
clearing  of  the  throat  at  jjcriodic  intervals  is  also  present.  At 
night  thc-^"  ])atients  are  freciuently  aroused  by  an  embarrassed 
respiration  and  occasionally  by  paroxysmal  suffocative  attacks. 
The  secretions  resemble  very  nmch  those  produced  in  atrophic 
changes  in  the  nose  and  pharynx,  and  are  occasionally  streaked  with 
blooit. 

Kxamination  of  the  larynx  reveals  a  slightly  congested  or  ana'tnic 
larynx,  having  a  peculiar  glazed  appe.-irance.  with  grayish-white 
crusts  adhering  to  the  interarytenoid  region,  to  the  vocal  bands,  and 
the  subcordal  region. 

The  prognosis  is  not  very  favorable  to  a  restitution  to  the  normal. 
.\t  times  great  improvemeni  may  be  gained  and  great  comfort  U> 
the  patient  afforded. 


p-^:: 


fXFLAAnfATOnV  J ) IS i: ASKS  OF  THE  UPPKH  Alii  PASSAUKS.     825 

Treatment,  The  saiiic  line  of  trciitmciit  in  a  constitutional  way 
should  Ik>  instituted  as  I  iiavc  diiwtcd  in  atrophic  rhinitis:  the 
administration  of  tonics,  iron,  arsenic,  strychnine,  and  cod-liver  oil; 
tile  proper  care  of  the  skin,  hathiufr  and  clothinjj;  terjiin  hydrate, 
for  its  seemingly  six'citic  action  on  the  mucous  surface,  should  be 
administered  in  0.02  to  0.(M5  doses.  The  local  treatment  of  the  nose 
and  pharynx  when  diseased  should  not  be  nej^lected.  It  is  strongly 
advised  before  adopting  any  local  treatment  to  thoroughlv  cleanse 
ihe  laryngeal  nmcous  surface  (jf  all  crusts  and  secretions  by"  spraying 
with  an  alkaline  aseptic  solution.  .\s  a  slightly  stinnilan't  solution 
an.swering  the  same  purpose  one  may  use  a  solution  of  sulj)ho-carl)o- 
late  of  zinc,  0..30  to  the  litre  of  water.  I  wish  here  again  to  protest 
against  the  use  of  mentholated  oily  sprays  in  this  tyjM'  of  inflamma- 
tion. The  only  solutions  that  can  be  of  value  are  those  that  will  act 
as  active  stimulants  to  the  laryngeal  mucosa,  through  which  we  hope 
to  stimulate  the  activity  of  degenerat(>(l  glands.  Chief  amoi;g  the 
agents  which  we  use  fc-  this  purpose  are  chloride  of  zinc,  silver 
nitrate,  and  protargol  in  strengths  varying  from  1  to  3  i)er  cent. 

Pachydermia  Laryngis.  (Plate  .\X\'..  Vigs.  .'J,  4 :  also  Figs.  419,  420.) 
l'achy<lermia  laryngis  is  a  chronic  inflannnation  of  the  laryngeal 
mucous  membrane  which  may  involve  any  |)ortion  of  the  larynx,  but 
is  esp(|cially  jjrone  to  affect  those  portions  covered  normally  with 
liat  epithelium.  It  consists  ess(>ntially  in  a  proliferation  of  the 
ei)ithelial  and  papillary  layers,  \irchow  ably  described  this  condition 
ill  1S,S7,  and  thereby  aroused  the  interest  of  the  laryngological  world 
ill  its  existence.  Pachydermia  had  frequently  been  obser%-ed  by 
laryngologi.sts  before  this,  but  had  not  received  the  attention  and 
c  ireful  ilescript ion  that  it  did  during  the  year  1SS7. 

Etiology.  There  appears  to  be  a  universal  acceptance  of  the  idea 
tliat  pachydermia  is  most  freipiently  the  result  of  chronic  laryngitis, 
llic  overindulgence  of  spirituous  drinks,  and  the  excessive  use  of  to- 
liacco.  Schmidt  .seems  to  think  that  atrophic  rhinitis  and  j)haryiigitis 
arc  factors  through  the  cough  and  persistent  clearing  of  the  "throat 
excited  by  this  ecmdition.  Among  constitutional  conditions  may  be 
mentioned  tuberculosis  and  syphilis.  This  condition  is  more  prev- 
alent among  men  than  women,  and  is  more  frecpient  during  young 
adult  life.  The  infiltration  may  be  found  upon  any  portion  of  the 
larynx  where  normally  flat  epithelial  cells  are  present.  It  is  found 
most  fre(iuently  about  the  arytenoid  region,  that  is,  in  the  interary- 
teiioid  space,  or  on  the  inner  surface  of  the  arytenoid  cartilages,  and 
ujioii  the  i)rocessus  vocalis.  The  })achydernna  is  usually  flat,  and 
in;iy  be  more  or  less  diffuse  or  circumscribed. 

Symptoms.  The  symptoms  which  are  excited  by  the  presence  of 
l)achy(lerniia  vavx  greatly.  The  interference  with  no"rmal  function  con- 
>ists  in  alteration  of  the  voice,  difficulty  of  breathing  and  swallowing, 
riie  functions  are  afT(>cted  in  greater  or  less  degree,  according  to  the 
incadon  of  the  infiltration.  Where  the  growth  is  on  the  processus 
vocalis  or  on  the  posterior  wall  there  may  be  marked  hoarseness  to 


^ji. 


826 


yOSE  AM)  THROAT. 


compleU'  aphonia.  At  other  times,  with  pronounced  growth  on  the 
inner  wail  of  the  arytenoid,  on  aeeount  of  the  depression  formed  in 
one  of  tiie  two  growths,  tliere  may  be  only  a  very  moderate  change 
in  the  voice.  Freciiiently  patients  complain  of  a  feeling  of  fulness 
and  of  more  or  less  stiiTiiess  in  deglutition.  The  amount  of  difficulty 
in  lireathing  depends  upon  the  degree  of  interarytenoid  infiltratioii 
and  fixation  of  the  vocal  hands. 

On  inspection  th(>  ajtpearance  will  vary  according  to  the  region  of 
the  larynx  affected.  In  its  milder  forms  pachydermia  shows  itself 
in  a  slight,  irregular  bluish  or  grayish-white  wavy-like  elevation  of 
the  mucous  membrane  in  the  interarytenoid  regidii.  The  e])ithelial 
layer  seems  to  be  most  affected  in  tJiis  type.  The  same  milk-white 
or  bluish-white  lustreless  thickening  of  the  epithelial  layer  may  be 
observed  also  over  the  processus  vocalis.  In  this  latter  type  the 
swelling  over  the  vocal  processes  may  show  marked  increase  in  growth 
in  every  direction,  even  extending  on  to  the  true  cord,  formnig  a 
growth  from  1  to  2  nun.  in  length  to  O.o  to  1  mm.  in  width.     With 


Fio.  419. 


Fli).  4'JO. 


Flu.  aiii-Pachyilerniia  larynRis  affecting  Inner  surfaoe  of  Hrylenoids  iiml  prwcafus  vcx»Us. 
Fi(i.  41'U  — I'HihyiliTinia  laryngis  of  the  intemryteiioiil  region. 

this  increase  in  size  one  or  the  other  of  the  growths  shows  a  depres- 
sior  on  its  surface,  into  which  the  prominence  of  the  other  fits  more 
or  less  exactly.  In  the  arytenoid  region  ofttimes  the  infiltration  is 
very  great,  forming  prominent  round  or  irregularly  outlined  eleva- 
tions with  intervening  clefts  which  look  like  fissures;  these  are 
covered  with  hard  epitheliimi  which  h..s  a  snow-white,  a  grayish- 
white,  or  a  yellowish  ap|)(>arance. 

Diagnosis.  The  diagnosis  of  pachydermia  is  readily  mad(>  from  the 
characteristic  find  of  the  laryngoscope.  The  presence  of  the  thick- 
ening over  the  i)rocessus  vocalis  or  both  vocal  cords,  one  of  whii'li 
shows  the  peculiar  indentation  or  the  round,  irregular,  grayish-white 
.swelling  on  the  posterior  wall,  causes  one  to  think  almost  inmiediafely 
of  pachydermia.  It  is  difT(>rentiated  from  i)apiil,>;na  bv  the  fact  that 
pai)illomata  are  always  superficial.  Tlie  papilloma  is  very  feebly 
attached,  growing  only  from  the  ej)ithelial  surface,  while  the  diffuse 
pachydermia  is  very  Hrmly  attached,  and  retpiin^s  the  use  of  cuttinir 
forcei)s  to  detach  it.  The  jKipilloinata  also  have  the  chara>  .eristics 
of  new-growths,  while  l)achyd(  rmia  have  the  r.ppearance  of  hiflani- 


.■**^ 


L\FLAMMArOJiY  DISEASES  OF  THE  UPPER  AIR  PASSAGES.    «27 


inalury  .swellings.  When  pachych'rniia  uffects  the  cords  anterioi  to 
the  processas  vocalis  or  the  ventricle  of  Morgagni  it  is  extremely 
(lifHcult,  if  not  almost  impossible,  to  differentiate  it  from  cancer,  an<l 
lial)ility  to  error  is  not  entirely  avoided  by  microscopic  examination 
of  a  portion  of  the  removed  growth. 

The  prognosis  is  in  the  mild  ty|M'  of  cases  a  favorable  one.  Those 
due  to  simple  irritation  and  to  conditions  that  can  Im-  removed  offer 
a  very  favorable  prognosis.  Cases  after  a  sh(jrter  or  longer  jx-riod 
of  existence  occasionally  spontaneously  heal.  Such  a  spontaneous 
resolution  is  al.so  occasionally  seen  in  pachydermia  due  to  tubercular 
infection,  as  a  result  of  tlie  marked  improvement  in  the  general  con- 
dition. The  duration  of  the  condition,  however,  is  usually  a  pro- 
longed one.  extending  over  a  period  of  sotnetimes  many  years.  \\'ith 
a  due  consideration  of  the  causative  elements  and  the  proper  in.sti- 
tution  of  a*  )roi)riate  treatment  good  results  can  be  brought  about 
ill  a  fair  pr()i)ortion  of  cases,  and  in  many  the  arrest  of  further  exten- 
sion of  the  proliferation. 

Treatment.  For  all  types  of  the  pachydermia  the  treatment  should 
be  dir  -d  to  the  removal  of  the  cau.se,  systemic  and  local  sources 
of  irriti.tion,  and  the  improvement  of  the  general  health.  Many 
advise  the  administration  of  the  iodide  of  potash  in  small  doses. 
There  should  be  restriction  placed  upon  the  u.se  of  the  voice.  The 
local  treatment  of  any  coexisting  (lis(>a.se  of  the  no.se  or  pharynx 
shoulil  receive  most  thorough  attention,  as  well  as  the  chronic  inflam- 
malion  of  the  larynx.  This  i.s  all  that  is  necessary  in  th(<  majority 
of  mild  cases  presenting  themselves  for  treatment.  Locally  in  the 
more  pronounced  cases  of  infiltration  it  is  wi.se  to  make  local  appli- 
cations of  silver  nitrate  in  1  to  4  \wt  cent,  .solution,  or  of  .salicvlic 
acid  in  20  per  cent,  solution  of  alcohol.  The  galvanocaut(>ry  can"  be 
used  as  well  a.s  electrolysis  in  a  strength  of  10  to  12  milliam])eres 
applied  for  three  to  five  minutes.  If 
the  growths  are  pn)nounced  on  the 
inner  surface  of  the  arytenoid  and  are 
causing  marked  alteration  of  the  voice, 
it  is  well  to  resort  to  the  use  of  cutting 
forceps,  as  through  them  the  growtli 
can  be  removed  (|uickly  and  leave  a 
clean,  healthy  wound. 

Singers'  Nodes  or  Chorditis  Nodosa. 
A  sing(>r's  nodule  is  an  inflanunatory 
growth  situated  on  the  free  edge  of  the 
\'ocal  cord  at  the  junction  of  the  ante- 
rior and  middle  third.  These  growths 
may  be  single,  but  are  more  frequently 


Fig.  ai\. 


multiple,  being  situated  on  vocal  cords 
located  identir 


singers'  nodes 


'  opposite  each  other. 


This  condition  is  classed  ^-son.e  authors  with  parhydermia, 

veil  as  in  path-  logical  organization 


are  entirelv  dissimilar 


they 


828 


XOSK  A.\l>  rif  OAT. 


Etiology.  The  iiixlulo  is  more  frcciiiciit  in  youiiji  adult  life.  It  is 
fouiiil  iimrp  often  in  the  fctnalc  sex,  ami  is  far  inori'  ('(iMimon  anionji 
tli(i9(>  wiio  siiig(.r\vii()  arc  cuitivatiiifitlu'ir  voices.  The  most  eoimiion 
cause  for  the  existence  of  the  nochile  is  tlie  improper  use  of  the  voice 
eitiier  in  .s|)eakin<i;  or  sinjrin<;.  It  i.  in  the  pnuluction  of  the  tone 
tiiat  tlie  injur'-  is  ilone.  that  is.  tlie  stroke  or  impact  is  imperfectly 
placed,  so  that  attrition  between  the  sefjments  of  the  cords  is  possible. 
Tlie  attrition  so  |)ro(luce(l  sets  u|)  an  hiHunnnatory  irritation  which 
results  in  the  pnxluction  of  the  nodules.  The  greatest  injury  is  done 
in.  the  use  of  the  upper  middle  reu:ister.  The  condition  is  said  to 
:iri.s<>  during  attacks  of  acute  antl  i  iironic  laryngitis,  and  from  vocal 
fatigue. 

Symptoms.  The  nodule  is  usually  characterized  In*  more  or  less 
hoarseness  of  the  spoken  voice,  the  ilegree  of  the  hoarseness  de|)ending 
upon  the  situation  and  the  development  of  tiie  growth.  The  voice 
breaks  readily,  and  singers  are  unable  to  tix  tiie  tone  or  sing  with 
any  degree  of  certainty  as  to  jjitch  or  resonance.  The  patient  is 
unable  to  carry  out  any  prolonged  elfort  on  account  of  the  great 
laryngeal  fatigue  and  \)iiu\  entailed.  They  often  present  even  marked 
hoarseness  of  the  spoken  voice.  The  diagnosis  c;in  only  be  rendered 
clear  by  an  examination  of  the  vocal  cords.  The  singer's  nodes  are 
very  characteristic  and  sliould  not  be  mistaken  for  any  other  condi- 
tion. They  an-  situated  at  the  junction  of  the  anterior  and  middle 
third  of  the  vocal  cords,  and  apjiear  as  small  intensely  white  or  yel- 
l)wisli  i)in-like  points  on  the  free  border  of  the  vocal  cords.  They 
are  about  the  size  of  a  pin's  head,  sessile,  opa(|ue,  and  usually  sym- 
metrical bodies  placed  one  on  each  vocal  cord.  As  the  nodes  come 
in  apposition  they  cau.se  a  slight  cleft  between  tlie  cords. 

Diagnosis.  The  diagnosis  is  readily  made  from  the  subjective 
symptoms  and  the  laryngeal  examination.  It  is  possible  for  a  coujile 
of  ix-ads  of  mucus  vibrating  on  the  vocal  bands  to  be  mistaken  for 
vocal  nodes.  The  differentiation  can  always  bo  made  by  causing 
the  patient  to  clear  the  voice,  which  removes  the  mucus. 

The  prognosis  is  usually  favorable. 

Treatment.  The  most  important  feature  in  the  restoration  to  the 
normal  condition  in  chorditis  nodosa  is  the  correction  of  th(>  method 
of  singing.  .Most  sing(>rs  so  affected  are  those  given  to  the  clavicular 
method  of  breathing.  Thes(>  shoulil  be  taught  the  inferior  costal 
method  of  breathing  with  fixed  high  chest.  They  .should  be  placed 
in  the  hands  of  a  good  singing-master  who  can  instruct  tlicm  in  the 
|iroper  method  of  tone  placing.  ('om])lete  rest  from  singing  othi'r 
than  instructicms  given  should  be  insisted  upon.  Tliis  method  will 
usu.ally  in  a  short  time  bring  about  com])lete  n  .-solution.  Many 
authors  advise  the  use  of  a  2  per  cent,  solution  of  silver  nitrate,  while 
others  favor  stronger  solution.  It  is  also  advi.sed  to  cauterize  the 
nodes  with  solid  nitrate  of  silver,  chromic  .'icid,  and  the  galvano- 
cautery.    Others  advise  the  removal  of  the  nodes  with  cutting  forceps. 


iR'.W«{ 


CHAPTER    XIX. 

DIPirniERIA  OF  NOSE  AND  THROAT ;    INTUBATION ; 
SYPHILIS,  TUBERCULOSIS,  LUPUS  AND  LEPROSY 
OF  NOSE  AND  THROAT;   CHRONIC  LARYN- 
GEAL STENOSIS ;   FOREIGN  BODIES  IN 
NOSE  AND  THROAT ;  RHINOLITHS. 

Bv  WILLIAM  KELLY  SLMPSOX,  M.D. 

DIPHTHERIA  OF   THE  NOSE  AND   THROAT. 

Dii'HTiiKiUA  is  iui  aeuto  infectious  and  contaftious  disease,  recurring 
eiliier  endeinically  or  epideniieaily.  eiiaracterized  by  a  hi)rinous 
exudation  on  any  nuicous  surface  of  tiie  Ixxly  or  wound,  heing  de- 
lieiident  for  its  cause  on  the  al)sor|)tion  of  the  toxins  produced  by 
ihe  Klebs-Loeffler  i)aciilus.  Tlie  ])arts  most  freciuently  affected  are 
tlie  cavity  of  the  piiarynx,  and  less  frequently  the  larynx,  nose, 
nasoplunynx,  and  conjunctiva'. 

No  age  is  exempt,  although  it  is  most  particularly  a  disease  of 
childhood.  When  the  larynx  is  involved  there  is  a  decided  tendency 
toward  extension  to  the  brf«nchi 

The  lesi')n,  viz.:  the  diphtheritic  exudate,  is  the  .same  in  character- 
istics, both  in  the  nose  and  the  throat;  and  in  a  general  way  we  may 
consider  them  together.  The  .systemic  symptoms  are  also  about  the 
same.  Occurring  as  they  typically  do  in  children,  there  are  one  to 
lwo  days  wherein  they  are  slightly  ill,  gradually  becoming  worse, 
with  .-i  rise  of  temperature  and  acceleration  of  pulse  and  general  pro.s- 
tration.  until  they  show  a  localization  of  the  membrane  in  either  the 
iiiise  or  the  throat. 

The  Nasal  Tjrpe.  The  initial  symptoms  in  the  iiose  are  generally 
those  of  a  ,s(>vere  coryza,  existing  for  a  day  or  so,  with  nasal  discharge, 
which  soon  becomes  ichorous  in  character,  .swelling  of  the  mucous 
lui'inbraiie,  and  from  the  mechanical  presence  of  the  exudate  very 
Mioii  there  suix'rvenes  a  very  marked  na.sal  obstructum.  As  a  rule, 
this  nasal  obstruction  is  bilateral,  and  from  the  character  of  the  secre- 
lioiis  the  exterior  of  the  nostrils  is  very  liable  to  l)ecome  acutely  ex- 
coriated, imlicating  a  more  or  less  grave  intrana.sal  inflammation. 
Ilxamination  of  the  no.se  will  reveal  more  or  less  of  a  grayish-white 
membrane  ([uite  well  anteriorly,  and  often  that  is  ail  that  can  be  seen. 
as  the  intranasal  obstruction  prevents  any  der>per  examination  of  the 
nose.     The  exudation  may  be  evenly  ilistributed  over  the  entire 


fti. 


"iC/'-t-l 


8;J0 


yost:  Axi)  Til  no  AT. 


iiitrniiasal  imicuus  ii»«inl)r;iiu«,  sliowiiiK  lui  spci-ial  point  of  sclcctioii, 
and  is  practically  always  bilateral. 

As  a  rule,  the CMnlatidii  extends  well  liack  into  the  nose  and  naso- 
pliaryn<;eal  cavity,  and  il'  it  he  possible  to  make  a  posterior  nasal 
examination  we  will  lind  the  nasopharynfjeal  cavity  cnverecl  with  an 
exutl.Mie  similar  to  that  in  the  anterior  nares.  In  the  more  acute  type 
of  cases  the  cliild  by  this  time  Im-comk-s  .|uit«!  ill,  witii  more  or  less 
j>landiilar  swelliiifi  in  the  cervical  refjioii.  In  a  certain  mimber  of 
cases  tiie  membrane  may  extend  to  tiie  pharynx  below,  and  even  to 
the  larynx,  |)resenlinfr  all  the  symptoms  of  a  jjeneral  diphtheria,  liut 
this  is'not  always  the  case,  for  I  am  led  to  believe  by  an  extensive 
observation  that"  the  nasal  and  n:isoi)harynj;eal  exudation  may  Ix'conio 
limited,  and  does  not  of  necessity  si)read  to  the  jjharynx  nelow,  and 
we  may  have  a  purely  nasal  or  nasoi)harynp;eal  diphtheria  in  a  class 
by  itsoif.  .\lthoufrh,  :us  a  rule,  na.sal  and"  nasopliarynpvil  diphtheria 
runs  a  more  or  less  acute  course,  the  nature  of  the  trou!)le  becomin}; 
very  evident  from  the  outset,  there  are  a  certain  number  of  cases, 
especially  where  the  membrane  is  localized  in  the  nose,  which  are 
very  slow  in  development,  the  child  not  becomin.n  ill  anil  the  intra- 
nasal exudate  remaining  a  loiifj  while  in  a  latent  condition,  apparently 
without  very  much  constitutional  manifestation  on  the  i)art  of  the 

child.  "  .    . 

I  have  known  of  a  number  of  instances  of  na.sal  diphtheria  existmg 
for  a  number  of  weeks  without  giving  rise  to  very  severe  sym{)toms, 
the  exudation  being  present  in  a  greater  or  less  degree  the  entire 
time,  together  with  the  Klebs-LoefHer  bacilli.  The  severity  of  tlie 
constitutional  symptoms  seems  to  vary  in  different  ca.ses,  and  I  have 
often  been  iinim'ssed  with  the  mildness  of  the  constitutional  .'ymp- 
toins  when  compared  with  the  amount  of  membrane  which  existed 
in  th(>  nose  and  the  nasopharynx,  wliich  would  seem  to  indicate  in  a 
certain  proportion  of  cases  that  when  limited  to  the  nose  and  the 
nasopharynx  there  exists  a  certain  immunity  from  absorption  into 
the  general  system  This  may  be  somewhat  contrary  to  the  general 
belic'^f.  but  we  often  .see  it  illustrated  by  the  little  patients  who  freiiuent 
our  various  clinics 

Diagnosis.  The  diagnosis  of  nasal  diphtheria,  aside  from  the  pres- 
ence of  the  Ktebs-I.oeliler  bacillus,  of  which  we  will  speak  later,  is 
surmised  by  the  finding  of  a  membrane  in  the  anterior  nares,  and  in 
arriving  atOur  conclusions  as  to  the  ])resence  of  the  ineml)rane  we 
must  be  sure  not  to  confound  an  exmlation  with  inspissatecl  mucus 
or  dense  mucopurulent  discharge,  which  often  exists  in  severe  cases 
of  coryza,  and  which  is  difficult  of  exjmlsion.  The  best  way  of  arriving 
at  a  positive  conclusion  as  to  the  presence  of  membrane  in  the  anterior 
nares  is.  after  thorough  cleansing  by  a  pledget  of  cotton,  to  try  to 
dislodge  th(>  suspected  exudate  from  the  mucous  membrane  beneath, 
when  we  will  find,  if  it  l)e  an  exudat(>,  it  will  be  sonu'what  difficult 
to  dislodge,  and  will  leave  a  bleeding  surface  beneath;  and  if  it  be 
considerable  in  extent  a  (luitc  well-marked  epistaxis  may  be  induced. 


^F-«r 


^mi 


DirilTllKJilA  OF  THE  SOSE  ASD  THROAT. 


■S.Jl 


Hut  tlic  most  |)<)siliv(>  moans  of  diagnosis,  in  fact  the  only  rcliahic 
means  of  dctcrmininj;  wlii'tlicr  the  exudate  lie  (li|ilitli»"ritic'or  not  is 
l)y  takiiifja  ciiltmc,  wlicii  tlif  |nvscnccoral)scnc('of  tiic  Kicbs-LocHlcr 
liacilltiswiilsiihstantiatc  tliccliaractcrof  tlicfxudatc. 

It  has  l.,'('n  my  cxixTicncc  in  tlic  cxaminatiun  of  a  ^rvnX  many  cases 
<if  mcml)ranf  in  the  nose  and  nasopharynx  t<>  find  the  Klchs-LocHlcr 
hacilhis  prcs^'nt  in  by  far  the  Krcatcr "proportion  of  i-ascs,  Imwcvcr 
Iniij;  standing  tiny  may  have  been,  or  liowcvcr  insifrnilicant  the 
symi)toms,  Icadiii);  me  to  believe  that  nearly  all  cases  of  so-called 
membranons  rhinitis  are  of  a  true  diphtheritic  nature,  and  shouhl 
be  viewed  as  true  (Hi)htheria.  doing  away  with  the  term  memi)ranous 
rhinitis,  wliich  Ls  so  constantly  used,  and  is  misleading,  and.  also, 
thereby  illustrating,'  the  absolute  necessity  of  making  a  bacteriological 
examination  in  all  cases. 

Differential  Diagnosis,  The  conditions  to  Im'  confounded  with  nasal 
diphtheria  are  .severe  coryza,  foreign  bodies  in  the  no.se.  and  the 
sloughing  of  traumatisms.  The  first  can  Ix-  excluded  bv  the  ab.^.  ice 
ot  membrane  after  repeated  examinations  and  the  siib,se(|uent  C(  rse 
of  th(>  disease.  The  main  point  of  differentiation  from  foreign  Ixxlies, 
which  often  produce  a  sloughing  membrane  and  ichorous  discharge^ 
is  that  foreign  bodies  are  as  a  rule  unilateral,  whereas  diphtheria  is 
bilateral,  and  a  mechanical  examination  by  means  of  a  i)robe  will 
ill  the  case  of  foreign  bodies  detect  their  presence.  Traumatisms  are 
to  be  determined  by  the  hi.story  of  their  reception. 

The  Pharyngeal  or  Faucial  Type.  Pharyngeal  dijjhtheria,  or 
diphllwrm,  !is  we  generally  use  the  term  in  a  generic  sen.se,  is  ushered  in 
by  more  or  less  constitutional  symptoms  of  nialai.se,  rather  gradual 
111  their  ons(>t,  which  may  extend  over  a  j)erio(l  of  a  few  days  before 
the  jiatient  makes  a  special  reference  to  the  throat. 

The  temperature  in  this  initial  stage  may  become  quite  elevated, 
the  pulse  accelerated,  and  as  the  .symptoms  progress  it  soon  becomes 
evKlent  that  the  patient  is  .suffering  from  some  constitutional  ab-sorp- 
tioii.  The  first  symptoms  as  a  rule  referable  to  the  throat  are  those 
nt  painful  or  difficult  deglutition,  when  examination  reveals  the 
presence  of  a  membrane  or  exudate. 

rh(>  diphtheritic  membrane  when  seen  in  the  early  .stages  appears 
111  the  form  of  a  .small  whiti.sh  patch  which  mav  have  its  origin  in 
any  portion  of  the  faucial  region.  It  is  generallv  thin  at  fir.st,  and 
IS  It  progres.se.s  in  extent  becomes  thicker  and  heavier  in  its  charac- 
''•risiK's,  changing  to  a  duller  or  grayer  color,  with  sometimes  a  dark 
-oughmg  cigo,  and  from  a  small  origin  mav  spreatl  to  cover  the 
"lit ire  faucial  area. 

The  spreading  and  rapi«l  confluence  of  the  membrane  in  the  ma- 

i'lity  of  cases  are  (piite  characteristic  features,  and  ;us  the  })rocess 

Aieii.ls  the  exudate  takes  upon  itself  the  appearance  of  an  organized 

'eini)rane  or  a  true  necrotic  proce.ss,  and  if  detached  bv  anv  mechani- 

il  means  it  will  be  found  quite  adherent  to  the  underlying  tissue, 

■avmg,  as  a  rule,  a  bleeding  surface. 


HJ2 


SUSE  A.W  Til  HO  AT. 


Location  of  the  Membrane.  Tlii>rc  is  no  siMTial  sont  fur  the  itiitial 
loi'utiim  of  the  iiu'iul)raiic,  luit  m-iuTally  it  iiiakcs  its  apiM-arann-  first 
(III  tlu'  tonsil,  ami  spreads  ijuitc  rapidly  to  tlic  adjaci-iU  tissues,  and 
as  a  ruh-  is  bilateral.  Tlie  tonsils  themselves  may  or  may  not  1m'(  .ime 
eonsiderahly  enlarged :  that  will  dejM'nd  somewhat  upon  their  ])revious 
eondition.  In  seven-  eases  as  the  disease  progn's^'s  then'  is  gener- 
ally a  very  stmng  odor,  whieh  is  considered  hy  some  to  Ix'  eharae- 
teristie,  and  then-  is  freijuently  assoeiated  with  the  faueial  eonditions 
a  swelling  of  the  adjacent  lym|)li  glands  of  the  neck.  Aside  fmni 
the  |)n'sence  of  the  exudate  then-  is  al.so  mon-  or  less  marked  fauciai 
n-dness  or  hypera-mia,  Hiving  a  general  angry  ap|K'arance. 

Differential  Diagnosis.  The  main  condition  to  Ix*  differentiated  fnuii 
diphtheria  is  acute  confluent  follicular  tonsillitis.  The  main  clinical 
points  of  dilTen'iice  lietween  these  coiiilitions  an-  that  in  acute  follicular 
tonsilliMs  the  ons<'t  is  more  sudden,  the  exudate  is  nuicli  more  friahlc. 
not  a  true  menihrane,  less  confluent,  more  punctate  in  character, 
and  the  tonsils  usually  mon*  swollen  and  the  exudate  limit<'d  to  the 
tonsils  jilone,  whereas  in  di|)htheria  the  characteristics  an'  confiuency 
and  density  of  the  exuilate,  and  not  being  necessarily  limited  to  the 
tonsils.  It  may  he  said  in  general  that  any  exudate  not  limited  to 
the  tonsils  may  be  considered  as  a  strong  point  in  favor  of  diphtheria. 
Sometimes  we  are  called  u|)on  to  differentiate  Ix'tween  diphtheria 
and  the  mucous  patches  of  secondary  syphilis,  and  the  ulceration 
which  attends  the  early  m.anifestation  of  tertiary  syi)hilis.  the  results 
of  caustic  applications,  swallowing  of  irritant  poisons,  traumatisms, 
and  the  exudate  following  operations  within  the  cavity  of  the  fauces. 
I  ;im  becoming  mon'  and  more  convinced,  however,  especially  when 
ditfen-ntiating  tVom  confluent  follicular  ton.sillitis,  not  to  n-ly  on  the 
clinical  pictun',  but  always  to  insist  on  making  a  culture,  deciding  the 
diagnosis  on  the  presence  or  ab.sence  of  the;  Klebs-LoefHer  bacillus, 
which  is  the  only  true  way  of  differentiation.  Kspecially  is  this  tin- 
more  important  in  mild  and  not  well-defined  cases. 

Laryngeal  Tjrpe.  The  i.-ryngeal  type  of  diphlheria  '  its  general 
o.Mset  and  symi)toms,  when  primary,  is  the  same  :  the  other 

forms,  only  varying  fnim  them  by  the  pn'sence  of  u,.-  memhram' 
in  the  larvnx  or  tnichea  giving  rise  to  the  set  of  symptoms  which 
are  classified  under  the  term  of  (Uplitluritir  rrnup. 

Larviigeal  diphtheria  may  be  either  primary,  that  is,  the  membrane 
forming  first  either  in  the  larynx  or  trachea,  or  it  may  be  the  result 
of  extension  of  the  membrane  fnmi  the  nose,  na.sopharynx,  or  pharj-nx. 
When  the  larynx  is  iin.ided,  either  immarily  or  from  extension,  \\v 
first  symptom  to  attract  our  attention  will  be  a  slight  cough  whicli 
soon  liecomes  U"  e  frecpient  and  bra.ssy  in  character,  and  as  the 
membrane  extends  takes  upon  itself  the  well-known  characteristic  i>l 
a  croiipy  cough.  The  row  and  crij  of  the  child,  which  at  first  may 
be  but  slightly  hoarse,  become  as  the  disease  extends  ven*-  hoarse 
indeed,  and  almost  aphonic. 

In  some  instances  whore  the  membrane  begins  in  the  subglott;' 


JSW^r 


IW^^^-W^'^^^-T-W' 


JIII'IITIIEIUA  OF  THE  SOSE  ASl)  TUllUAT. 


833 


rcjiioii  \\\y  voice  may  not  Im"  interfered  with  to  any  great  extent, 
and  tliis  i.s  used  as  a  i)oint  of  diagnosis  in  the  localization  of  tlje  suli- 
si'(|iient  stenosis. 

After  the  cougli  and  clianpe  of  vo.  ave  jjcrsisted  for  some  little 
tiriie  tliire  h'^ins  to  Ik-  (h  (icecj  an  interference  with  the  breathing. 
This,  at  first,  in  the  majority  of  ciises  is  slight,  and  may  Ix-  only  spas- 
modic in  character,  generally  \vors<'  at  niglit.  and  interfering  with 
sle-p:  l)ut  as  the  stenosis  progresses  the  hreathing  Ix-comes  very 
much  more  continuously  embarrassed,  and  in  bad  j)rogressive  cases 
it  ends  in  the  well-known  stri<lulous  condition  of  laryngeal  croup. 

In  severe  cases.  esjK'cially  when  from  extension,  and  where  there 
is  much  c<.nstitutional  al)sor|>tion,  the  temperature  may  Ix-come  as 
high  as  104°  or  10.-)°,  the  puis.-  be  rapid  and  weak  from  exhauw- 
tiuii,  and  the  respinitions  much  increased  in  fre(|uency,  Ix-coming  as 
rapid  as  m  to  NO  j)er  minute.  In  many  ca.ses,  however,  these  ex- 
tremes of  temperature,  j,  ilse,  and  respiration  are  not  reached. 

At  this  .stage  the  child  iK'comes  very  restless,  tlirowing  him.self 
about  the  l)ed  in  a  vain  endeavor  to  get  sufficient  uir,  culUng  into 
play  the  extraneous  muscles  of  resj)iration.  with  the  characteristic 
talhng  in  of  the  ilavicular  and  epigastric  n'gion.s,  and  only  becoming 
(piiet  as  cyanosis  or  exhaustion  sujM'rvenes. 

If  at  this  time  tlie  child  Ix*  old  enough  to  a(hnit  of  a  laryngoscupic 
exammation.  tiie  epiglottis  and  arytenoi<l  region  will  be  found  con- 
sidiTably  swollen  and  covered  more  or  less  witli  memlirane,  which 
at  once  estal)lishes  the  chanicter  of  the  (liseu.se.  \W*  =m  small  children 
it  gf«'s  without  saying  that  we  are  unable  to  make  tiiis  examination, 
and  m  vaim^s  of  j)rimary  invasion  of  the  larynx  we  must  depend  for 
oin-  ihagi.'isis  uixm  the  character  of  the  syiiiptoins  and  the  presence 
or  absence  of  the  Klebs-Loeffler  bacillus,  as  will  Ix'  referred  to  later. 

In  all  cas<>s  of  na.sal  or  pharyngeal  diphtheria  where  laryngeal 
siihirrtire  sipnpiows  supervene,  it  must  be  taken  for  granted  as  indi- 
cating a  downward  progression  of  the  diseas*'. 

Diagnosis.  The  two  main  conditions  to  Ix>  differentiated  from 
primary  diphtlieritic  croup  are  acute  catarrhal  laryngitis  with  croupy 
symptoms,  and  spasmodic  croup  or  laryngismus  stridulus  (false  crou])K 

111  catarriial  laryngitis  the  hoarseness  and  cough  may  become  very 
marked.  The  cough,  as  a  rule,  dcx's  not  Ix'come  so  croupy  in  char- 
■I'tcr,  and  the  breathing  very  rarely  l)ecomes  .seriou.'*ly  embarrassed, 
and  there  is  a  general  tendency,  either  by  self-limitation  or  by  treat- 
ment, toward  abatement  of  the  symptoms. 

In  diphtheritic  croup  the  main  point  for  establishing  a  diagnosis 
oilier  than  by  the  presence  of  the  bacillus  is  that  the  symptoms 
hiroir  proffrexsirfly  worse,  and  we  may  say  that  in  any  instance 
where  the  croupy  symptoms  progress  to  that  severity  sufficient  to 
warrant  surgical  interference,  we  may  lx>  verv  sure  that  the  case  is 
one  of  diphtheritic  en.    >,  whether  we  find  the  bacillus  or  not. 

In  spasmodic  croup  or  laryngismus  stridulus  the  attack  generally 
comes  on  verv  suddenly  out  of  a  sound  sleep,  and,  although  for  the 

53 


lliilf.^.2§S 


H.i4 


.VO.s/v  AMI  TllliOAT. 


inoiiifiit  the  rroiipy  syinptoiiis  may  Imtoiik'  very  .M'vcrc,  tlir  Jittack 
is  nt'iu-rally  I'lilldwcil  by  a  ('cssiliiui  of  .sympttiiii."*,  and  tlu-  following 
.lay  the  imticiit  may  Im-  to  all  intents  ami  purposes  ixTfectly  well, 
and  tlierc  is  no  evidence  of  progressive  eroiip.  Another  im|M)rtant 
point  is  that  there  is  often  a  history  of  reeurriiiR  attacks  of  croup 
in  the  child,  which  is  fre(|uently  manifested  in  the  course  of  an  exist- 
irg  coryza. 

Sequela.     The  common  seipiehe  of  diphtheria  are  o»itis  media,  from 

extension,   supi)Uiative   adenitis,    fienerally  of   tin rvical   «''""'"- 

lironchopneumonia.  nephritis,  ami  postdiphtheritic  jiaralysis. 

This  latter  neniTally  first  invades  the  soft  |)alate,  and  it  may  extend 
to  a  paralysis  of  the  entire  muscular  .system.  It  may  come  on  very 
early  in  the  di.sea.se,  orl)e  delayed  for  a  varialile  [K-riod  after  the  acute 
symptoms  have  disappeared.  It  apparently  docs  not  .seem  to  de|K'nd 
upon  the  severity  of  the  disejuse.  This  latter  fact  is  (piite  frequently 
emphasized  hy  the  patient  pa.ssin>;  throush  a  mild  diphtheria,  pos.sihiy 
unnoticecl  until  we  are  made  aware  of  it  by  the  .  iset  of  a  i)ostdiph- 
theritic  |)aralysis  of  the  soft  palate.  However  severe  <ir  exten.sive 
this  paralvsis  may  iM-come,  the  general  tendency  is  toward  recovery, 
unless  it  affects  the  mu.scles  of  the  heart,  which  may  occur  at  any  time 
during  the  pronress  of  the  disease,  fre(|Uently  causing  sudden  death. 

Treatment  of  Diphtheria.  I'erhaps  there  is  no  disease  which  in 
modern  times  has  Imh'Ii  so  revolutionizeil  in  its  posit iveness  of  iliapiosis 
and  treatment  :is  di|)htheria.  This  has  Imh'U  hmufrht  about  by  the  dis- 
covery of  the  Klebs-I.oefiler  bacillus  as  a  positive  cause  of  diphtheria, 
and  the  use  of  the  antitoxin  treatment  as  its  most  eflective  cure. 
This  latter  statement  may  seem  rather  strong,  and  may  possibly  call 
forth  criticism  from  some  (|uarters:  but  I  think  we  can  safely  say 
from  the  accumulated  ex|)erience  and  writings  at  the  present  time 
that  we  have  in  the  antitoxin  tre.itmeni  of  diphtheria  as  near  a 
sjx'cific  as  it  is  po.ssible  to  obtain. 

The  limitations  of  an  article  such  as  this  in  a  work  of  this  kind 
prevent  the  writer  from  ff>\uii  into  detail  as  to  its  substantiation, 
so  we  will  have  to  rely  ujton  the  above  statement  as  beinji  the  con- 
sensus of  opinion  of  medical  thoufrht  at  the  present  time.  One  has 
only  to  compare  his  experience  ■[  results  in  the  i)re-antitoxin 
days  with  the  present  mode  of  treiitiiicnt  in  order  to  emphasize  the 
streiifjth  of  the  forcfioing  statemeni ;  and  the  writer  considers  it  the 
ab.solute  duty  of  a  |)hysieian  to  use  antitox'.  i  in  all  cases  of  diph- 
theria, of  whatever  tyix-  or  s(>verity  they  may  be. 

The  efficacy  of  the  antitoxin  treatment  is  l)est  obtained  when  u.sei I 
in  the  early  stages  of  diphtheria,  before  mixed  infection  with  strep- 
tococci has  taken  place,  that  is,  in  the  first  three  days  .)r  even  before 
the  positive  diagnosis  may  have  been  made,  .so  iis  to  gain  time  and 
prevent  the  spread  of  the  disease.  The  earlier  it  is  useil,  the  less 
liable  is  the  disease  to  progress,  and  the  less  likely  will  be  the  necessity 
for  the  re{)eatod  u.so  of  the  antitoxin;  but  at  any  time,  even  when 
seen  very  late,  antitoxin  should  be  given. 


■naa 


■%i-     J-^X.>*\-ir 


,'£'•.*'■=-  •   t^-* " 


DirifTiifjii.i  OF  Till-:  yosi:  AM*  tiihoat. 


H35 


Tf,(>  rrlii.l.ilify  of  inatuifacturo  aiul  th<'  pr(.|KT  fr.>shr„.ss  of  tlio 
antitoxin  sliouhl  !„■  „iir  ^n-atrM    (•o.isi.|,.ration   in  tlu-  rhoic..  of  the 
particular  .s,.rum.     Tl...  sirrnKtl,  aii.l  ronmitration  nf  tl.o  antitoxin 
11S.MI.  ('xpn..ss...|  in  „„its.  will  .|,.,M.n.l  sonirwliat  on  .|„.  M-vcritv' of 
tlH-  rsi-s,.  at  tlu.  tin,.,  w.-  Rivr  it.  an.l  th.'  ag..  of  tl,.-  patient.     H„t,  K.-n- 
.-raliy  s,..akinK  w..  .  ...ul.l  .rr  on  th,-  .1.1,.  of  giving  a  lar«,.  initial  .lose. 

Mi..t..\..r  may  Im-  th.-  a^...  kui.Iiiik  th..  .sulw«,u(.„t  Mtrengtli  .,f  the 
.l..s,«..  ar.-or.iinK  to  th..  proRms^  .,f  th..  v>m>.  This  is  osiM-.-ialiv  so  i„ 
larynp-ai  cas^.s.  '  • 

th..  in...!,,  of  a.ln.inist..rinK  antitoxin  is  hy  th.'  us<.  .,f  a  hy,K..I,.nnic 
s  nnK...  ,„„.  R..„..raly  ma.!.,  for  th,.  pnr,,.,.s,.,  an.l  in  using  it  we 
sli..ul.lcarry..ut  all  the. Hails  ..f  asepsis.  '^ 

Th.-  usual  lo,.atiori  for  giviiiR  the  antit.)xin  is  ..ither  in  th.-  intra- 
srapular  r,-gion,  tl...  .■..n.ieetiv,-  ti.s.sue  over  the  alxloinen.  or  th.-  .jeep 
tis.-u.-  ol  the  l)Utto,-ks.  ' 

We  may  say  that  th.-  av-.-raRe  initial  .l.,.se  when  giv-.-n  in  a  nio.l.-rat.-lv 
M-\.r..  .■a.s,.  ol  nasal  or  I'l-arynReal  ,iiphth..ria.  at  what.-vr  ag,- .>f  the 
pa  ..-nt,  shorn,  h.-  Jm)  units.  If  ,h,-  typn-  of  ea.se  1...  .sev.-re  at  the 
"..ts..t  or  1  It  has  proRr<..s.s,.,|  f„r  two  .,r  thn-e  .lavs  or  m..re,  a  larL^-r 
.IO.S,.  sh..ul.l  Ih-  Kiv,-n.  heginninR  with  ;«KK)  units,  .son,.-  authorities 
|ru  i.„.  ev..n  Aim  units.  In  laryngeal  .-ases,  .-ither  ,,ri,narv„r  extel^d- 
i"«  Irom  the  faun-s,  at  l.-ast  Hm)  units  sh..ul.|  Ik-  giv,-n  at  theout.st-t 
Dangers  of  Antitoxin.  In  com,.aris„n  t..  the  great  etti.-aev  ..f  anti- 
t.jx      in  Its   re.sults  ,n  diphtheria  we  may  say  that   its  poi.sono  s 

ff.-et.s  ar..  alnmst  ml.  an.l  tlu-y  shoul.l  in  no  way  .i.-ter  us  from  using 
"      IH  a  .•.-rtam  numlK-r  of  eas,.s  arthralgia  is'mor,-  or  l,-.ss  marke.l 
j.n.i  a  gen.-ial  ..ruption,  r,-.semhling  meiusle,s,   makes  it.^-  apm-aranoe 
l"i:  K  i<  fransi..nt.      rhes,-  mei,!,.nt-  are  I(.ss  fr,>,,u.-nt  s;;,,.,!    h.-  r„..re 
.-....•ontrate,  pn-parafons  .,f  .s,.rum  are  In-ing  u-s,-,!,  /. . .,  large,  numher 

;  t  '"-  lt>  an.l  small.-r  amount  of  .serum.     Hoteh'  ,|uotes  in  1,00()  (KK) 
n.|...-  .......  ..nly  hve  cas..s  of    .leath    oceurn-.i    which   eoul.l  in  Ty 

u  .  I ..  attnlmte.1  to  the  antitoxin.     Al.so  in  450()  ca.ses  i„  the  Bost.m 

n>    llusj.ital.  each  n-cen-mgan  average  of  two  inj.-ctions.  n..  ha.l 
u^u\u  toilow..,!.  an.l  .)ne  jKitient  received  2H.{H)0  units  an.l  ;va.s  dis- 

'l"'"'  '•ff<-ct  of  the  antitoxin  on  the  .liphtheritic  i)ro(-ess  is  gen- 
'  .;  I.v  shown  .vithin  the  first  twelve  to  twentv-four  Imurs,  ami,  if  a 
Miff.eient  ,lo,so  ,s  hrst  given,  it  fr,..,uently  happens  in  mil.l  an.l  early 
MM-s  hat  no.sul,..equent  tm.,lieati.,n  will  h,-  necessary,  an.l  th,-  .li.s,.a.s;. 
v.ll  piogr.-ss  t..  a  favorable  issue.  Tlu-  t,.m,H>rature  falls,  the  pulse 
--|m."s  1„.  ter.  an.l  there  is  seen  a  marked  absorption  or  exfoli  ii„n 
1.  -  ...emhrane.  f  th,-  .li.se^.se  is  severe  at  the  time  of  giying  the 
-antitoxin  an.!  the  sym,>toms  ,io  m.t  abate  sufficiently  the  anti- 

H  b,  r!!.     ♦  7"'''''^^''  '"  "  ?""'^'"  ''•"^''  ^^''t'""  twenty.-four  hours. 

I'l  >.  r.  p,-ate,l  again  m  a  similar  or  decreasing  strength'according  to 

tliedeyelopmentinthec.<i<w.  ^  .umg  u. 


'  Rotch,  DiKasea  of  Children. 


8;JG 


\()SJ-:  AMt  TlinoAT. 


Fur  ilctails  as  to  the  pre) liirai ions  of  aiititoxiii  scrum,  its  various 
strcii^tiis.  corHciitratioiis,  statistics,  the  reader  is  referred  to  larger 
general  works  oii  dii)!itlieria. 

Immunity.  Not  only  has  antitoxin  proven  itself  of  such  great  value 
in  the  direct  treatment  of  di|)htheria,  hut  also  we  have  in  it  a  strong 
prophylactic  measure  wiien  given  to  those  immediately  exposed  to 
the  contagion.  The  inmiunizing  dose  should  he  much  smaller,  iVM)  to 
KHM)  units,  and  it  has  hccn  jjositively  proven  that  the  iimnunity  lasts 
from  one  to  three  months. 

Local  Treatment.  It  is  the  writer's  oi)inion  that  local  treatment 
other  than  tus  an  adjunct  means  of  cleanliness  an<l  asepsis  is  not  of 
such  great  neces.sity  as  ni  the  i)re-antitoxin  days — and,  indeed,  in  a 
great  many  instances  where  its  administration  is  productive  of  much 
objection,  resistance,  atid  disturbance  on  the  part  of  the  patient,  it 
can  he  safely  dispensed  with.  If,  however,  local  treatment  is  indi- 
cated and  appears  n-cessary,  we  have  at  our  dispo.sal  many  of  the 
ordinary  cleansing  and  antiseptic  solutions. 

.\mong  them  may  he  mentioned  hydrogen  dioxide,  diluted  one  to 
six  times,  especially  used  in  the  pharynx;  normal  salt  solution,  bichlo- 
ride of  mercury  (1:  S(HM)),  lime  water,  boric  acid  (4  percent.),  Dobell's 
solution.  Seller's  solutitm,  and  others  of  similar  nature.  The  .solutions 
should  be  api)lied  warm,  and  should  be  bland,  to  obviate  any  excoria- 
tions. Irrigation  of  the  nose  is  often  very  diflicult  owing  to  the  nasal 
obstruction.  This  sometimes  may  i)e  partially  overcome  by  first 
(lro|)|)ing  in  a  mild  solution  ( '.  per  cent.)  of  cocaine,  mixed  with  adre- 
nalin, wliich  w  ill  cause  sufficient  depletion  of  tissue  to  allow  the  sijlutioii 
to  run  th.rough.  ( )ur  efforts  m:iy  be  aided,  if  the  child  bo  old  enough, 
by  the  |)roper  blowing  of  the  nose. 

.Much  m.iy  be  accomi>lished  in  ca.ses  of  nasal  irrigation  by  attaching 
a  small  perforated  flexible  rubber  c.-itheter  to  tlie  douche  and  passing 
it  through  the  nose  to  the  iiaso|)harynx  and  the  pharynx  below.  By 
this  means  a  more  thorough  ;ij)pli('ation  of  the  douching  may  be 
obtainiMl.  I'nless  there  be  a  competent  nurse  in  charge,  the  physician 
should  <'ither  attend  personally  to  the  douching  or  thoroughly  instruct 
those  in  charge  of  the  i)atient.  The  patient,  physician,  and  those 
in  attendance,  as  well  as  the  bedding  and  floor,  sliouM  be  well  pro- 
tected, and,  if  possii)Ie,  the  discharges  should  be  allowed  to  flow 
directly  in  a  large  basin  held  under  the  chin  or  over  a  rubber  sheeting 
to  a  receptacle  on  the  floor.  I  think  the  fountain  syringe  is  one  ol 
the  best  means  of  applying  local  solutions,  for  by  it  we  can  easily 
regulate  both  the  amount  and  force,  and  with  <lue  attention  to  tlie 
details  of  position  of  the  child,  and  cautioti  in  its  use.  it  is  as  free  from 
danger  and  will  accomi)Iish  perhaps  more  than  any  other  means  a' 
our  disposal. 

.\si(le  from  the  antitoxin  and  local  treatment,  it  is  also  necessarv 
in  certain  ca.ses  to  iissist  on  the  general  lines  of  supporting  treatmeni 
and  to  meet  indiviclual  iiulications  as  thr>v  pres(>nt  themselves.  AinoiiL' 
tlie.se  may  be  mentioned  pioper  nourishment,  the  combating  of  ui' 


,^v-*er  imt'mmms^i'TmF'^-'^^m^-^m&K"^^^^ 


iM^^ 


'i<>M^\mr^^msde' 


lyTuii.iTioy. 


837 


ii.M.allv  l.,«li  f..,Mi.oraturc.  canliar  woakncss.  all.u.Mi.n.ria.  tho  various 
>.'MU..|a.    a-Hl  att..Mt.u„  to  tlir  ;:,.,„.ral  In-altl,.     Al.s„!ut< '  n-st  i       ,  d 
""..I  all  uaM«..,.  ul  p,.s„liphth,.riti,.  paralysis  an.l  .nuscula,-  w,    kn  I 
liavrpass..,lsli...il.|l,..sfn,i,jrlviiisistc.lup<)ii  "<-»Kn(.ss 

Att«>Mh..M  t..  sanitary  .lotails  is  vory  import-  ,•  in  ..rcvonting  fl„. 

i-lat.nn  ol  tlH.  pat.,.Mf  from  otlu-r  .n.rnber  -  of  •(..  fan.iiv  ,/',,; 
^.nt.lat.o,,  an.l  sunlight  of  the  siek-roo.n,  h.  v.ari,,^-  o,  prot mi'L 
«nwns  on  I...  part  o  att,.n.la..ts  and  physid  ,,.  ,i  ,•  d-.Li  .i  |  s^ 
.l.^afon  ol  rm.ptac.l..s  an.l  instnunonts  of  c-.v.,ninat.oo.  .-  .ts  ,  s  S- 
ra -  pu-nsot  «an...  about  tlu-  fa.,  and  I.an-Is,  wl.ich  shoul.l  bo  n  ,  e- 
f  l>  d..stroy..d  alt.r  us,,  an.l.  abov.  all,  personal  d,.anli„,.ss  on  he 
I  .  of  a  I  who  conje  u)  nnn.ecliate  eontact.  These  an.l  all  .  t  It 
I et  ul  .,f  hke  natun.  have  an  n.erease.i  in.portanee  when  we  re.nen  er 
that  ,t  ,s  mostly  by  .hreet  eontact  that  the  eontaj^ion  of  .liphtheria  " 

Prognosis  That  the  present  mode  of  antitoxin  treatment  has 
.■.•.use, I  most  remarkable  .leerease  in  the  fatalitv  <.f  diphtl,  a  nus 
"■  ■•...•e.ve,  as  an  aeeepted  fact,  an.l  by  its  use  a'n.ost  f  ,vor  d  «  X 
nos,s  may  be  K.ven.  ..speeially  is  this  the  ease  in  larvn^eal  .lipl  tl  e  h 
'•  1.  ...  obvatn,^.  the  ne,.essity  of  ..p^rative  proe^.-hm.  w  e  g  v! n 
'a  iy  an.l  most  .natenal  y  ai.lin^  in  briufrins  about  a  favorable  ten 
Man.M.  n.  those  cases  where  tra.heoton.y  or  intubation  has  t.  be  e  - 
y.  m...l.  1  Ins  ,s  most  strongly  ..nphasi^e.!  in  the  report  of  a  eolleethr 
...^  es  i^'at,...-.  earr.e.|  on  by  the  Ameri.-an  Pediatric  Association  ' 

A  l.nel  refcre.ice  to  the  statistics  of  the  Hoston  Citv  Hospital  as 
|rm..  by  I?.,tch,^  w,  11  serve  to  emphasize  the  ,uesti..n  o  fSi;^ 
OfT.  ns,s.  „  a  state.|  rmmber  of  cases  before  the  ,Iavs  of  antitoxin 
i."  .lea  h-rate  was  50  p,.r  cent,  as  con.pared  to  U  ,,eV  cent  a  , 
!"■  '•;•.„.  smce  ,ts  use.  Tlu>  ^reat  .leerease  in  fatal  ca.ses  is  her 
-H.  m  m.l,v„lual  pnvate  practice  an.l  in  in.stitutions  where  the  .lis- 
'i  Th.  iTI  '  h''  n''n"''  '^'T  <'"'.?"■''■'  "^  •'^"  '^'"""'"f  ""  authority 
>  l.>latel)r.()I)wycr.  wh.,  .sa,.l.  "ha.!  he  waite.l  until  antitoxin 
M  b,.,.n  .hscver...!  he  never  w.,ul.l  have  invented  intubation  " 


INTUBATION. 

The  Mechanical  Treatir  ^nt  of  Laryngeal  Diphtheria.    When  the 

,:,    ;  T\  *'r  '"   "•"  "^  •■>"t't"xi"  •>^comes  evi.lent,  or  when 

Ml  Its  sev.>rity  befon-  antitoxin  has  been  piven,  the  .,u.>stion  of 

I     •l.v  operative  measures  b.^omes  paramount.     To  meet  this  con- 

:.,  n'V;  ♦;^-'>  Prnce.lures    viz.:  tracheotomy  and  intubation. 

I      !'.s  aitid..  the  latter. .nly  will  be  consi.lere.l.  as  without  poirifr  into 

m>  comparative  merits  of  the  two  measures,  we  can  safelv  nav  tint 


'  Archiveg  of  Pedl;.    leg.  July,  1896. 


'  Loc.  olt. 


838 


yoSE  AM)  in  HO  AT. 


as  a  i)riiiiarv  (ii«'ratii)ii  intubation  has  cnnniH^toIy  superseded  trache- 
otomy. The  iiidieatioiis  are  tiie  same  for  tlie  two  operations.  For 
tiie  tcehiii(iue  of  tracheotomy  tiie  reader  is  referred  to  works  on  sur- 

K'Ty. 

Aitlioush  th(>re  have  been  placed  befon-  the  profes.sion  a  number  of 
modihcations  of  the  original  intul)ation  instruments  as  originated 
and  perfected  by  the  late  Dr.  Joseph  O'Dwyer,  of  New  York,  this 
article  will  refer  )nly  to  the  O'Dwyer  instruments,  as  they  are  the 
ones  u.sed  almost  to  the  entire  exclusion  of  all  others. 


Fig.  •l-'i. 


O'Dwyer  s  intubation  tubes.  The  figures  on  the  scale  denote  the  age  for  which  a  given  tube  is 
indicated,  the  tube  being  nieasure-l  on  the  scale,  the  length  of  the  tube  corresponding  to  the  age,  as 
shown  by  the  llgures. 

The  instruments  for  intubation  consist  of: 

1.  The  tubes,  made  i/f  hard  rubber,  with  metal  lining. 

2.  The  obturators,  screwed  on  the  iiitroducing-handle.  In  this 
respect  a  recent  improvement  h;i.s  been  made  l)y  Krmold,  of  New 
York,  by  which  the  obturator  is  continuous  in  one  piece  with  the 
rod,  which  fits  in  the  introducing-handle,  thus  doing  away  with  the 
thread,  which  sometimes  becomes  loose  at  tli  •  junction  of  the  handle 
and  the  obturator,  allowing  the  tube  to  turn. 

;?.  The  introducer. 

4.  Kxtractor. 

5.  ,Scale. 
f).  String. 

7.  Mouth-gag. 

The  tul)es  are  of  variable  -ize«,  to  suit  'he  required  age,  and  are 
chosen  according  to  the  scale. 


IXTVllATWN. 

Flo.  423. 


839 


intubator  with  a  tube  in  the  proper  pcltion  for  insertion  In  the  larynx     A   Intubation  tuh« 

iLre\rs;reTnirorr'-  ^"- ''-''  "^'=''' "-  P-- ^--. =- r^ 


Fia.  434. 


Mouth-gag. 


-l^r.te'^L/f'?'''!!!'"  T^J  °'*,°-    "■  '*'*'•  P"*""  °°  ">"="  '°  *  downward  direction 
ja«" o^ned  "         '"^"""  "■"  ""'"  *"  ""="  '"^  '*^'"  °»y  »«  "epresaed  and  the 

Technique  of  the  Operation.  The  patient  shoul.l  Ih-  held  firmly 
"I'riRht  ..n  the  left  thigh  of  an  ;i.^si.stant  whose  leg.,  are  tightly  closed 
"M  the  pat,,.„t  ,s  legs.  The  left  arm  of  the  a..sistant  is  thrown  around 
>'  <  l)ack  of  th(.  patient,  holding  the  left  hand  and  arm  of  the  latter 

,:.',;'  '^'V'        .  "^''Z  '';""'  '"'■  ^'^'^^  hoKis  the  patient's  right 
"•i"-l.     The  right  sKle  of  the  patient  is  firmly  held  against  the  breast 


840 


yOSK  AM>  in.  OAT. 


KUi.  426. 


To  Bbow  the  method  of  iutubauug 
the  larynx. 


of  tliP  assistant,  tlio  loft  si.lo  of  the  i)ati«-.ii  bcinR  free.  The  sccoiul 
assistant  stands  l)aclv  of  tlic  patient,  holdinj^  tiic  licad  firmly  in  a 
suspended  position,  anil  steadyinj^  the  Mioutli-jiaR  with  the  lift  hand. 
There  should  Ix'  no  twistiuf;  of  tlie  neck  of  the  patient,  who  should 

be  held  perfeetly  straifiht.  This  cannot 
be  too  stronjjly  emphasized,  as  it  especially 
pertains  to  the  successful  introihiction  of 
the  tul)e.  The  pro|)er-sized  tulx-  having 
l)een  chosen  accordinj;  to  the  scale,  it 
should  be  threaded,  always  using  braided 
silk  of  a  size  which  will  pass  easily  tlimufih 
the  ojM'niiif!;  in  the  tube,  and  of  a  length 
which  will  permit  of  being  looped  over  the 
patient's  ear  when  the  tube  is  in  position, 
and  so  tied  that  the  knot  is  always  at  a 
point  farthest  away  from  the  tube. 

The  operator,  staniUng  or  sitting  in  front 
and  a  little  to  the  right  of  the  patient,  at  a 
height  which  gives  ea.-^y  access  lo  the  mouth, 
the  patient's  mouth  being  well  open  and  the  gag  on  he  i  'ft  side, 
piisses  his  left  forefinger  well  down  into  the  larynx  over  the  epiglottis 
until  he  feels  the  two  small  tips  of  the  arytenoid  cartilages,  which 
indicate  tiie  posterior  portion  of  the  larynx.  The  sensation  imparted 
to  the  finger  is  the  same  as  feeling  the  tip  of  one's  nose.  Then  the 
introducing  instrument  is  quickly  pitssed  down  over  the  palmar  tij) 
of  the  left  forefinger  until  the  end  of  the  tube  engages  in  the  larynx, 
gentle  pressure  Ix'ing  continued  until  the  tube  is  well  down  in  the 
larynx,  when  the  left  for(>tinger  is  transferred  to  the  head  of  the 
tube  and  the  obturator  removed  by  liberating  the  sliding  catch  on 
the  handle  of  the  introducer.  The  left  forefinger  should  remain, 
gently  pressing  the  head  of  the  fube,  until  the  obturator  is  well  out 
of  the  mouth.  Care  should  Ih'  taken  that  the  obturator  is  not  re- 
movi'd  in  any  way  from  the  tube  until  the  latter  is  well  down  in 
the  larynx,  thus  avoiding  any  danger  of  stripping  oflf  or  wounding 
the  mucous  membrane. 

Successful  introduction  of  the  tube  is  almost  immediately  rewarded 
by  relief  from  the  difficult  breathing,  which  becomes  more  and  more 
maiked  as  the  minutes  go  by,  and  the  patient  pas.^^es  into  a  condition 
of  rest  which  is  in  marked  contrast  to  that  which  necessitated  the 
(>peration.  The  means  of  knowing  that  the  tube  is  properly  placed 
in  the  larynx  are,  first,  the  relief  in  breathing,  and  second,  the  char- 
acteristic cough,  which  inuiiediately  occurs  and  is  of  a  moist  metallic 
character,  pnxluced  by  nmcus  and  air  passing  through  a  metallic 
tube.  This  cough  should  always  be  looked  for,  and  if  not  present 
should  be  provoked  by  the  administration  of  a  te!i.«poonful  of  diluted 
whiskey  or  brandy.  The  character  of  the  cough  is  peculiar,  and  is 
far  belter  appreciated  by  being  heard  than  from  any  descriplic'. 
Ofttimes,  in  moribund  cases,  the  cough  may  be  delayed  or  be  but 


mMSSSi*'^-     ^^"Sfi^Ai^^^V: 


T^^ 


lyXVliATION. 


841 


ffphio  whon  it  is  hoard.  Th"  po'irI.  is  valuable  in  cloariiig  the 
traclica  ot  secretions  and  as  an  indu'ation  of  the  firmness  with  whieh 
I  he  tul)e  is  retained  in  the  larynx. 

Another  way  of  determining  whether  or  not  the  tube  is  in  the 
larynx  is  l)y  |)assin>i  the  left  index  hnger  down  into  tlie  (esophagus 
and  (eehnfr  the  tube  through  the  anterior  wall  of  the  foriiHT  This 
means  IS  ot  great  service  if  for  any  reason  the  breathing  is  not  fully 
IV  leved.  and  if  it  is  desired  to  be  jxKsitive  as  to  the  position  of  the 
tube.  If,  however,  after  the  hitroduction  of  the  tube,  the  breathing 
IS  not  relieved  or  becomes  suddenlv  worse,  the  (lue.stion  of  having 
imshed  down  with  tlie  tube  some  detached  meml)rane  is  to  be  con- 
sidered 'I'his  aeeident  may  happen,  l)ut,  as  a  matter  of  fart,  it  is  very 
rare.  If  it  were  of  frwjuent  occurrence  it  would  be  a  most  serious 
objection  to  the  operation.  The  reason  of  its  iiifre(|uency  is  tliat 
the  stenosis  is  not  entirely  due  to  a  complete  membranous  cast  of  the 
larynx  and  trachea,  through  which  the  tube  has  to  pass,  but  also  to 
a  lessening  of  the  lumen  of  the  lar>'nx  by  infiltration  of  the  submucous 
tissue.  This  can  be  easily  observed  in  a  cross-.section  of  a  larvnx 
tniiii  a  case  of  diphtheritic  croup. 

The  accident  mentioned  is  more  likely  to  occur  in  late  cases  of 
••roup  in  which  the  in(>mbrane  has  begun  to  exfoliate,  and  at  anv 
tiine  \vli,.n  traumatism  has  been  oer;i..i<ine(l  bv  the  introduction  ()f 
th.'  tube  It  IS  accompanied  by  oxce.s.sive  coughing  and  a  Happing 
x.uiid,  cause<l  by  fh<"  loosened  membrane.  If  for  this  or  anv  other 
reason  the  breathing  is  not  relieved,  the  tube  should  be  witjidrawn 
•y  til.,  string  and  the  child  encouraged  to  dislodge  the  loosened  mem- 
I'raiie  by  coughing,  after  which  a  second  attempt  at  introduction 
>li<>ui,|  he  made.  It  sometimes  happens  that  pieces  of  detached 
nienibrane  accomj.any  the  withdrawal  of  the  tube.  If  it  is  reason- 
:ii)ly  certain  that  loo.se  membrane  is  blocking  the  tube  and  is  not 
ivailily  expelled,  a  short  cylindrical  tube  (foreign-body  tube)  mav 
he  ms(.rted.  Tlie.se  tubes  for  a  given  age  arc  much  larger  in  calibrV 
than  the  ordinary  ones,  an.l  allow  large  mas,ses  of  membrane  to  lie 
expelled.  Owing  to  their  larger  size  they  should  not  be  left  hi  the 
larynx  more  than  a  few  hours,  on  account  of  the  pressure  which 
they  cause. 

Another  accident  which  may  possibly  occur  is  the  introduction  of 
'lie  end  of  the  tube  into  one  of  the  ventricles  of  the  larvnx  This 
IS  obviated  by  using  the  present  type  of  tubes,  somewhat  bulging  on 
the  ('iKl,  which  thus  permits  them  to  override  the  ventricles,  and  bv 
Keeping  ,n  the  median  line  during  introduction.  Introduction  of  the 
tuhe  into  t..e  a^sophagus  will  sometimes  occur.  This  can  be  appre- 
nated  by  failure  to  relieve  the  difficult  breathing  and  bv  attempts 
on  he  part  of  the  patient  either  o  expel  the  tuhe  or  b^  efTorts  to 
Mvalow  If  the  string  is  observ.  I  to  be  disappearing  within  the 
mouth  It  IS  evident  that  the  tuhe  is  in  the  (p,soph.agu.^  and  it  should 
"<■  immediately  v  thdrawn.  This  accident  is  an  avoidable  oi  ,d 
tiood  not  occur  if  the  proper  rules  are  followed.     In  the  cases  in 


m^SiT^fim^ 


842 


SOUE  AXD  THROAT. 


wliich  I  havo  scon  the  tiilic  swallowcil  it  lias  passed  tlirouKh  the 
alimentary  eanal  within  from  two  to  four  days  without  any  aecident. 
The  tube  may  bo  ooea-sionally  .swallowed  when  eouf^lied  up  by  the 
))atient. 

Tlie  strinj^  should  bo  permitted  to  remain  in  place,  being  passed 
over  the  left  ear  until  ([uiet  breathing  is  restored,  from  hfteen  minutes 
to  half  an  hour,  and  should  then  be  removed  by  cutting  one  side  of 
the  loop  close  to  the  mouth,  taking  hold  of  the  long  end  and  with- 
tlrawing  while  the  loft  forefinger  is  making  gentle  pressure  down  on 
the  head  of  the  tube.  Never,  uniler  any  circumstances,  remove  the 
string  without  making  pressure  on  the  heail  of  the  tul)e,  as  the  string 
liecomes  twisted  ii.  the  mouth  and  will  bo  caught  in  the  eyelet  of 
the  tube  and  the  latter  it.solf  withdrawn  unless  the  counter-pressure 
is  made.  Another  very  important  precaution  in  regard  to  the  string 
is  that  the  person  holding  the  child  should  never  release  the  child's 
hand-s  until  the  -tring  is  removed  by  the  surgeon.  Almost  the  first 
thing  a  child  will  do  if  the  hands  are  released  is  to  instinctively  pull 
at  th(>  string,  resulting,  of  couise.  in  withdrawal  of  the  tube. 

It  is  the  practice  of  some,  in  preparing  the  child,  to  tightly  encase 
the  arms  and  chest  in  a  draw-sheet  wrapped  around  the  body.  While 
this  keeps  the  hands  out  of  the  way,  it  is  open  to  the  objection  of 
too  firmly  constricting  the  cliest,  and,  in  case  of  artificial  respiration 
being  necessary,  nmch  valuable  time  may  be  lost.  Also  some  opera- 
tors fjrefer  to  introduce  the  tube  wliile  the  patient  is  in  the  dorsal 
position.  I  have  had  no  experience  with  this  mode  of  procedure, 
and  cannot  speak  of  its  merits. 

In  extracting  the  tube  the  same  precautions  as  to  the  position  and 
management  of  the  patient  during  introduction  should  be  followed. 
The  instrument  for  this  purpose  is  called  the  extractor.  liefore  l)eing 
used  it  is  absolutely  imperative  that  the  thumb-screw  on  the  under 
side  of  the  instrument  should  I  "  so  set  that  the  di.stal  jaw  can  ojkmi 
ju.st  sufficiently  to  exert  the  proper  amount  of  pressure  within  the 
opening  in  the  tube.  If  the  jaws  are  open  too  widely  thero  is  great 
liability  of  lacerating  the  surrounding  mucous  membrane  in  inefTectual 
att<*mi)ts  at  removal.  It  is  good  practice  to  test  the  degree  of  opening 
of  the  extractor  on  a  tube  of  the  same  size  a.s  the  one  in  the  larynx. 
In  extracting,  after  the  introduction  of  the  mouth-gag,  the  left  fore- 
finger shouki  be  pa.ssed  down  on  the  head  of  the  tube  until  the  opening 
is  felt,  and  then  the  extractor,  closed,  is  passed  down  until  the  point 
strikes  the  head  of  the  tube  and  enters  the  opening  in  front  of  the 
tip  of  the  finger.  When,  in  the  opening  of  the  tube,  the  jaws  of  the 
instrument  are  opened  by  thumb-pre.ssure  on  its  handle,  and  the 
tube  withdrawn,  pressure  being  continuous  until  the  extractor  and 
tube  are  removed  from  the  mouth,  never  have  the  thumb  on  the 
lever  until  you  feel  sure  that  the  end  of  the  instrument  is  in  tli" 
tube. 

The  operation  for  extracting  is  j)erhaps  more  dithcult  than  that 
of  introduction,  as  it  ritjuiros  a  finer  degree  of  touch  to  determine 


^ 


S^T?!^^^^^^ 


P'f^aiP^- 


IXTitiA  Tioy. 


843 


t  .<•  ..pHung  in  th..  hoad  „f  tho  tub..,  an.l  tho  .lifficultv  is  incn-a^-ed 
n   I.rnp.,r  ,.„,   to   th.  s.nallnj.s  of  th.   tul...     MoclifiVatioas     n,' 
tn    .  to  t.m,-    hav<-  h.r„  ,na.l,.  in  th.  hca.l  of  the  tube  an.l    n  tl  " 
<l'^.^  ri^^^^^^^^^     "/ac.htate  r.Mnoval;   hut   th.   original   promlur.    j 
<l<>mb.Ml.  ,s  the  one  ahnost  universally  employed.     Extraction  hv 
|.ush,nK  out  the  tube  from  below  without  any  Lstru.St  n  ay  su?- 
eessfully  be  ,,erfonue.|  if  for  any  reaso.i  great  difficulty  is  exS,  "Jl 
M  the  application  of  the  usual  method,  or  in  ca.se  of  emergency  when 
the  tube  nuis   be  removed  by  the  n-rse  in  the  alwnce  of  the  „. 
This  .s  .one  by  slightly  inverting  the  pati.  .t  and,  with  mouth  open' 
placing  the  thumb  in  the  episternal  notch  and  pushing  tl,  tube  up 
.n  the  mouth  and  gra..ping  it  with  the  fingers  of  the  other     and 
or  with  a  pair  of  ordinary  forceps.      This  cL  be  done  b    "^0^  f 
<.r<hnary  intelligence  m  charge  of  the  case,  and  is,  under  theS^cir 
cun^tances,  a  most  admirable  method  of  extraction 

AfU.r  remova  of  the  tufx^  the  patient  should  not  be  left  until  there 
.>  safteu-nt  evulence  that  the  tube  will  not  have  to  be  replace.       A 
small  dose  ot  opiate  may  then  be  given  to  allay  cough  an.f  Stion 
blight  cough  ami  hoai^eness  generally  continue  a  few  days  to    wo 
.mt  inVE""-'  ^'^  '"^'^"^^^^'  "'"^'h'  ^°--'-'  Pa-s  a^y  wlth- 

Feeding  after  intubation  is  best  accomplished  by  having  the      ild 

Ile/l  ;he'"ft''"f '-'^^  ""r!  '-"'^''-v-     This  is 'commonly 

he   itTf  ^'XY'^'     "'^^hod.     It  is  be.st  performed  by  raising 

h!  I  }    }^'\'  '•"""^''"K  the  pillow,  and  bringing  the  child  t., 

the  e,lge  ot  the  bed  on  the  si.le,  and  using  for  the  pfirpose  of  fee  ing 

nn  on  inarj-  duck-shaped  feeding-cup.     This  procedufe  ™us    in 

.•nr':7c  "7-'^  f-"-"^-"'^'  the  tube  und  the  actom;rnying 
F).rox>.sm.s  of  coughing.  However,  it  is  remarkable  how  n-adilv 
s..ne  children,  with  a  tube  in  the  larynx,  will  learn  to  swullow  n 
t*e  ordinary  upright  po.sition. 

I  consider  it  also  very  excellent  practice  to  keep  the  patient  in 

he  feeding  position  during  the  entire  period  in  which  the  tube  li" 

mms  m  the  larynx  in  order  to  lessen  the  chances  of  secretion"  pa^ 

.ng  down  through  the  tube,  and  thus,  possibly,  causing  the  deVeC 

...ent  of  imeumoma.     The  frequent  renmval  of 'the  tube  for  purS 

ol  feeding  h..s  been  advocated  by  some,  but  I  think  such  a  practS 

sh.mid  be  mentioned  only  to  be  conderiined  ^ 

■ivSe,  ""si '''""'' VT  ""'''  '\^^^^^oM,  solid  particles  of  food  being 

i  t      h    t  »       "t"^  ^"  '""  ^^'  '''^"S*"'"  °^  large  pieces  being  drawn 

.the  tube.     In  ca^e  great  difficulty  is  experienced  in  the  uS  of 

rthlJh  thf  """T"^  r'°T'  ••— «  -ay  be  had  to  alimen 
atioii  through  the  oesophageal  catheter,  passed  either  through  the 

;:;;:: ;;:  i^rihti  """'' "' "  ^ '"-'  ^^"^^'  '^^'^  ^""^^'^ 

I  think  it  most  important  to  watch  the  re.^};ir.ition  during  the 
m.re  period  of  intubation,  as  bearing  on  the  progre  s  of  tl^e  Sat 
If  they  continue  about  normal  it  is  indicative  of  favorable  pmrrS"; 


BE^^  •iJw\'^^'iBW'rda&^ 


844 


yoUE  AX1>  THROAT. 


II 


I  i-  : 


if  tlicy  slum-  a  tciidoncy  to  increased  rapidity,  it  is  iiidicativo  of 
I'Xtfiisioii  of  tlic  inciiihraiic.  rortiiiiatcly,  iiowevcr,  the  latter  does 
not  occur  as  fre(nientiy  as  it  did  in  pre-aiititoxin  days. 

Tiie  ])roj:Mosis  of  diplitiieritic  crou|)  under  the  present  coiuhiiied 
treatment  is,  1  tliink,  reinarkabiy  favorable,  especially  as  compared 
with  the  results  formerly  obtained.  A  reference  to  this  point  in  the 
report  of  tlie  collective  "investigation  of  the  American  I'ediatric  So- 
ciety, referred  to  above,  fjives  the  mortality  in  cases  operated  upon 
by  intubation,  and  in  which  antitoxin  \v:us  administered,  as  27.24 
pl-r  cent.  This  is  in  strong!;  contntst  to  the  previous  mortality,  which 
raiifred  from  li!).")  per  cent,  to  75  per  cent.  I  have  no  d()ul)t  that 
the  jirojinosis  will  continue  to  l)e  even  mon-  favoral)le  as  there  is 
gained  a  better  understandin};  of  the  combined  treatment. 

In  a  very  small  numlwr  of  cases  it  may  become  necessary  to  per- 
form tracheotomy  in  the  event  of  failure  of  intubation;  but  ^-heii 
this  has  been  done  th(>  |M'rcentaRe  of  recoveries  has  been  very  small, 
and  conditions  have  i)een  found  which  could  hardly  be  reached  by 
either  operation. 

In  contemplating  the  performance  of  intubation  one  should  not 
rely  entirely  upon  written  description  for  his  guidance,  but  should 
aciiuaint  himself  with  the  operation  by  practice  on  the  cadaver. 
This  is,  I  think,  a  sine  qua  mm.  The  perf(>cted  tubes  of  the  present 
time  are  made  of  hard  rublMT  over  metal.  This,  as  I  have  saiil 
before,  allows  the  tube  to  be  retained  longer  without  the  occurrence 
of  calcareous  deposits.  These  tui)es  exert  less  pressure,  and  can  be 
more  easily  expelled  in  case  of  plugging  with  membrane. 

When  to  Operate.  The  (juestion  of  when  to  o])erate  is  always  of 
vital  importance,  and  especially  .so  if  for  any  reason  antitoxin  is  not 
employed.  We  can  recall  the  various  opinions  which  have  i)een  held 
on  this  i)oint,  ranging  from  intubating  at  the  very  beginning  of  the 
manifestations  of  croupy  symptoms  to  waiting  for  the  more  positive 
condition  of  progression  marked  by  recession  of  the  extraneous  muscles 
of  resi)iration  and  signs  of  cyanosis. 

It  has  Im'cii  well  proven  by  the  report  of  the  American  Pediatric 
Society,  already  referred  to,  that  in  00  per  cent,  of  the  ca.-^es  of  laryn- 
geal diphtheria,  intubation  -^  not  refpiired,  if  reliable  antitoxin  has 
been  properly  administenvl  at  an  early  stage  of  the  disease.  If,  ho\v- 
ever,  croupy  symptoms  super^-ene  and  progress,  the  use  of  the  anti- 
toxin should  be  continued,  the  dosage  })eing  based  upon  the  age  of 
the  child  and  the  amount  previously  given,  .and  at  the  same  time 
the  croupy  symptoms  should  be  watched,  reinembermg  that  it  some- 
times requires  twenty-four  hours  for  the  full  effect  of  the  antitoxin 
to  be  manifested.  This  is  esjx^cially  important  if  the  symptoms  of 
laryngeal  .stenosis  are  the  first  indications  of  the  presence  of  diph- 
theria. In  either  event,  and  here  the  initial  dose  of  antitoxin  should 
be  a  full  one.  in  tiie  interval  while  waiting  for  the  antitoxin  effect, 
if  the  symptoms  of  stenosis  are  progressive,  intubation  should  be 
inmiediately  performed;  never,  in   any  instance,  is  it  justifiable  t« 


ISTVliAriOX. 


«4.j 


awai  th.«  appn.aoh  ..f  the  scvror  symptoms  „f  st(>n..sis.  After  ii.- 
lu  mtmn.  th,.  ,,s,.  ot  a„t>t..xm  sh„ul.|  l„.  ,.onti;u,e.|  on  the  priru-ipl.-s 
al  ....ly  ^Mv.-n.  n  „■  d.sc-„ntmu...|  as  tl„.  ,n...nl,ra.H.  shows  a  inarL.I 
t  :M.I,.nry  to  .xlohat..  an.l  tl...  r,-spiratory  symptoms  a  t.-nd.-n  •  to 
-lisapp..  r.  an.l  as  to  the  other  «,.„eral  eo.nliti.ms.  ..speeially  the  puis 
anJ  te„  jH-rature  resu,„,.  a  n.r.r..  nearly  nonnal  ...n./ition  ^ 

How  Long  ShaU  the  Tube  Remain  In  the  Larynx?     In  i)re-antitoxin 

.ays    he  average  peno.l  <h,ring  which  the  tul.e  was  allowl.l  to      na  n 

t  ..  larynx  was  tro.n  s.x  to  seven  full  days.     Tn.ler  the  present 

n.o,le  of  eoml.me,!  treat.nent  the  ti.ne  mav  Im-  somewhat  shorter 

varyms  m  .l.tTerent  exjH.rienees  fn.r.,  ;hre,     ,,  five  ,lavs      The  usual' 

the  .\e«  \  ork  I'oun.lhnp;  Hospital  three  .lays.  Porsonallv  'in  nrivite 
|;.-a;'tu-.-  I  prefer  to  leave  the  tube  in  the  larvnx  .luring  ij;  f .  11  ,'^ 
It  tlH.re  are  no  m.l.eations  for  removing  it,  on  the  genml  pri  ri.le^of 
av.)i.hngunnecossarvn"intro.luctions  pnn(i,m.,i 

In  liospital  practice,  when,  assistance  is  ahvavs  at  hand  in  case  of 
.:."erg..ncy.  then;  ,s  less  danger  in  leaving  the  tuhe  in  a  shorter     me 
....  should  occasion  arise,  ,t  can  Ih«  at  once  n.place.1.     Wrhal  n-ports 
t m  ..  the  inst.  utu.ns  mentione.i  .lo  not  show  any  comparativ   im-  e  so 
.|t    h..  .ec..ssity  „r  remtr.Klucti.,ns  between  the  ol.ler'an.l  the  pres -nl 
;;■    ....is  .     eoml,me,l  treatment.     The  .luration  of  the  .li.seise  Is 
nvT.,.e    t7"'r',  "'  **"^I"-*"«'"^  treatment  that   tmdoul.te.llv  in 
of  rSnirhic^i*;;,'"'"  ""^  '^^'  ""'"^•^•'  oanier  without  the  necessity 
Th.'  principal  in.Iications  for  removing  the  tube  previous  to  its  final 
n.moval  an;  severe  .liscon.fort  .,r  pain  fn.m  {.res-sute,  esix-ciallv  if   he 

'"1.  M.  en.  attacks  of  coughing,  an.l  su.l.len  .stenosis  <lue  t..  the  l...lire- 

li;-..    ..    niembrane  m  the  lumen  ..f  the  tube.     This  last-name.    -IS- 

ti.  1    ,>    perhap,>,  nu.re  likely  to  ari.s,.  earlier  un.ler  the  antitoxin 

..  ...tinent  .„,  account  .,f  the  earlier  exf.     ,ion  of  the  membrane      In 

.m.._  .nstances,  however,  if  the  membn.n,.  be  sufficientiv  l.,osen;.,l    o 

.     'k  up  the  tube,  the  latter  will  be  coughe.l  up  with  the  mem  r  ne 

Is  IS  esiK^cially  th,.  ca.se  with  th..  pn..sent  rubber  tubes,  especially 

I'-'.tube  .Iocs  not  fit  too  tightly.     If  un.ler  these  circum  ta.  ceMl2 

..■  IS  ..xp,.|le.|.  Its  reintn.ducti..n  may  not  be  necessarv.  or   at  any 

.1.  Vv,  "i  '"'"''"^•'^  "^  remtroduction  will,  as  a  rule,  be  sufficientiv 

^l<'  a><..l  t.,  permit  remtnuluction  by  the  physician  in  charge 

..f    hi!  r;    '-"'r"^"^"  ''^r^""  "^  intubation,  after  the  original  cause 

.        n.sis  has  cease.l    to„perate,  there  occurs  a  more  or  less 

'   nar„.nt  se„o..s,  necessitating  almost  constant  use  of  the  tube 

t' •>  th.'  period  of  a  few  days  to  some  months.     These  cases  are  cl-iss^l 

Z^^^;^V''^'''^'ff^''^'''^    Thecou^^eamS 

•  D     (  -Dwr    !•""  M  f''^  r  '■^'^"••'^t^Iy  set  forth  in  a  classical  article 

S oc  etv     S^)7- 1  'tr    '-^^f'^">;f^':  ."T-ting  of  the  American  Pediatric 

exposition  of  the  subject,  although  it  requires  further  experience  for 


846 


yOSE  ASD  TIUIOAT. 


its  full  plucjilation,  which  will  only  roinc  from  a  wry  careful  study  of 
the  few  cus»'s  that  will  occur  from  time  to  time. 

Dr.  O'Dwver,  in  giviii>?  the  cause  and  s<'at  of  this  i)ersistent  stenosis, 
says:  "1.  The  cause  of  iHTsistent  stenosis  foUowing  intubation  in 
laryngeal  <liphtheria  can  be  sunuued  up  in  the  single  word,  trauina- 
tisin.  Paralysis  of  the  vocal  cords  may  |K)8sibly  furnish  an  occasional 
exception  to  the  rule.  2.  The  injury  to  the  larynx  is  done  by  a  tulx* 
which  does  not  fit  projx'rly.  It  may  result  either  from  an  imjierfectly 
eonstructed  tulw',  or  from  a  perfect  one  which  is  too  large  for  the  lumen 
of  the  larynx,  although  suitable  to  the  age  of  the  child,  or  from  a  tuoe 
that  is  perfect  in  fit  and  make,  if  it  is  not  cleaned  at  pro|x>r  intervals. 
3.  The  s<^at  of  th(>  lesion  which  keeps  up  the  stenosis  is  just  below 
the  vocal  cords  in  the  subglottic  division  of  the  larynx,  or  that  portion 
bounded  by  the  cricoid  cartilage.  Exceptions  to  this  rule  result  from 
injury  protluced  by  th(>  head  of  the  tul)e  on  either  side  of  the  ba.se  of 
the  epiglottis  just  above  the  ventricular  biUids." 

Dr.  ODwyer  sums  up  the  avoidance  of  its  occurrence  and  its  treat- 
ment when  present  in  a  full  appreciation  of  its  causes  and  the  skilful 
use  of  tubes  of  projx'r  size,  shape,  and  construction,  and  the  us<'  of 
the  hard-rubber  tube  now  in  vogue,  which  can  l)e  worn  indefinitely 
without  the  occurrence  of  the  calcareous  granules  which  apixmr  on 
the  metal  tubes,  and  which  may  lu'come  a  focus  oi  ulceration;  further, 
the  rubber  tubes  at  their  impinging  ints  do  not  produce  the  same 
degree  of  pressure  as  do  the  metal  tub 


STPHILIS  OF  THE  NOSE  AND  THBOAT. 

Syphilis  of  the  no.se  and  throat  may  be  either  congenital  or  ac- 
quired. Whc"  congenital  it  generally  shows  itself  in  very  early  life- 
although  it  may  be  somewhat  <lelaved,  it  usually  makes  its  apiWirance 
before  the  age  of  puberty.  It  is  generally  as-sociated  with  other 
bo.iiiy  lesions,  u.id  our  first  attention  is  attracted  bv  the  usual 
manifestations  of  a  sy|)hilitic  birth,  viz. :  snuffles  of  the  nose,  mal- 
nutrition, and  possibly  ulcerations  of  the  skin. 

In  attacking  the  interior  of  the  nose  it  usually  .shows  a  preference 
for  the  bony  stru.  tures,  esf)ecial!y  the  septum,  but  may  attack  the 
other  bony  portions,  and  as  the  patient  grows,  if  it  outlives  the  first 
manifestations  it  generally  results  in  a  lo.ss  of  the  septum  and  the 
characten,stic  falling-in  of  the  bridge  of  the  nose.  Sometimes  adhe- 
sions take  place  withm  the  nose,  producing  more  or  less  complete 
obstruction. 

Pharynx.  Congenital  .syphilis  of  the  pharynx  is  perhaps  more 
common  than  that  of  the  nose,  but  frequently  they  exist  together 
being  s'-uply  an  expression  of  the  general  syphilitic  invasion.  John 
iN.  Mickenzie,  sjieaking  of  the  time  of  appearance,  states  that 
about  oO  per  cent,  of  the  cases  occur  within  the  first  year  of  life,  and  as 
many  as  33J  per  cent,  within  the  first  six  months.    The  usual  mani- 


i'l.AT!-;    XXV!. 


F.-i    I     r,. 
F ..I   M     r.t 


IN     ^\  |.li.li~    ..I    T..n, 

I.,1A     --v  |,l,ili-    ..|-    I --. 

\     -s  |.li  :  h-    ..I     H.M.I     r  .h 


I    ..I        i        T.-Ill.ll',     S>|.l.,l,-.    ,,f    S,,l!     (>;i 


v >•."/'//„. s  <tF  Tilt:  snsi-:  a\i>  Tin:o.\r.  f^^J 

tVst;.'i..n  in  tl...  ..haryiix    is   an    ul.rn.Iion.  griuTally  ult!u-kiii«  the 
iH.ny  .siruct.in-  hrst.  viz.:  tl...  h,,nl   palat...   |.r.«lu,-inK  hTlnratioM 

w.'ll,  an.l  wl,,,,  thosuf,  palat..  ,.n.l  la.irial  pillars  l,<.ru,n.' ulmat...| 
II  iiM.ally  .■i„!s  Ml  ll...  pr...lucti.,n  <>(  a-lhosicns  h.-tw.H-n  ti.c  pharvnK..ai 
wall  an.l  suit  palatr.  Conurnital  syphilis  .,f  the  larynx  is  vm"rar..|v 
s.'.-ri.  Ih.'  Kcncra!  ty,.."  an.l  appraraiur  „f  tlu-  l.'siun  (Ic's  not  vary 
In.ni  hr  losiui.  .,(  the  a.-.iuircd  frtiary  f..r.n,  which  will  Ih"  .Icsi-ribcd 
more  hilly  iinilcrthat  heading. 

Acquired  SyphiUs.  In  its  prin.ar>-  forn.  un.l.T  the  torn.  ..f  ..xtrn- 
j:.'nitai  .•hanrr...  il„.  nntial  Icsi.m  is  rath.-r  infnviuont  in  the  noso  hut 
;"">■'•  lr,.,,u<'nt  n.  th.-  lips.  fmRu.-  (Plate  X\\J..  1%.  i,,  ,„„|  ,;„,„.. 

times  ...r.irnnK  on  .>i r  ctluT  nf  the  tonsils.     W  h.-n  <e,.„  i,,  „,.,nv 

"  tliese  positions  it  .io,.s  not  vary  Iron,  the  general  tyjH- <.f  genital 
;l';"|.Mv.  V.Z.:  that  of  .•.  localize,!  induration  with  tnore'.'r  less  sup,"' 
nml  ul.vration.  Pron.  its  rarity  in  this  position  it  is  not  infr,..,u,.ntlv 
nistak...,  I..r  epithelioma,  hut  th.-  sul.s<M,uent  .secondary  n.anifesta'- 
li..n  soon  estal.l..shes     its  character.      Asa    rule,     the    se,.o„darv 

.       ;   ■;  •■'";'•••<"""■   '"<"'    -vere  in  their  nature  than  when  '„. 
'Ii.ii.cie  i>  o(  the  usual  genital  variety. 

Secondary  Syphilis.  Secondary  .syphilis  is  extremely  rare  in  the 
;..-.;  ,n  the  pharyt.x  (l'lat<.  XWI..  Fi,,  ,>,  ;,  is  e.xtren.ely  co.n- 
mon  and  oc.-urs  ,n  a  very  !,.„ge  proportion  of  those  affected  with 
M  i  T'  ;''''"7;"*^  "'""";'  ""Vthne  within  a  few  we-ks  to  months 
.'Iter  the  initial  lesion  an.l  a.s.sociated  as  a  rul.'  with  other  s,.co.ulary 
'-ni  .'statiotis.     It  may  attack  ai.y  porti.u.  of  the  cavity  o     t  ."e 

na  th.  VIZ. :  hps,  msides  of  the  ch.-ek.  the  sid.'s  of  the  tongue,  or  the 

'iiK.s.     It  ,..  „,,,st    characteristic  when  seen  in  the  faucial  region 

;M.a  b- tuanilestn^  .t^-lf  by  a  symmetrical  erythema,  having  ^^l^: 

ne  1    ateral  fan-shaped  appearance,  sp  rem  ling  over  the  anterior 

.   >  ol  tl...  tauces,  and  u.sually  ...eluding  the  tonsils  ..md  the  posterior 

"ll-i..^.     In   a  wel-marked   vinilent  cas<-  the  entire  posterior  region 

.y    u"c,.me  iniplicated.  ami  ..nn.timesit  spreads  to' the  m.se,  .LJ! 

-  I  .n.uigeal   .space,  and    Kustachian    tulx-s.      In    typical    ca.ses  our 
II    ent,,,,.    becomes   almost    in.n.e.liately  .lirecto.l   u,   this   bilateral 

.       r  emia  of  the  fauces  by  ob.s,.rving  their  sup.Tinr  reddened  n.argins 

.        c  I  TT  r,    "''"'''•"'  •■""'  '''^  ''"'>■  '*^*'""'  ""^  "'  '•"'"•f  against  the 
M  lor  o      he  .superior  portions  of  the  palate.     W  ithi.rthis  area 

■I  l.u.ial  er\thema  and  at  various  j,oints  th.Te  appear  the  chanc- 

-  IS  ic  ,K.arl-co  ored  plaques  calle.l  "  mucous  patXs,"  h  h  -re 
J-  ightl  elevate,!  fro.n  the  surface  of  the  erythema,  am!  frec,uen  ly 
ll.  u>  an  ai,pearan,-e  as  ,t  they  ha,l  b,'..n  flatteno,!  out.  \\hen  small 
■;    more  or  ess  ,.solat,.,|,  they  are  generally  cre.scentic  in  appeanuiS 

:t^A:.C^S^%::\:^^^^'  --  t.,  have^/hee„tir; 
Mthoni^i,  ..  ,  "  .  " '"^  ^''-  :"n-i'=,  wrtcrrd  wnn  the  mucous  patch. 
Alttmufth  a  typical  ca.se  of  secondary  syphilis  as  above  described 

-  comparatively  easy  of  diagnosis,  and  whin  once  sc-en  ca.mot  very 


><48 


NO.SE  AXD   I II  no  AT. 


well  l)c  (•(iiifouiidcil  witli  any  otlicr  Ic.-ions,  the  diaftiiosis  of  a  mild  or 
a  I'adiiifi  case  is  ot'tcii  very  ditiicult  of  diafriKtsis.  It  is  not  infrciiuciit 
to  notice  a  l)ilatcral  liy|M  niTuia  of  the  fanccs  wliicli  is  Ix'iiijrn  in  its 
ciiaractci-.  i)iit  tlir  liy|MTainia  of  secondary  syphilis  is  (h'cper  and 
more  siihmucoiis  in  its  nature  and  may  Im-  paler  in  color,  and  usually, 
'.'.  not  always,  when  the  free  ed^jes  of  either  the  anterior  or  posterior 
l)iliars  have  })een  afi'ecte(|  then'  will  l)e  left  evidences  of  a  slight  erosion 
somewhat  serrated  in  appearance. 

In  reachinj;  a  conclusion  in  the-  difficult  and  suspected  cases  I 
have  come  to  look  upon  this  last  appearance  as  a  very  .-trong  point 
in  the  (lia<;nosis.  Sometimes  the  secondary  manifestations  affect 
the  tonsils  only,  producing  what  may  bo  called  a  .syphilitic  tonsillitis. 
When  this  occurs  the  tonsils  become  acutely  enlarged,  of  a  pale-gray 
color,  and  their  whole  surface  covered  with  this  irregularly-shaped 
gray  pla.jue  formation.  This  hypertrophy  is  very  stubborn' in  char- 
acter and  yields  but  slowly  to  treatment.  It  is  not  necessary  here 
to  detail  the  evidences  of  general  .systemic  involvement,  which,  how- 
ever, must  be  looked  for  in  diagnosis. 

The  subjective  symptom^  of  faucial  .secondary  .syphilis  are  tho.se 
usually  of  an  onlinary  .sore-throat,  but  lasting  niucJi  longer,  the  pain 
and  intensity  of  which  vary  with  the  severity  of  the  ca.se.  When 
severe,  a  more  or  less  decided  salivation  is  present. 

Secondary  syphilis  of  the  pharynx  is  very  prone  to  recurrence,  an<l 
even  after  being  api)arently  thoroughly  (•bliterated  by  treatment  it 
may  recur  often  after  th<'  lapse  of  months. 

Diagnosis.  It  usually  lies  between  herjits,  diphtheria,  follicular 
tonsillitis,  aphthous  sore-throat,  and  tubercular  ulceration,  the  v;  iou- 
characteristics  of  which  will  \m\  described  under  their  separate 
headings. 

Secondary  Syphilis  of  the  Larynx.  This  is  comparatively  rare  in 
occurrence  and  exists  usually  associated  with  secondary  .syphilis 
of  the  pharynx.  Wry  rarely  does  it  exist  by  it.self.  There  are  the 
subjective  symptoms  of  irrit.ation  of  the  larynx  with  more  or  less 
hoarseness,  the  hoarseness  being  of  a  peculiar  raucous  character 
The  local  ai)pi';trances  are  tho.so  of  a  more  or  less  catarrhal  infection 
of  both  the  true  and  false  cords,  with  hypera'tnic  spots  and  .sometime- 
the  .-iiipfviraiice  of  a  true  plaque  formation,  or  verv  sup(>rficial  ulcera- 
tions, usually  bilater.'il.  on  the  vocal  cords.  Tlie  epiglottis  is  als>' 
sometimes  the  seat  of  thes.ame  manifestations,  and.  in  addition  to  tlir 
ordin.ar  .•  secondary  .symptoms  as  described,  we  may  have  a  formiitici 
of  condylomata  of  the  laryngeal  nuicous  membrane,  which  excn- 
cences  may  become  sullicient  to  cause  considerable  stenosis  of  ih- 
larynx.  In  one  instance  reported  i)y  the  writer  the  steno.sis  w:i  • 
sufficient  to  warrant  an  intuli.ation  to  save  the  life  of  the  patient. 

The  treatment  of  secondary  syi)hiiis  of  the  throat  is  mainlv  con- 
stitutional in  character,  consisting  of  the  administration  of  mercuiy 
in  some  of  the  usual  forms,  ami  wlicti  the  character  of  The  manifc--: 
tion.«  seem  to  be  deep  with  infiltration  the  treatment  is  enhanced    y 


^'»r^ 


SYl'UILlS  OF  THE  XOSE  A  SI)  THROAT. 


849 


tlio  addifioii  of  the  iodide  of  potash,  rominonlv  called    the  mixed 
Ireatiiiciit. 

Local  treatment,  altliouph  sometimes  used,  as  a  rule  is  unnecessarv 
as  the  eoiiduion  fieiierally  responds  to  constitutional  treatment  aiid 
object  of  the  local  treatment  would   he  only  as  a  matter  of  cleanli- 


the 


ness.  it  the  mucous  patches  of  the  pharvnx  are  very  extensive  it  is 
|.ossil)le  that  their  healing  may  be  somewhat  hastened"  bv  the  applica- 
tion ot  inild  caustics.  Among  the  various  spravs  or  antiseptic 
Har^Hes  which  may  be  used,  a  sargle  consisting  of  the  ordinary  black 
'vasli,  dihite(|.  IS  of  assistance  in  the  treatment. 

Tertiary  SyphiUs.  Tertiary  syphilis  of  the  nose  and  throat  is  very 
romih.Mi  and  one  of  the  most  frecpient  manifestations  of  the  tertiary 
lorm  of  the  disease.  It  is  peculiarly  ulcerative  and  destructive  in 
Its  nature,  being  the  result  of  a  l)reaking  down  of  a  gummatous  infil- 
tration, resulting  in  the  nose  in  the  destmction  of  the  septum  and 
other  mtrana.sal  bony  portions,  and  in  some  cases  producing  by  the 
necrosis  ot  these  bones,  a  falling  in  of  the  exterior  of  the  nose,  with 
Its  characteristic  deformity. 

Nose.  In  the  nose  it  usually  begins  with  symptoms  of  more  or 
less  severe  intranttsal  irritation,  soreness  and  jiain  being  quite  i)rom- 
iiu'iii,  nocturnal  pain  IxMng  very  characteristic.  When  high  up 
external  swelling  with  some  nnlness  and  tenderness  on  pressure  are 
tnM|ii.-ntly  noticed,  causing  (luite  a  noticeable  broadening  of  the  bridge 
ot  the  nose.  As  the  condition  progresses  nasal  obstruction  becomes 
more  and  more  marked,  and  soon  there  supervenes  a  breaking  down 
or  ulceration  of  the  induration:  this  may  take  place  at  any  point 
iHit  usually  lM>gins  on  the  se{)tum.  It  may  be  unilateral  or  bilateral,' 
^^ncrally  the  latter,  attacking  either  the  cartilaginous  or  bony  sep- 
timi.  and  m  its  course  may  include  the  entin-  intranasal  bony"struc- 
'iirc.  I  Iceration  at  the  external  Uiml  orifice  is  often  noticed,  and 
II  may  extend  to  contiguous  portions  of  the  upper  lip.  With  this 
iil<'cration  there  is  a.ssociat.vl  a  bloodv  mucopurulent  discharge  fre- 
incntiy  extensive  in  amount,  with  (lislodgement  and  expulsion  of 
i'.nts  ol  the  intranasal  mucous  membrane  and  bony  portions-  some- 
"mcs  the.lischarge  becomes  hard  and  dry.  and  is  "either  expelled  in 
m-pissated  masses  on  the  part  of  the  jjatient,  or  retpiires  the  a.ssist- 
mce  nt  the  surgeon.  After  the  necrosis  has  existed  for  some  time 
'lie  discharge  becomes  very  offensive  and  charact<'ristic  in  odor 

Treatment.  Treatment  otlu-r  than  con.stitutional  by  iodide  of  potash 
)^hicli  \vi!l  !«•  all-suHicieiit  if  th<>  nasal  invasion  is' recognized  early' 
'"•lore  deep  destruction  is  established,  must  \w  sui)pleniented  In- 
•li  Tough  ;u..l  repeate.1  cleansing,  which  is  all-important,  bv  stimii- 
■'tion  ot  tl„.  ulcerations  by  mild  caustics  and  by  insufflations  of 
!'"l"t<'nii  or  by  some  of  its  e(|u,illy  good  .substitutes. 
^  When  bony  necro.sis  is  present  "and  the  secpiestrum  is  not  as  yet 
"ose.  (niretling  or  trephining  may  be  employed.  When  .any  pnrt"ion 
"1  tlie  bony  structure  becc.mes  loose  the  secjuestra  may  be'removed 
'  \   rong(.ur  or  traction  forceps  or  by  their  combined  use:  when  too 

64 


"T--^ 


860 


yOSE  AND  THROAT. 


large  for  removal  by  either  of  the  above  combinations  it  may  be 
necessary  to  resort  to  some  major  operation,  among  which  may  be 
mentioned  that  of  Rouge.'  which  consists  in  the  removal  of  the 
sequestrum  through  exposing  by  incision  the  intranasal  cavity  by 
eversion  of  the  upjx>r  lip  and  external  nose,  thus  leaving  a  mini- 
mum of  ileformity  tus  the  result  of  ojx'ration. 

Pharynx.  In  the  pharynx  any  jjortion  may  be  attacked,  resulting 
in  more  or  less  loss  of  tissue,  ancl  producing  adhesions  and  cicatri- 
zation of  the  various  parts  affected,  with  perforations  both  of  the 
hard  and  soft  palat<'.  (Plate  XX\I.,  Fi--.  li.  4.)  The  lesion  may  l)e 
unilateral  or  bilateral.  The  cicatrix,  we  nnght  say,  is  always  present 
as  a  result  of  a  severe  tyi)e  of  ulceration.  It  is  (juite  characteristic. 
ho'mfr  whitish  or  yellowish  hi  color,  and  more  or  less  stellate  and 
radiating  in  shape,  and  may  occupy  an  extensive  area  from  the  naso- 
pharynx to  the  larynx,  according  to  the  extent  involved.  This 
cicatrization  is  one  of  the  most  characteristic  evidences  of  tertiary' 
syjihilis.  In  extensive  cases  the  resulting  cicatrization,  adhesions, 
and  contraction  may  materially  encroacli  on  the  lumen  of  the 
pharyngeal  space,  so  as  to  seriously  impede  the  power  of  deglutition. 
When  .seen  early.  l)efore  ulceration  h:is  taken  place,  there  is  generally 
a  marked  induration  (the  gummatous  formation),  the  surface  of 
which  has  more  or  less  of  a  velvety  ap])earance,  and  is  seen  mo.st 
typically  when  it  affects  the  soft  jjalate.  The  surface  of  the  indura- 
tion is  red  and  angry  in  appearance,  and  .  oon  gives  way  to  a 
breaking  ilown  or  ulceration  at  almost  any  i  ohit. 

The  character  of  the  ulceration  is  that  it  is  deep  and  destructive  in 
nature,  the  edges  more  or  less  well  defined,  irregular  in  appearance, 
and  the  surface  of  the  ulc(>ration,  .as  a  rule,  covered  with  a  thick,  yel- 
lowish, ropy  secretion.  This  featun;  varies  according  to  the  parts 
in\(ilved.  there  lM>ing,  as  a  rule,  more  of  the  thick  .secretion  when 
the  {posterior  pharyngeal  wall  is  implicated.  Subjectively  there  may 
be  mon'  or  less  pain,  with  pain  and  difficulty  in  deglutition:  but 
severe  pain  is  not  a  constant  characteristic  as  compareii  with  the 
pain  of  malignancy  or  tuberculosis,  and.  indeed,  it  is  (|uite  conmion 
to  find  quite  an  extensive  amount  of  ulceration  with  comparatively 
little  pahi.     This  will  dejM'nd  upon  the  area  involved. 

Diagnosis.  The  diagnosis  of  tertiary  syj)hilis  of  the  pharynx  lies 
between  tuberculosis,  malignancy,  lupus,  traum;itisms.  ancf  ulcero- 
membranous angina  a.s,sociated  with  tlie  b.-icillus  of  \'incent. 

Treatment  of  ph;irvngeal  syphilis  is  m;iinly  constitutional,  in  the 
administration  of  iodide  of  potash  aided  by  thorough  cleansing  of 
the  parts  and  |)ossil)ly  the  application  of  mild  caustics,  as  indicated 
in  the  individual  type  and  condition  of  the  ulcenition.  The  resultiiiL' 
adhesions  re(iuire  suitable  surgical  means  of  uilatation  and  excision^ 
to  meet  the  si)ecial  ca.se. 

>  Rmie.''"  Operation  for  Remiiv.i!  of  Sa.ia!  Seiii«tr;iin,     Hr  "'  II  Knfght,  New  Vofh.    Pbl!«*?' 
rhlk  Mndical  New<,  January  3, 1H91. 


?3S^*(T=— .■-^L-E^V-fT^'. 


TUBERCULOSIS  OF  THE  NOSE,  PHARYNX  ASD  LARYNX,    ggi 

Tertiary  syphiUs  of  the  larynx  is  of  very  oonmion  occurrence  beinc 
present  in  ;i  large  percentage  of  cases  of  syphilitic  infection  Tth2 
perl'aps  ru.t  an  fre,uent  .s  pharyngeal  invoK-enien  Tn^^^^^ 

affe<-t..,i   m. iefH^n.lently  or  by  extension   from  the  pharvnx       The 

t.:  hrVnx'    Sr '/"  ""f  fr^r"  "^'"^••''^'^  ^^e  entirlTtructure 
1  th(  Kirjnx.     The  nature  of  the  lesion  is  the  same  a.s  in  other  nor- 
tions  VIZ.   a  gumma  with  a  sul,.se,,uent  destructive  ulceration  r^t?hi 
...g    he  same  generic  characteristics,  but  only  varyingTn    he  Tatu^' 

iinasion  of  that  kind  within  the  larynx 

Although  there  are  instances  of  long-standing  lesions  of  chronic 
hickemng   where  tlH>  cords  lose  their  color  and  contour   the  con 
.on  l«;mg  kept  in  alx-yance  by  treatment,  and  theTbcipal   vm^^^^^^ 
benig  that  of  hoarseness,  still  the  ten.lency  of  terfia^  svph  iS^t^ 
produce  an  encroachment  on  the  lumen  of  the  larjTix  e  ther  in  the 
formative  stage  of  the  development  of  the  induratiranl  elrlv  £ 
stmctive  ulceration,  or  in  the  resulting  .leformities  of  conTractior 
adhesion,  and  adventitious  tissue,  producing  not  only XTr^iess' 
but  the  more  serious  condition  of  pr(,gres,sive  in.pairni.uit  of  bre.th 
.ng  due  to  the  laryngeal  stenosi-'    Perichonclrit^  S  t  fe  c  v^h 'es" 
n  ay  be  produced,  and  may  occur  as  a  n>sult  of  the  necr otTc  Smilsbn 
o  vanotis  cartilaginoas  portions.     Pain  within  the  lar^m  I  n tr 
able  symptom,   being  more  prominent  in  the  early  Jt^^e      l,;i^,re 
.i.ronicity  is   estubhshe.l.  and    external    pain    am     teSnes.    m 
I-r^sure  may  ensue,  according  to  the  extent  of  the  deeper  "nvdv'e- 

Treatment.    The  treatment  is  constitutional   in  giving  iodide  of 

\    lunt  and  rapid  results  have  been  procured  bv  the  combination 
h  bu-hlon,  e  of  mercurv-  given  hypoctrmicallv. '  For  the  niechTn- 

TUBERCULC  THE  NOSE,  PHARYNX.  AND  LAEYNX. 

.■xSnns''.?lmo  ■'       •  T'l  '-^  '"  -^*-:-'-V --are  affection,  and  when 

tl,„  I    •      ■  •        •)     .  "K  affected.     Hill   reports  one   case  in  whinh 

•u.    >.Kh,s  ahso  report  primary  tuberculosis  of  the  .septum     ™™"'' 

It  occun.,  a.  a  rule,  in  two  forms;  ulceration,  generally  on  the  sep- 


iiffH^r-.     V-a  "T5,'«7r 


852 


NOSE  AND  THROAT. 


turn  or  floor  of  the  nose ;  or  the  hyperplastic  form,  either  on  the  septum 
or  the  inferior  turbinate  l)one.' 

Some  authors  attribute  perforation  of  the  septum  so  commonly 
seen,  to  a  tubercular  origin.  The  latter  course  of  the  lesion  is,  as  a 
rule,  very  slow  and  indolent  in  its  progn'ss,  existing  sometimes  for 
many  years  without  giving  rise  to  verj-  marked  symptoms.  The 
ulcers  are  painless,  rather  small,  slightly  depressed  and  irregular  in 
shape,  with  a  tendency  toward  the  formation  of  crusts,  and  bleeding 
quite  easily,  their  centre  having  a  caseous  appearance.  The  hyper- 
plastic form  is  generally  in  the  shape  of  small,  grayish,  warty  growths, 
situated  on  the  surface  of  an  induration,  rather  soft  and  bleeding 
easily,  and  not  unlike  papilloma.  The  diagnosis  is  generally  made  on 
finding  the  tubercle  bacillus.  From  the  position  of  the  lesion,  local 
applications  are  easily  matte,  but  there  is  always  a  very  marked 
tendencj'  to  recurrence. 

The  local  treatment  is  the  same,  as  will  be  described  elsewhere,  as 
in  the  local  treatment  of  pharyngeal  and  laryngeal  tuberculosis. 

Tuberculosis  of  the  Pharynx-  Next  to  tuberculosis  ot  the  nose 
that  of  the  pharynx  is  the  most  rare  of  the  tubercular  manifrstations 
of  the  upj)er  air-tract,  and,  indeed,  until  quits  recently  it  was  con- 
sidered extremely  rare,  but  later  extensive  ii  dividual  research  and 
obser\'ation  have  bi'ught  pharyngeal  tuberculosis  into  a  greater 
degree  of  [jrominence  It  is  almost  always  ;issociated  with  laryngeal 
tuberculosis.  It  may  attack  any  part  of  the  pharynx,  including  the 
soft  palate,  uvula,  tonsils,  pharyngeal  wall,  and  lingual  tonsils,  without 
any  .special  reference  to  any  one  seat  of  election.  When  one  part  is 
affecteil  it  shows  a  rapid  tendency  toward  extension,  which  in  some 
cases  is  a  very  marked  feature. 

Symptoms.  In  a  well-marked  instance  the  subjective  symptoms 
are  those  of  very  severe  involvement  of  the  throat,  pain  being  a  promi- 
nent ami  severe  symptom,  constant  in  character,  and  producing  a 
very  marked  dysphagia.  The  general  aspect  of  the  patient  is  one  of 
suffering  and  emaciation.  The  local  lesion  is  generally  one  of  ulcera- 
tion of  the  type  peculiar  to  tubercular  ulceration  of  the  mucoas  meni- 
braiio,  rather  superficial  and  having  an  angry  appearance,  without 
nmch.  if  any,  induration,  excei)ting  perhaps  on  the  edges  in  the  older 
cases,  covered  with  a  variable  degree  of  secretion,  ano  surrounded 
by  a  red,  inflamed  area,  presenting  fre(|uently  a  coalescing  tendency 
and  the  appearance  of  bu/rowing  or  a  "  worm-eaten  "  appearance. 

The  character  of  the  ulceration  seems  deefjer  as  it  attacks  the 
faucial  or  lingual  tonsils,  the  author  having  seen  almost  an  entire 
lingual  tonsil  rapidly  destroyed  l)y  acute  tubercular  ulceration. 

Prognosis.  The  prognosis  is  extrem(>ly  bad,  the  })atient  succumb 
mg  either  to  the  primary  pulmonary  tuberculosis  or  to  the  star\'ati<iii 
and  inanition  produced  by  dysphagia  from  the  j)haryngeal  involvc- 

'  HerynK,  in  a  reTiew  of  ninety  cane!,  found  the  leaion  to  occur  In  lbrt]r^!i(ht  u  ulcere  sod  i- 
forty -two  a«  tumon. 


i3ffv«~TT«»'=a-"3»»'  y^masoff^  « 


^sxm£T^'im,\i.  :•■ 


I'M 


F^l.A  T!-;   XXV!  I. 


S.  11 1 II'    F  ■  .1  1  n-  ■  •!    I  .:  1 1  \  III  1.  nl   Ti  1 1  rr  i  i  1 1 1. 


TUIiKlWlLOSIS  OF  THE  SOSK,  I'llARYSX  AXD  LARYXX.    «5;} 

iiu'iit.  Altliniiuli  tlic  location  of  plimynjitcal  tulxTciiIosis  sft'iiis  to  Im* 
i('"al  for  the  ap|)li('ation  of  local  treatment,  an<l  althouKli  the  iiuli- 
vidiial  areas  of  ulceration  may  become  healecl  by  treatment,  there  is 
ah»  ys  a  marked  tendency  to  extension.  The  local  treatment  in 
.let..il  will  he  referred  to  under"  Larynj^eal  Tuberculosis."' 

The  diafTiiosis  lies  bet\ve<>n  syphilis  and  carcinoma,  and  can  l)e  made 
|)ositivi'  by  the  findinji  of  the  tubercle  bacillus  in  tlie  secretion  or  l)y 
histological  examination. 

Tuberculosis  of  the  Larynx.  The  larynx  is  by  far  the  most  coin- 
mnti  seat  of  tuberculosis  of  the  upper  air-tnict,  and  it  is,  as  a  rule, 
if  not  always,  secondary  to  or  associated  with  pulmonarj-  tulierculosi.s. 
Me:irin>j  on  this  subject  of  the  fre(|uency  of  larynjieal  tuberculosis,  in 
tile  rei)ort-  of  the  Hromptoii  Hospital,  Kngland.  oO  per  cent,  of  laryn- 
P'al  tuberculosis  is  jjiven  as  occurring  in  all  cases  of  pulmonary 
tuberculosis.  Willigk  s'ves  237  cases  out  of  1300,  and  Kidd  gives 
20  per  cent. 

This  \  iew  of  hiryngeal  tuberculosis  being  always  secondary,  is  held 
by  almost  all  observei-s,  and  is  jjroven  by  the  findings  of  autopsies, 
there  being  very  few  recorded  cases  of  death  by  laryngeal  tuberculosis 
where  pulmonary  involvement  has  not  been  found.  The  ojjponents 
of  this  view  are  very  few  in  number,  the  most  prominent  of  them 
being  Dr.  (Jleitsmann,  o<"  New  York,  whose  researches  have  been  ex- 
tensive and  who  rejMjrts  two  cases  of  primary  laryngeal  and  |)haryn- 
jreal  tuberculosis  in  his  own  practice  wiiich  were  cured.  In  tiie  report 
of  his  cas(>s  in  the  Journal  of  Tubcrculosix,  April,  1891,  he  (juotes 
Deiiime,  K.  traenkel,  Pogrebinski.  (^rl.i,  Coghill,  J.  S.  Cohen,  Dehio, 
and  Lancereaux  in  .support  of  his  view. 

The  subject  of  primary  tul)erculosis  of  the  larynx  is  so  imjwrtant, 
bearing  on  its  }irogres.>^  and  curability,  that  we  may  digre.ss  for  a  mo- 
liient  by  saying  that  it  is  almost  an  impossibility  to  prove  the  exi.st- 
ence  of  primary  or  di.s.sociated  tuln-rculosis  of  the  laryn.x  without 
.lutopsy.  It  is  possible  for  the  laryngeal  involvement  to  be  appar- 
ently primary  to  pulmonar}'  involvement,  by  reason  of  the  patient 
lir<t  calling  attention  to  the  larynx,  or  by  the  preponderance  of  the 
i;iry:it;eal  condition,  or  to  exist  where  the  pulmonary  tui)erculosis 
may  be  for  the  time  in  abeyance.  An  examination  of  tiie  chest  may 
iiWc  negative  results,  but  this  in  no  wise  proves  that  the  lungs  are 
lint  inv<ilved,  and  if  we  find  during  the  course  of  the  (lisea.s<>  that  the 
lungs  do  become  involved,  notwithstanding  the  fact  that  our  attention 
has  tir- 1  been  called  to  the  laryngeal  .symptoms,  we  cannoi  say  that 
the  case  wjis  one  of  primary  tubercular  laryngitis.  The  a.-;sociation 
"f  the  two  conditions  is  very  strong,  if  not  positive  evidence  that  tiie 
hings  were  first  involved  ;md  the  larynx  secondarily  so,  for  we  know 
'iiat  it  is  possible  to  have  certain  forms  of  pulmonary  tuberculosis 
not  giving  ri.se  to  many  physical  .symptoms  at  first. 

In  wiriie  mri' insiiiiirt'soi  Uniitizoit  iiidiilont  formx  of  pburyngeal  ulceraium  or  induiatloni  per- 
I  iiui  lit  hi'iiliiiK  hHs  titt'ii  obtaiiie<l  by  local  measures. 
-  »Vatsoii-\VilMamn. 


[ 


854 


NOSE  A.W  TUnUAT. 


\ml  iieain  if  lurvt.Rcal  tubcrt-ulosis  were  primary  or  dissoeiated 
to  a  V  sn-at  i-xfrnt  "tluTe  n-rlainly  w.ml.l  Ih«  nun.  posmve  evulenee 
of  it  wlien  we  c.isi.ler  the  extremely  e..miu(.n  occurrem-e  o  a  >..- 
1  tulH-reulosis.  It  is  true  tluit  in  .some  instances  laryn^ea  tuber- 
l^dosis    .nay   prepon.l.Tate    over    pulmonary   tulH-.Tulos.s    for    the 

^"'IV  mth  r  ha.s  seen  many  e:i.ses  of  tuln-rcular  laryngitis  which  he 

,h,  u«h  primarv,  and  whi.-h   for  a   time   s<.e„,ed  to  y.e  .1  to 

reatme ut    the"  subsequent    progress    of    the   ''j-;^; .;;-;; 

proved    fatal    through    the    '^->'-'''''-^^>'7^'''''%  ;'.•';' ';-^ 
nlH-rculosis      It  is  possible  in  a  sus|M>eted  mstance  of  piimarv    uIm r 
.     .r  lar vngitis  wher-'  the  pulmonary  signs  are  negat.ve  that  the  use 

of  th. -X-rays  may  disprove  or  substantiate  the  presence  ot  puhnonary 

'"sySiptol':    The  svmpt(Mns  of  tubercular  laryngitis  vary  acconUng 

to  th^  tvp«>  of  invlvenu-nt.     In  the-  typical  ciise  the  hrst  subjective 

vn'rtonMuay  be  an  alteration  of  the  voice   which.  "---;-- ^ 

d'epeu.l  somewhat   upon  the  localization  of  the  lesion      The     oice 

ecomes  slightlv  hoars.-:    but  it  may  progress  to  c.inplete  aphonia 

wi      t  le  exum^ion  of  the  disease.     The  •■haracter  of  the  hoarseness 

s     .ore  ..f  the  soft  or  weak  variety  =.s  distinguished  from  the  harsh 

„ualitv  of  paralvsis  or  laryngeal  growths.     This  hoarseness  is  not 

a-™  due'to  marke.l  tubercular  involvement,  but  may  be  due  to 

the  general  muscular  weakness  «.f  the  larynx 

Cough  is  a  verv  prominent  symptom  which  may  procee.l  either 
from  associat.-d  pulmonary  tub<-rcul.. sis  or  from  laryngf|iil  irritation. 
IV  <  also  a  wrv  prominent  sympt..m,  esp<.c,ally  where  there  is 
ulceration.  The  pain  is.  as  a  rule,  lancinating  in  character  and 
radiating  to  the  ears.  This  latter  feature  when  the  '-vnx  is  in- 
volved is  almost  pathognomonic  ..f  laryngeal  ulcerati-.  jhe  1  fi 
becom.-s  excessive  in  accordance  with  tlu;  progress  of  <  ,e  ulceration 
until  it  mav  pro.luce  marke.l  an.l  very  .listr.'ssing  .l>>i.hagia.  hx- 
cessive  pain  is  indicative  .)f  .l.'ci.l.'d  ul.-eration. 

Dysphagia  is  .)ft.M.  a  promin.'.it  symptom.  es,«^cially   n  the  later 

.taSslf  the  .lis,.ase.  an.l  often  to  such  an  extent  that  patients  re  use 

food  '«oth  from  their  inability  to  swalL.w  or   from  the  excruc.atmg 

nain  whi.-h  th.«  latter  .-auses.     In  th<«  indurating  .an.l  n..n-ulcerative 

vpe  ..f  tulH'rcular  laryngitis  pain  may  not  l«-  a  pnuumeiit  >^yinptom. 

■  Expectoration  and  Secretion.     i:xi)."ct..rati..n  is  almost  always  pre^ 

ont    b.'ing  ..f  tlu'  usual  tubercular  natur.".  generat.'.l  either  in  the 

lungs  or  m  th.-  larynx.     S..metimes  from  the  pain  ^-'"/'h/^^'  "">*";" 

of  th.-  larvnx  pn..lu.-es.  an.l  fn.m  general  weakn-ss  of  th*-  SJ"     > 

th,'«  tulK-rcular  inv..lv.-ment.  ex,>..ct.)rat...n  becnu-s  v.jy  <  'ffi"»lt-  '^  <» 

from  its  thick  charact.-r  an.l  accumulati.m  within  the  larynx  .nay 

;  ve  ris..  t..  s.-v.-r..  fits  .,f  .■hoking.  ..fttim.-s  causing  great  exhau.sti.n 

Tuter  rep.-at.'.l  .•ff.-rts  at  .-xpulsi..n.     \omiting  .s  not  infn'.iu.-nt  > 

;'uJe.l  by  .-x.-.-ssive  eff.-.ts  .hie  t..  c.ughing  and  the  eiuleavor  t« 

expel  the  mucus  from  within  the  larynx. 


TUHEIiVL'LO.SIS  OF  THE  XOSE,  PlIARYSX  ASh  LAHYSX. 


855 


Appearances,  l-aryngcal  tulM-rculosi.s  is  cliicHy  cliaractcrizod  by  the 
ajiiH'iiranfc  of  iii.liiratioii  and  uln  ration.  In  the  usual  variety  of 
tulxT.  tilar  laryngitis  the  first  change  in  the  niucc.as  nieinhraiu"  |M'r- 
('.■ivcd  t..  laryngeal  examination  is  tlic  change  in  eoior.  In  some 
instances  the  larynx  Ixromes  very  ana'mic,  which  is  considered  by 
some  to  Im-  of  |)ath()Knom(inic  significance,  an.l  when  it  is  :issociated 
with  otiier  Keneral  conditions  it  is  sometimes  spoken  of  as  the  pre- 
tiibercular  an:emia.  This  aiuemia  is  not,  however,  necessarily  indica- 
tive of  tubercular  laryngitis,  as  it  may  Ih'  an  expres.sion  of  the  general 
aiuemia  of  the  patient.  There  are  some  cji-scs  to  the  contrary,  how- 
ever, where  marked  redness  or  hy|)era'mia  mav  i)e  the  first"ciiange 
Ml  color,  and  jx-rsisting  to  tiie  end,  usually,  however,  !i.s.sociated  with 
more  or  less  mduration  of  .some  portion  of  the  larjTix.  A  localized 
redness  of  one  or  both  cords  may  l)e  among  the  earliest  tul)ercular 
indications.     Induration  of  some  portion  of  the  larvnx  makes  a  very 


Klu,  4L'7. 


Flu.  4SS. 


Extensive  cliib-iiliaped  swelUnfr  of  arytenoid  cartilages,  with  swelling  of  ventricular 
bands.    (Cohen.) 


•■ariy  ai)i)earance.  and  may  have  its  initial  seat  in  almost  any  portion 
ol  the  larynx.  However,  one  of  the  vocal  cords  is  generally  the  first 
part  to  become  involve.l,  and,  although  there  has  been  an  attempt 
to  localize  this  first  apfwarance  of  induration,  we  may  say  that  it 
may  m.ike  its  first  apjM'arance  almost  anywhere  within  the  laryngeal 
cavity.  When  it  attacks  the  vocal  cords  thev  lo.se  their  normal 
contour,  becoming  .somewhat  rounded  and  nodular  or  flabbv  in  char- 
■icler.  :md,  if  very  much  reddened  they  may  at  the  .same 'time  lose 
ilii'ir  identity  in  the  general  swelling  of  the  .surrounding  tis.sues.  This 
mduiation  of  the  vocal  cords  may  be  either  unilateral  or  bilateral. 
I  lie  false  cords  or  ventricular  bands  .sometimes  become  involved  to 
such  an  extent  that  they  overlap  and  obliterate  the  true  cords  on 
tiicir  respective  sides.  When  the  induration  in\oive>  the  arytenoid 
cartil.-ige  a  characteristic  condition  is  established.  They  lose  their 
.-sharply  defined  appearance,  becoming  somewhat  club-shaped,  and 


8.jG 


AO.VA'  A.Mt  III  no  AT. 


31 


wlicii  it  cxtt'iitls  tit  tlif  aryt<"ii(M'|ii>;lottic  liKaiiioiit  tlio  iiililtruliuii 
presents  ji  coiulitioii  wliieli  is  extremely  characteristic  of  tiiltercular 
laryiijiitis.  A  i>yrainiilal-slia|)eil  swelliiij;  or  imliiratioii  of  one  or 
Ixitli  arytenoid  cartila>»es  may  1m'  taken  as  one  of  tlie  stiun;;  p'  thojr- 
iiomoiiic  sijins  of  tiilH-rciilar  laryngitis. 


Fl(i.  4.W. 


Flu.  tVt). 


Fid.  431. 


Fkj.  4l"j  — TiirbHn-dhaped  swelliug  of  epiglottis.    (Cohen.) 

Fii!.  ^:!ll  — .\  tubercular  ulcer  on  the  left  ventricular  lionil  and  left  vocal  conl.    l'ear-i!hai»-<l 
leiletuHiiiu!!  swelling  of  ar.vepiglottic  fohls.  more  Intense  on  the  siile  of  tbe  ulceration.    iC'ohen.i 
Fio.  131— <ieneral  tubercular  uleeration  of  larynx.    (Cohkn.) 

Ulceration  in  larA-ngeal  tuberculosis  is  of  constant  occurrence  and 
usually  |)re.sent  at  some  stage  of  the  disease.  The  ulcers  iiuiy  vary 
in  size  from  the  very  small  to  those  coveriiift  (|uite  an  extensive  area, 
they  may  he  single  or  multiple,  limited  to  one  side  or  portion  of  the 
larynx,  or  they  may  he  bilateral  or  indiscriminate  in  their  situation, 
There  is  no  absolute  {)ositive  diagnostic  difference  helween  tuber- 
cular ulcerations  and  those  from  other  causes,  other  than  possibly 
tulwrcular  ulcerations  may  he  more  superficial  in  character,  have 
less  indurated  edges,  and  are,  as  a  rule,  less  deeply  destructive  in 
their  nature.  If  the  ulceration  lia.s  (>xisted  for  some  length  of  time 
and  is  slow  in  its  progress  and  not  extensive  in  character,  when  taken 
in  connection  with  other  symptom:-  ;>f  tuberculosis,  it  is  probably  of 
a  tubercular  nature.  When  isolated  they  are  generally  surroumh-d  by 
a  re(|  outer  border,  shading  (ttT  .sometimes  into  tiie  surrounding 
tissue,  and  .are  fre(|ueiitly  depressed,  and  if  large  in  extent  the 
ulcerating  centre  may  present  a  sunken  papillary  condition,  and 
soUHrtimes  the  inner  eilges  niay  l)e  gray  or  white.  When  sif.i.'ited 
over  a  large  area  of  broken-down  induration  the  surface  of  the  ulcer 
presents  a  very  uneven  character.     In  this  comiection  it  may  be  said 


-"Afi  "^9X7=,  or:  ssrrgs&  >Ji«»MBJjeiE.gyyaiBWii>anar^ 


TUBEliVlLOSlS  OF  Tilt:  yonE,  fllARYSX  ASD  LAUYSX.    807 

that  SLiiH'tiiiifs  we  tiiul  a  lo-w  of  tli(>  vocal  conls  wliich  sociii  to 
have  (lisa|)|M-arc(l  iiioiv  hy  a  process  of  absorption  tliaii  ulceration, 
with  practically  no  syriiptoins  of  ulceration  having  previously  Iwen 
present.  It  is  not  infreciuent  to  find  the  suinniit  of  smooth  indura- 
tions (lotted  with  line  ulcerations,  which  is  (piite  a  characteristic 
ap|H>arance.  and  it  is  also  not  unusual  to  find  the  whole  surface 
ol  the  true  and  ialse  cords  together  in  a  state  of  ulceration- 
and  Ireipiently  we  tnid  the  whole  surface  of  one  or  other  of  the  ary- 


Klu.  432 


Flu.  433. 


Fio.  4;l-.-Tiit«nml«r  iiiBllralion  of  the  lnterarytenol.1  space  with  tuUsreuUr  paplllonuU  of  bolb 
vocal  conls.    Charactcristk-  .nleirialoiia  liililtratlon  of  the  aryeplifloltlo  fol.ls     (fi.HEN  ) 
Fici,  4a!.-TiiUTcular  ulceration  of  left  V(h»1  conl,  with  swelling  of  right  aryteuol.l  cartllaire 

.('OH K.N.)  "    ■ 

teiioid  cartilaKcs  considerably  destroyed  by  this  ulcerative  process, 
and.  on  the  contrary,  it  is  not  uncorntnon  to  find  the  typical  swelling 
of  the  ai^ytenoids  to  exist  for  a  long  time,  even  through  the  entire 
period  of  the  disease,  without  breaking  down  into  ulceration.  The 
epiglottis  i.s  fretpiently  ulcerated  in  the  same  characteristic  rnaniuT, 
the  ulc(>rations  attacking  almost  any  |M)rtion  of  it.  There  is  some- 
times (jrii;'  a  marked  destruction  of  the  epiglottis  by  this  ulceration. 


Flu.  434. 


Fia.  436. 


r,,;.  m-Swelling  a.1.1  hypt-wmia  of  veiitrlpular  bands  with  tU-H-ttlon  of  trae  cords.     (CoHtN  ) 
H...  U>.-Siir«^rhcialiilcerau.m  of  Kuinralt  and  frie  border  of      i    -.ted  epiglottis.    (Cohk.s.) 

In-itea.l  of  pres(>nting  a  rod  or  angry  appoaraneo,  it  is  not  uncommon 
In  fmd  but  little  change  in  color  over  the  nhole  ulcerated  area,  the 
wji,,!(.  surface  of  involvement  giving  the  appearance  of  an  unhealthy 
aiuemic  or  sodden  condition.  Perichondritis  of  the  cartilages  of  the 
larynx  may  su|)ervene  from  the  e.xteiisitm  of  the  ulceration,  csik- 
'■i.uly  of  t!.e  arytenoid  canihige.  in  some  instances  resulting  in 
'•xpulsu.i,.  of  a  F)ortion  of  the  cartilage.  The  perichondrium  in  some 
instances  may  become  primarily  aiTectcd  in  the  tubercular  process. 


liai 


858 


XVat:  AM>  THRO  iT 


iui.l  lint  nm's.><arily  tin-  n-^uit  ol  an  .M.  n-^i-n  from  the  su|»rrfici!»l 

ulciTatiiiii.  .     ,  ,  I 

Asiilc  Iruiii  till-  ■•(iiidilioiis  inclii<i«'l  in  ti  ■•  lyinciil  form  Jiinl  cimM- 
of  tiilMTciilar  larviinitis  thciv  an-  ■>'\\vr  foi  -^  ..[  tulMTtular  iiivolvt-- 
iiKMit  "f  till-  larviix.  p'n<T,,lly  mauiffst^d  l.y  lo.alizi-d  indurations  or 
intiltratinns.  fln's<'  iiifiltratiuii^  or  iiidiiritioiis  may  omir  :i.«  tho 
only  Irsioii,  and  mav  W  situated  at  any  iMunt  williui  the  larynx;  tin  y 
do 'not  .i'  a  n«'(M'ssitv  iMMoinc  ulft-ratcd  I'ot  ma,  Ix'  <'las-.'d  as  tlu- 
induratc.l  form  of  tulMTciilar  larynKiti^  '  ii'y  :.:  •  quite  ire(|uently 
seen  about  the  arvteiioid  rcKi"n,  .•ither  in.  vw  the  aryMioid  .-ar- 
tila^es  tlicins<'lves,  ..r  a|)|)earinn  in  th<>  .i.>  'iiirv  «i">'d  ^\<.w^\  and 
when  seen  in  this  location  are  ([uite  rh:ii;t<-t« -i.-i  «■  In  apixaranee. 
These  iiiterarvtenoid  induraiioiis  may  e\i-.'  i.i  ;i  |.  rniiary  or  corrii- 
jialed  form,  (ir  the  induration  may  !>•  v.  n  l.irp-  uiti,  a  broad  ba^-. 
the  aiM'x  of  which  extends  well  into  t;i(  (".:•..  '1..  lary  x.  This 
condition  whiMi  seen  in  the  iiiteiaryt<-ii.  m'    j-ac.  "sci.Ihu  by  some 

authors  as  pathognomonic  of  tubercular  :  lyujriti-.  Thus  is  imt  inva- 
riably so,  be,-.iuse  it  is  not  infre.|uent  to  find  simp,  p-inllary  corni- 
fr.'itioiis  aitliin  the  arytenoid  sjiare  whi.li  are  appiirei  tly  Immijiu  in 
their  charaet.  r:  but  it  i.iust  be  said  that  a  dirtilnl  induration  in  the 
iiiten.rsteiioid  space,  wliH-h  projtM'is  well  mto  the  cavitvni  Mic  larynx, 
is  very  -i-initicant  of  tubercular  involvenicnt.  even  wh,      it  is  uuas- 

sociated  with  other  Icm ms.  Thes'> 
localized  indurations  may  also  a|)- 
jM'ar  on  the  true  and  false  cords. 

Diagnosis.     The  (l'::i;iiio>.i-;of  tuln^r- 
cular    laryngitis,    when      lepe-idenl 
uiM>r  the  lesions  themselvi      is  often 
a  dillicult    pr.Jilem.  there  b'   nfi  no 
absolute    characteristics    to     listin- 
icuish  th.-m  whii'h  are  imt  present  in 
other    forms    of    laryiijieal     ulceia- 
'.  1  ins,  unless  it  b^  the  tvpical  form 
of  uniform  induration  i    vol'  uip  the 
arytenoiils   and   t':»'  ei)i<Tlonis    and 
in  almost  all  instances  we  must  look  for  confinnatioii  of  our  diuir- 
iKo'is  (ither  by  the  jreneral  i)roKress  of  the  <liseiisc,  its  a.ssociutioti  with 
ireneral  pulmoiiaiv  tuberculo-^is,  bv  the  microscopic  examination  of 
the  tissue-,  or  bvthe  (indiiifr  of  the  tubercle  bacilli  in  the  ex|)e<-tora- 
tion  or  scrai)inf£s,  and  we  might  add  by  tiie  tendi-ncy  to  fatal  pioji- 
res^  of  the  disease,  despite  all  our  efforts  at  treatment.      The  cmi- 
.litions  to    Im-  differentiated    from    tubercu!  sis   of   the    hm-nx  -^re 
•^yjihilis,  carcinoma,  and  lupii.s,  which  will  be  considered  ill  dc'ul 
under  their  re-pective  heail-. 

Mixed  Lesion  Instances  of  association  or  imxed  lesions  of  1  .  -t- 
culosis  of  the  larynx  with  tertiary  sypiiiis,  Jiavin):  ,iiaiact.ristK-  .i 
both,  have  be<'n  described  by  so-ne  writers;  i.nl  it  is  a  conditi'  ■;=« 
diflicilt  of  differentiation  (if,  indeed,  it  <lo<>s  exist,  which  is  jrr       iv 


Iiiltn-iif.  iiMiDiil  thii  ki'iiliiK  ,  ulccmUon  of 
Curd. 


wBHaiai 


TlBEItCirLo^rs  OF  THE  SOSh    PJU  fYSX  ASD  La,   iWX.    85t> 

•i-nl.lr,|  l.y  tl,r.aiitl...r),  ,(„(  „  ,.a„„„t  b«.  wHId-scnl,.  -i  uimI    ,no„|v 


1   tllf  i|isc;isr.       it  is  Vf 

otIi'T  iHiitioti-  of  the  u| 
WduM  cxiM-r-t  t(i  find  it  ii 
Tr#<iktment.     Tl,     tie; 
-tiiitioiial  and  local,     i 
wliici,  pertain  Iw  gcticml  tiitwrrni     . . 
ail  li.<"il  irrainicnt  shonl.l  Ix-  .siipf.i, 
Tfafiiii'iii.     In  sorm    fonn-  of  far  v 
larviiv  ,,  Hot  .sciiously  in\    Ivcd,  .1    . 
■<iitlii     t«.  .lire  or  iv,  ,      ii.  al^-vanre 
ncrtuiii  with  (h»>  gen.  ral  imi.  ,)\cnir 

h:tvr  liif>.   i'H(i>'    M  v'iow 

1.  'I'npical  •:     ilicatiun.s  !ur     ' 

'III'    rt.  (•(Uljlh,  j  ,1111,  (|y    l.najji; 

2.  Curative  nic  f-  ;r('s,  wnh 
the  tultercular  h'si.ii. 

Tlie  principles  ih.>lve.;  tt,  '!)< 
ii"ii  to  any  portion  1  the  t;  j),-r 
ill  the  tnliercnlar  pi  -<,  ,i,„'j  »■ 
ilcpend  upon  the  lo,    : ,  m  ar 

nlweP'    iliiin. 

^\i'  III      !    fi     'finhcr  tli;it      rea:  ng 
iv  delicate  pi     .dure  re    iiirin^  .dl 
I'llxMi       Frp(niti;tly  thi   prientsan 
III'  r     iroats  are  render    '■  very  s<'n^ 
iiilly  (,|  "lanipulati^'n. 

Uie  fii-t  Ir-adiiifi  <>t 
nil  a  proiiiioent  featu 
•M  pr()[)er  application 
fcretic  I  I  kni'w  of  n. 

'   •'•    irogen.     hirh  shouMi 

■"      I    if  to  six      Mog.     T'  is 

'      I-'.  fhp\ 


rare.  1nde.1l.  to  notir-e  thJK  mixed  l.-sion  i„ 

r  respmui.rv  tra^-t,  arid  i'  it  did  exist  wf 

iiilff  It'KJul.v  :w  Well   ,s  ii,  the  Jarvux 

nent  of  Mil-Tcul  •      arvfirtis   ;..  h,',th  con- 

r  Ihr  f.  ri,i-  r  th-     c;,  .-r  is  r.  fem-d  to  works 

a»  »  MWiy  only  In  i^iiid  he-  that 

lent.- 1  '<y  -  .rlie  f..rtn  of      rieral 

'ijImtc    .ir    trvtijiifi.s.  wl         tlie 

'dt  iMT    11  ;,  i.ntiKT  c!in;:ite  niii  v 

'     '«'^  «'■■'    vni[  n  con- 

the  'fulniofiary         uiirm. 
iii    fl iitjf.     f.H-    try lijnti- should 


'If  Fuiri 
ind  the 

U'V     to 

}>ove 

r-trac; 

'■luiiri 

Ml'- 


■!.jt 


the      '{j 


loai  di- 

IS. 

din 


illOi! 


the  individii; 


I-  appii. 
'ecor;ie  in\  oivi 
proi  tdure  ^nu^5 


il  Ciuse  under 


rcular  larynx  is  often  a 

tact  and  skill  we  can  l)rinj>: 

■i  \V(,ik  bodily  conditio-',  and 

.  adding  greatly  to  the  difti- 


I'nd. 
-h.  ii!d 
;iiid  i'of 
is  mill' 

t'\i(j 

ilted  I 

!li' 

itii 


cleansing  of  the  parts 
onifort  of  the  patient 
measures.     Where  there 
iian  the  application  of 
Ix'  ii.se<i  with  an  atomizer  and 
will  have  the  eflfect  of  disinte- 


uei 
lor  t 
ijiient 
111  an*' 


Hi..   Ill,  ,.fji 

I   S'ilor  .-..iuti:      au-swerine 
''.•II  ilien,u(-,,!i-   .letiibrai. 
iiefore  tn;iki-<:  aiiv    applica 
I    to   precwi.     tlieir  ii.se   I 

line  in  . 
-''i|iien( 

-y,  <.f  ;dr. 

\'U:        . 


lay  be  further  dislodged  by  the 
in-        -oat  and  coughing.     In  order  to  perfect 
■xM.     fiMuJd  h.   tollowed  bv  the  use  of  ■■  .  i,>  one 
no!     ieaasii  -  an.!    inti.septic  solutions,  the    Dobell 
he  iH.'pose,   in    order  to  completely 


-Miatever  T  think  it  a  wise  precau- 

,       ,  -pray   of   \   per  cent.  solutif)n  of 

r  to  render  the  mucous  nienihrane  less  .sensitive  to  the 

iicatn.ns      If  tiiere  be  con.siderable  hviwrarnia   ■,  s„h,- 

.  cliioiide  may  be  added,  so  as  to  make  a  strei  .'th  of 

•K),  with  the  cocaine  solution.     The  effect  of  this  com- 

.v  grateful  to  the  patient  in  reducing  irritabilitv,  sensi- 


«l>0 


xosE  Ayn  THROAT. 


tiv.-ucss,  ana  iviKl.-riiiK  all  aftcr-ai)l>licati(.n  inudi  .-asicT  of  arrnm- 

lilisllllU'llt.  ,  •  r  •> 

I'MN-  AM-  l)Ysi'iiA(!iA.  ('ocaiiic  111  strciiRtlis  varyiiiR  from  1  i>("r 
cent  to  S  iKT  ffiil.  solution,  in  cotijwnction  witli  adn-iialin.  is  jxThaps 
tli(>  ix'st  means  for  allavinj;  the  i-ain  and  .lyspli.-'fiia.  to  l)c  aiM-linl 
imm.-.liatclv  lu'fon-  eating.  Care  slioul.l  !.<'  talicn  ti.at  tlu-  cocamc 
hal.it  is  not"f()rm<-.l  l.v  its  contimiai  iiso.  In  somr  cases  constitutional 
symptoms  of  cocaine-poisoning  may  interfere  with  or  preclu.le  the 

use  of  the  druR.  .  .  ,    , 

OiniioKoi'M.  When  there  are  ulcerations,  caiisMifi  |uuii  and  <lys- 
i)ha"ia  marko.1  relief  is  nro.luced  by  the  use  of  ortl.otorm,  either  m 
theh.rm  of  powder  insulllations  or  an  egR  emulsion  wth  or  without 
menthol  d'J  per  cent.l.  as  suggested  by  Freudenthal,'  (t  New  \ork, 
to  he  aii|>iied  with  an  ordinarv  cotton  applicator  or  by  means  ot  a 
larvn<'eal  svrijige.  The  advantage  of  orthoform  is  that  it  is  non- 
poisonous,  and  its  effects  last  longer  than  cocaine,  although  it  is 
slower  ill  beginning  its  action. 

IvniYi,  Ciii.oiUDi;.  Th(>  author  has  obtahied  excellent  effects  trom 
the  local  anr.'sthesia  produced  by  ethy'  .'hloride,  notably  in  the 
pharviiK  and  at  the  base  of  the  tongue,  when  its  application  is  made 
casy"l)y  the  glass  tube  manufactured  for  that  purpose— for  local 
aiuesthcsia.     Its  effect  is  not  very  lasting. 

Intualakyngkai.  AM)  TuACHKAL  Inmkctions.  .Vs  a  means  of 
applying  local  remedies  directly  to  the  larynx  .hikI  trachea,  I  am 
fully  convinced,  l)otli  for  curative  and  for  jnirposes  of  local  amelioia- 
tioii,  we  have  in  intralaryngeal  and  tracheal  injections  with  a  properly 
constructed  svringe  one  of  the  most  efficient  means  at  our  disposal. 
The  larynx  !)«■ -omes  gently  and  thoroughly  bathed  with  the  s..lution. 
and  it  exercises  its  local  influence  as  it  passes  down  and  is  absorbed 
in  the  trachea  amlbroiichi,  thus  producing  a  constitutional  absorption 
as  well.  The  number  and  character  of  the  solutions  that  may  Ih' em- 
ployed, either  oilv  or  a<pieous,  are  numerous,  and  may  be  chosen  to 
meet  tiic  indications  demanded.  The  effect  in  relieving  cough,  local 
pain,  dysphagia,  and  producing  a  general  comfort  of  the  jiatient  i< 
sometimes  verv  marked.  The  injections  shouM  be  jirecetled  by  local 
aiuesthesia,  and  after  the  details  become  mastered  the  production 

1  Journal  of  the  Anurlran  Mwlical  Aw«Kmtion,  M«rih  li,.  I'.mi 
I  aiipenil  the  formnliiol  the  ortholi.rm  .•mulsi.m  us  siitfgeBte<l  hy  Kt'  iiileiithHl.  with  liirectu'i- 
for  its  use     It  iimv  Iw  uwil  without  meiilhol.  If  •«i  ilcsire-l. 

••InKllirrilati..iisof  the  larynx  luemliol  is  of  excell.-m  service.     It  reli.x.-- the  cough,  and  «it., 
this  much  of  Ih.'  weretion.    This  is  the  Tmmn  I  udileil  menthol  to  the  al*ive  emuMon.    I  use  ili- 

followinn  : 

■'  Menthol.  1. '.,  in.  or  |."ij 

ol  nrnvRilal  ilnlc,  3D 

Vltelli  ovonmi.  -''] 

Orthoformi  1-  > 

Aiiusedest..  q.  ».  Kl.     100 

Ft.  cinulfio. 
"  I  commence  with  1  per  cent,  menthol  in  this  emulslcm,  and  as  nuukly  ii-  ilie  loieratioii  •■f  v- ^ 
patient  iwnnits  I  increase  it  U)  10  |«r  cent.,  and  it  has  been  In  the  rarer  cases  only  that  I  have  us. 
ir>  per  cent,  menthol." 


TUBERCULOSIS  OF  THE  XOSE,  PHAHIXX  AM)  LAHVyX.    g(jl 

4if  any  irritation  is  roducpd  to  a  ininiinum  and  the  procedure  becomes 
well  tolerated  by  the  patient. 

Dysphagia  may  become  so  extreme  that  it  may  be  necessary  to 
resort  to  artificial  feeding  through  a  stomach  tul)e,  and  in  some 
instances  fairly  comfortable  swallowing  may  be  attained  in  the  so- 
called  " Casselberry "  position,  being  the  method  used  in  feeding 
during  intubation. 

CuKATivK  Mk.vsikks.  Under  this  heading  are  included  local  appli- 
cations to  the  surface  of  the  lesion,  and  the  direct  eradication  by 
means  of  more  decided  surgical  measun'  ■ 

The  list  of  local  reme(li(  s  is,  indeed,  a  \  .ry  long  one,  each  having  its 
advocates,  and  most  excellent  results  having  been  reported  with  all  of 
them.  A  detailed  tie.scription  of  their  respective  merits  would  carry 
IIS  too  far  in  an  article  of  this  length,  and  we  willcontent  ourselves 
with  their  enumeration,  a  partial  list,  including  iodoform,  euroj)hen, 

Fig.  437. 


■^yriiiKe  used  for  intralaryngeal  and  tracheal  injections  of  both  a«iueous  and  oily  aolutiuiiK.    (Mi'lB.) 


menthol  in  oily  solution,  creasote,  guaiacol,  ichthyol,  parachlorojihenol, 
.-ulplmricinate  of  phenol,  enzyinol,  iodol,  aristol,  camphor-menthol, 
and  also  lactic  acid  directly  to  the  ulcerating  surface  or  in  combina- 
tion with  cun'ttement.  to  1«»  spoken  of  later.  The  author  has  seen 
most  beneficial  effects  from  the  application  of  lactic  acid  to  the  ;  urface 
nf  the  ulceration,  even  without  curettement.  and.  perhai)s,  there  is 
no  one  remedy  which  will  give  better  results  when  judiciously  em- 
lil(\v<'(l.  The  lactic-acid  treatment  was  first  introduced  by  Krause, 
wliK  advocates  rubbing  it  in  thoroughly  on  the  ulcerating  surface  by 
means  of  a  laryngeiil  cotton  ai)plicator  or  injecting  it  by  hypodermic 
~yiiiige  into  the  deeper  tissues  of  the  ulceration.  One  may  begin 
with  a  10  [M'r  cent,  or  a  20  per  cent,  solution,  increasing  it  to  75  |)er 
cent.,  (ir  to  full  strength.  It  may  Iw  em{)loyed  daily  or  every  other 
day  at  first,  diminishing  the  intervals  as  the  caustic  action  followed 
by  cicatriziition  show  themselves.  The  j)arts  should  lie  thoroughly 
incniiiized  prior  to  the  application  of  the  lactic  aciil. 

<  M  th<'  intralaiyngeal  surgical  mea.sures  may  1m'  mentioned  curette- 
ment, as  !i(|vocated  by  Heryng  and  Krause,  either  by  itself  or  in  con- 
iiiii-'tiiiii  with  the  rubbing  in  of  lactic  acid  ov(T  the  curetted  .surface, 
and  the  excision  of  tubercular  indurations  and  infiltrations  by  means 


8G'J 


NOSL  AM)  THROAT. 


of  cutting  t(im>|)s,  as  recoiuinondcd  l)y  the  above  surgeons,  witli  in- 
struments bearing  tlicirnaMii". 

We  an-  in(lel)teil  to  Dr.  (lieitsinaini,  of  New  \  ork,  more  than  to  any 
other  Ameriean  writer,  for  a  full  exposition  of  the  suhjeet  of  intra- 
laryngeat  surgical  treatment,  and  the  reader  is  referred  to  his  most  ex- 
cellent article  read  before  the  American  I.aryngological  Association, 
1S<).")  and  found  in  the  Trnnsaction."  of  that  societj,  for  that  year, 
ami  published  as  well  in  the  New  York  Medical  Journal,  OctolM-r 
lit  1S9.">.  He  enters  most  especially  into  the  discussion  of  the  merits 
of  and  indications  for  curettement  "of  tubercular  ulcers  and  excision 
(.f  indurations  as  carried  out  i)y  Krause  and  Heryng,  with  descriptions 
(  f  the  instruments  usetl  by  these  surgeons,  and  summarizes  the  indica- 
tions and  contraimlications  as  follows: 

"  When  summarizing  the  indications  for  curettement,  it  is  to  be 
recommended: 

"  1.  In  cases  of  primary  tubercular  affections  without  pulmonary 

complication.  ■      •  ■  ■     • 

••  2.  In  cases  of  concomitant  lung  disease,  which  is  either  m  tlie  m- 
cil>ient  stage  or  has  at  h-ast  not  progressed  to  softening  and  hectic 

conditions.  .  .  ■   ^.i 

•'  :i.  It  is  best  adapted  forcircum.scribetl  ulcerations  and  mhltration> 

of  the  larynx. 

"4.  lM)r  the  dense,  hart!  swelling  of  the  arytenoid  region,  tiie  ven- 
tricular band,  the  posterior  wall,  for  tubercular  tumors,  and  for  affec- 
tions of  the  epiglottis. 

'•,1.  In  advanced  lung  di'^ease,  with  distressing  dysphagia  re.sultmg 
from  infiltration  of  the  arytenoids,  curettement  is  justifiable  as  the 
(luickest  means  to  give  i.  lief. 
"  Contraindicatioi.s  are: 
"  1.  Advanced  pulmonary  (hsea.so  and  hectic. 

"  2.  I)is.seminated  tubercular  diseast>  of  the  larynx,  leaving  little  i)r 
no  area  of  healthy  tis.sue. 

• ;{.  I'Ateiisive  infiltrations,  producing  severe  stenosis  when  trache- 
otomv  is  indicated. 

"  We  will  also  not  n>commen(l  surgical  treatment  to  nervous  di.s- 
trustful  patients  who  lack  the  nece.-isary  perseverance  or  confi'i.'-'ice 
in  their  jihysician.  On  the  other  hand,  it  is  f)ften  suri)ri.siiig  how 
willingly  patients,  knowing  their  precirious  condition,  submit  to  tin- 
opi'ration,  how  cheerfully  they  |)ermit  the  necessary  manipulation 
when  the  i)iiysician,  guided  by  purest  motives,  devotes  iiis  best  ener- 
gies to  the  relief  of  the  sufferer." 

For  curetting  or  scraping  of  an  ulcerated  surface  the  single  curettes 
of  Il(>ryng  are  used,  while  for  excision  of  infiltrated  areas  the  double 
curettes  of  Heryng  an<l  Kiau.se  are  indicated.  These  latter  in.«tru- 
ments  should  more  projK'rly  be  called  exci.sion  forceps. 

In  porfortninR  the  operation  of  curettement  or  excision  the  parts 
should  be  thorouglily  cocainized  with  a  strong  solution  either  bv 
spra'  ,  potton-ai)plica"tor,  intralaryngeal  syring'>,  or  curved  hypodcr- 


!M! 


wm 


TUUEHrULOSm  OF  THE  SOSE,  PHARYSX  ASD  LAIiYSX. 


863 


iiiic  syriiipc  into  the  tissue  suhst.incp.  In  order  to  prevent  hemor- 
rhage, which  is  sometimes  troublesome,  we  have  a  most  valuable 
ajrent  wiiieli  renders  the  procedure  practically  i)loodless  in  a  l:o(K)(» 
solution  of  adrenalin  chloride  applied  in  the  same  manner,  either  alone 
or  in  combination  with  cocaine. 

Inflammatory  action  sometimes  follows  the  operation,  which  must 
be  met  b>  the  ordinary  means  applicable  to  larynpeal  iiiHanimation. 
\V(>  may  supfrcst  the  external  apjjlication  of  ice  ami  larvnpeal  spray- 
ini;  with  adrenalin. 


Fio.  43«. 


Fio.  439. 


~^^ 


Fi(!.  4;is.— Double  rotary  curette  of  HerynR.  A.  Instrument  complete,  ready  for  uk.  B.  Canulated 
Shan,  with  haniile  and  curettes  detached.  K.  Thnmt>8crew.  C.  Attachment  with  rectangular  o|>en- 
iriir.  This  is  attached  at  K.  1),  E,  F.  Donblecurcttcswhichflt  into  the  rectaiigularojwningC.  This 
nilaiiKular  opening  prevents  the  curettes  fhim  twisting  out  of  proper  coaptation,  and  l)y  rotating  f 
■ri  the  canula  the  curelle  can  lie  set  at  any  desired  anElo.  G.  Curi'lte  for  ventricular  band.  The 
inslrumont  Is  In  reality  an  exclsor  forceps  and  not  a  curetle     ((iI.kitsma.nn.) 

Fill  ^xt  —Sot  of  Heryng's  knives  and  curettes. 


SiHMi  cors  I\.iKfT!o.\.     This  method,  both  with  lactic  .icid  and 
with  creasote,  has  been  {)racti.sed  with  considerable  succ(>ss,  the  latttT 


iibstaiice  i)einfr  hijrhly  e 
it  superficially  anil  by  t! 
rations  with  a  specially 
lunation  he  uses  is: 


d  by  Chappell,  of  a'cw  ^'ork,  who  uses 
ections  into  the  substance  of  the  indu- 
.ucted  syringe  and  needle.     The  com- 


Creasote  (beechwood), 

Olel  ESuUhertffi.  4i  mj. 

Olel  hydrocarbon,  s). 

Olei  ricinl,  sly. 


H(H 


yOShASI)  TlinoAT. 


i 


Tho  proportion  of  croasotc  iiinylM'  chaiigcMl  to  iiipct  the  variod  con- 
♦litioiiH. 

Incisions.  1  can  only  loi.K  uj'oii  incisions  into  tiic  infiltrated  areas 
as  practise*'  by  Moritz  Scl.nidt  as  Ix'ing  of  service  in  depletion, 
and  especially  where  tlicre  U  ddoinatous  tissue  present,  although 
radical  results  have  been  cUiiiijcd. 


Flu.  4«. 


CbappeU's  sfrlnKe  for  submucous  laryngeal  injections.    (Meyrowitz.) 

Galranoca uteri/  and  electrolysis,  although  having  .some  advocates,  are 
not  extensively  practised,  the  former,  unless  used  very  carefully  and 
in  selected  ctises,  being  apt  to  be  followed  by  severe  reactionary 
results.  The  latter  is  difficult  of  application  and  slower  in  its  final 
effects,  especially  over  any  extiMidod  area. 

Tracheotomij  is  used  when  severe  stenosis  is  present,  and  also  with 
the  idea  of  giving  ri-st  to  the  larynx  in  severe  advanced  cases.  It 
is  a  peculiar  fact  that  however  severe  may  be  the  laryngeal  involve- 
ment in  tuberculosis,  it  rarely  produces  sufHcient  stenosis  to  call  for 
relief  by  tracheotomy. 

Intubation  an  be  recon\mende(!  only  to  meet  a  sudden  emergency 
of  .suffocation,  as  the  constant  pressure  of  the  tube  in  the  larynx 
would  cause  pain  and  ulceration,  and  would  not  be  well  borne. 

Prognosis,  .\lthough  considerable  |)r()gress  has  been  made  in  the 
treatment  of  laryngeal  tubi'rculosis,  and  the  disea.se  has  undoubtedly 
been  arrested  in  certain  ca.ses,  especially  in  the  indurated  tvpe  and 
in  lonilizcil  tubercular  growths  and  ulcerations,  and,  although  even 
when  'hci-e  has  been  extensive  involvement  of  the  larynx  in  advanced 
geneial  tuberculosis,  the  local  symptoms  have  been  ameliorated  and 
a  certain  degiee  of  comfort  afTordetl  the  patient,  we  cannot  but  admii 
that  the  general  |)rognosis  is  very  bad,  ai.  !,  as  a  rule,  we  nmst  look 
upon  the  involvement  of  the  larynx  as  indicating  an  extension  and 
|)rogre.s.«i  of  the  tubei-cular  process  which  will  ultimately  eii  1  in  flic 
death  of  the  jiatient. 

There  are  no  positive  means  by  which  we  can  say  how  long  a  patient 
will  liv(  after  tuberculosis  of  the  larynx  has  manifested  it.self,  and 
the  iTiimediate  jirogiiosis  depends  greatly  upon  the  type  of  the  in- 
volvement, the  condition  of  the  pulmonary  involvement,  and  the 
resistance  to  the  di.sea.se  offered  by  the  individual  patient.  The 
chances  for  the  extension  of  life  and  the  arrest  of  the  tubercular 
process  by  treatment  are  undoubtedly  lietter  where  we  have  to  deal 


LUPUS  OF  THE  SOSE  ASD  TUHOAT.  ggg 

with  !i  purely  localized  condition.     All  this  shr.uld  guide  us  in  the 
ciioice  of  treatment,  uimI  shc.uld  make  us  utilize  every  possible  means 
at  our  disposal  to  hrmp  about  a  favorable  result,  for  it  is  undoubtedlv 
true  that  although  the  process  is  indicative  of  a  fatal  terminatioil 
much  n-hef  can  Ih'  gained  by  judicious  treatment 

As  to  figures  we  might  <iuote  from  John  N.  Mackenzie,  who  deduced 
the  fact  that  from  100  cases  death  resulted  in  from  twelve  to  eighteen 
months  after  the  usual  symptoms  showed  themselves,  and  that  in 
«)  |)er  cent,  a  fatal  i.ssue  occurred  within  si.x  months.  Bosworth' 
gives  iorty-six  months  a.s  the  longest  time,  and  three  months  as  the 
shortest  time  after  pulmonary  tuberculosis  wjis  complicated  bv  larvn- 
geal  invasion  or,  to  .luote  his  summary:  "The  average  duration"  of 
lite  m  an  ordinary  attacK  of  pulmonary  consumption  is  three  vears 
the  average  duration  of  life  in  an  attack  of  pulmonary  c.msunipti.m' 
<umpl.cated  by  laryngeal  invasion  is  two  years,  and  the  average  dura- 
tmi.  of  life  aft<'r  the  supervention  of  laryngeal  invasion  is  eighteen 
months.  " 


LXTPUS  or  THE  NOSE  AND  THEOAT. 

Two  salient  points  are  always  to  be  thought  of  in  the  general 
<'oiisideration  of  lupus  of  th<.  upper  air-tract:  first,  it  is  practicallv 
a  ways  secondary  to  or  associated  with  lupoid  manifestations  of  the 
<kiii.  generally  of  the  face,  and,  .second,  it  should  be  viewed  as  a 
tubercular  lesion.  .As  to  the.se  two  points,  bv  far  the  greater  num- 
ber of  investigators  concur.  Rare  instanc(>s  of  primarv  lui)us  of 
the  pharynx  and  larynx  are  claimed  by  .some,  and  in  .supFwrt  of  its 
.•Mstence  tlw  subject  has  received  an  exteiisiv.-  consideration  bv 
I'.nnI  Mayer  (,f  .New  York. ^  who  re,)orts  in  detail  two  cases  of  his 
nwii.  and  refers  to  others  collected  bv  Kubenstein 

The  .|iiestion  of  the  tubercular  natiin>  of  lupus  apparentlv  is  «„ 
tlH.roughly  proven  by  the  finding  of  the  tubercle  bacilli  that  it  is 
suggeste.1  In-  some  authorities  to  dispen.se  altogether  with  the  term 
lii|)u.s  a.s  It  pert.-.ins  to  the  larynx.  While  from  a  bactei-i.-logieal 
standpoint  the  relation  between  lupus  and  tuberculosis  is  api,arr.ntlv 
I'lentieal.  still  we  cannot  but  be  impress<.d  with  the  great  difference 
111  the  clinical  course  of  the  two  lesions.  Tuberculo.sis  in  almost  everv 
tnrm  IS  more  or  less  rapid,  is  associated  with  puhnonarv  lesions  gives 
use  to  more  pain,  is  progressive,  and  ends  fatallv,  with  some'  asso- 
<-iatcd  tubercular  concurrence  Luims,  on  the  other  hand,  is  verv 
slow  and  insidious  in  its  development,  not  necessarilv  as.sociate.l  witli 
[Hilmon.ary  tuberculosis,  gives  a  minimum  ainount'of  local  di.scom- 
t-.rt  has  a  tendency-  to  heal,  cicatrize,  and  recur,  and  often  dcH's  not 
result  ni  death  from  puhnonarv  involvement. 

Lupus  of  the  nose  is  so  associate.!  with  the  contiguous  skin  lesion 
tl.at  the  r.ader  is  referred  to  works  on  .iermatologv  for  it,s  description 


Twentieth  r-^titury  Pntciioe. 


60 


•  New  York  Medloil  Journal,  Janoary  1, 18W. 


aE^ 


866 


NOSK  ASn  THROAT. 


Pharynx  and  Larynx.  Ht'lativc  to  its  fiviiuciuv  H.  Mygind,'  in 
uii  cxainiiiatioii  of  2(M)  patii-nts  with  lupus  of  tiic  skin,  found  tlic 
larynx  atTcctcd  in  10  jht  rent  of  tho  cases.  Fifteen  of  the  laryngeal 
ciuses  were  f(>inales  and  five  males.  Hunt,'  in  a  tabulation  of  411 
cjises  of  external  lupus,  found  either  the  pharynx,  larynx,  or  nose 
involved  in  20  |M'r  cent,  of  the  niunher.  In  I7:i  ea.ses  of  lupus  ot  the 
nuicous  lueinhrane  occurring  in  the  clinic  of  Doutrelepont  only_(> 
eases  were  free  from  cutaneous  lesions  ami  of  this  same  nunilxT  ".'> 
i-;i.ses  were  affected  in  the  nose-,  .il  cases  in  the  pal-te,  and  l:}  eases 
in  the  larynx.  Females  are  more  often  att'ected  than  males,  and  the 
lesion  is  more  apt  to  show  itself  before  puberty. 

Symptoms.  The  subjective  symptoms  at  firs*  are  not  very  prom- 
inent, which  is  a  characteristic  point:  it  is  only  when  the  lesion  ha,s 
existed  a  long  while,  causing  sympt(>ms  from  destruction  or  stenosis, 
that  our  attention  is  particularly  arreste.l. 

Appearance.  The  appearance  of  the  lupus  varies  according  to  the 
progressive  stages  of  the  lesion,  the  characteristics  Ix-ing  the  same 
a-s  i"  affects  either  the  pharynx  or  larynx.  When  the  uvula  or  soft 
l)alate  is  involv<M|  there  are  produced  in  cons(>(iuence.  first,  a  tume- 
faction somewhat  reddened  in  color,  followed  by  the  formation  ot 
nodules  over  the  area  of  the  induration,  variable  in  size,  and  when 
dense  and  confluent  producing  a  distention  of  the  uvula  and  soft 
palate,  this  nodulation  being  followed  by  ulceration  and  subse(iuent 
cicatrization.  The  whole  process  of  ulceration  seems  to  be  a  suc- 
ces.sive  breaking  down  of  these  nodulatirns,  which  in  turn  may  heal 
a.s  new  nodules  appear. 

Larynx.  When  the  larynx  becomes  involved  the  (lisea.se  usually 
makes  its  hrst  ai)pearance  on  the  free  margin  of  the  epiglottis,  causing, 
in  some  instances,  a  considerable  amount  of  destruction  In-fore  in- 
vading the  interior  of  the  larynx:  this  feature  of  limiting  it.self  for  a 
long  whih'  to  the  epiglottis  is  a  valuable  |)oint  in  the  diagnosis  between 
lupus  and  other  long-standing  destructive  lesions. 

The  appearance  of  laryngeal  lupus  is  well  described  by  Breda,  ijs 
follows:  "The  epiglottis 'is  thickened  and  irregular  at  its  free  bi^rder, 
with  slightly  raised  pale  or  grayish-red  eminences.  These  we  may 
observe  to  become  whit  ■  jit  their  apices,  a  slough  forming  which,  on 
separating,  leaves  a  small  ulcer  with  sloping  edges  and  grayish-yellow 
l)a.se,  but  without  anv  surrounding  hypera'mia  or  infiltration  of  its 
margin.  These  ulcers  are  slow  of  healing,  and  ius  one  cicatrizes 
another  nodule  breaks  down  or  is  absorbed  without  ulcerating.  In 
this  way  a  worm-eaten  appearance  is  given  to  the  edge  of  the  epi- 
glottis, "which  is  very  characteristic  of  the  (lisea.se.  As  the  process 
goes  on  the  epiglottis  becomes  paler  initil  it  comes  to  have  a  dead- 
white  color  and  to  the  probe  is  stiff,  fibrous,  and  resistant.  Steno.sis 
of  the  larynx  only  rarelv  results  from  lupus,  and  may  be  due  t<) 
blocking  of  the  larynx  by  lupoid  tis.sue,  to  fix.ition  of  the  vocal  c<mls, 


1  Arohlv  f.  Laryngol.  tl.  Rhliinl.,  Berlin,  vol.  x.  Part  1. 


<  Watmu-WiUiaiiu,  4lb  ed. 


.V  TKSOSIS  OF  THE  LA  li  J'AX  .,. , 

..r  .•..ntracti..,.s  msulting  fr.„n  nciHrhatmi.     It  is  n'markHhlc  l.,.«- 
M.l.lon.  lrach.-.,t«..i,y  is  n".,uir<Mi  in  lupus  "  '"arkal.K    |.,.w 

Diagnosis.     Th,.  diagnosis  lies  hotwc-n  tuhrroulosis,  carcinoma  s-.r 
c-uma,  a.Hl  syphihs.   „  ,s  pcrl.aps  fr„n.  so.ne  forn.s  ,  f      c  ,"  '/^  't h  t" 
(liHcrcntiatK.n  is  the  ni,.st  difficult 

Treatment.  ThouKi.  tl„.  .iisca.sc  is  a  .slow  {jroRrcssivc  „nc  there  is 
a  te,Hlen..y  u.  son.e  ,nstan-es  to  a  spontaneous  arrest  "hie  m.v 
.'■.na.n  lor  some  tune  to  he  followe.l  by  a  recurrence  f  r  ,  7 
.M'"t  .s  .Mainly  th.-.,  of  escharotics  an.l  surRical  proce  lur  "  u-tt 
j'arl".  .<•.  and  chnmnc  acid,  with  Ralvanocauterv  an.l  Xr  ctu  ti^ 
hav..  I,e,.n  ..nploy.-d,  while  in.-isions.  curettc-nu^nt  a  u  'xH^^^^^^^^^ 
the  surK.cal  n...asures  n,.|ieate.l.  Watson-Willian.s  men  i  ..w  I  e 
.•  ...H-y  ..I  sui.n.u<-ous  „.j..cti.,n  of  tuberculin,  and  n-fens  ,  e  pol  i- 
iulities  ..f  the  cmj)l.)yment  .)f  the  X-ravs.  ^ 


LEPROSY  OF  THE  NOSE  AND  THROAT. 

I.o,.n.sy  of  the  upper  respiratory  tract  in  this  country  is  an  cxtremelv 
.a.    d.s,.ase.  an.l  wh,.n,-ver  occurring  is  always  s..con.lary  to    e  "o  y 
of  the  skm  -  ncv.T  a  primary  disease.     It   may  -itt-ick  "  l.l  .  ,        ' 
n^^mbnuH.  of  the  nose,  pha^nx.  or  larynx!  W  shll^M'  ,^1:^ 
V  hen   these  parts  b.-ctn..  myohe.l   by  markcvl   structural  c.  1' 
J  unng  th.>  eours,.  o    gen.-ral  leprosy.     The  subjectiye  s^^^^pt,^,^^^^^^^^ 
U.t   are    very    mil.l.  mamly    those   of    irritation.     The    t    c  urt 
«-hanK..s  follow  the  order  of  cngestion,  tun...facti..n.  tubercle      m 
.I<-.Ta  .on.      The  progress  is  slow  and  i,.t,.rmittent.  and    reatnS^^ 
IS  by  the  application  .,f  caustics  an.l  sur^^ical  rem<,;al        '"''""^"* 
The  rem  ,T  :s  n-ferrcl  to  a  m.>st  cmplete  a.ul  exhaustiye  doscrip- 
ti..n  ..f  th., li.seii.se  by  Dr.  Ramon  de  la  S.,ta  y  I.ji.stra   in  Burnett's 
'-system  of  Dusensex  of  the  Ear,  N„,e,  ami  Throat,  xo]    i 


STENOSIS  OF  THE  LARYNX  AND  ITS  TREATMENT. 

s,„^!kr,?'''  "^  /''^''^'•ynx  may  bo  either  acute  or  chronic.    Generally 
^  '<"akmg.  acute  stenosis  is  r..gar,led  ..i.s  that  ty,H>  .seen  in  the  dS 
.ontic  croup  „f  chi  .Iren  which  h.us  been  coa^illercl  un  ler  tTu    ub 
J.      of  diphthena.     W  e  are  wont  to  cla.ssify  other  forms  a.s  c  Ironic 
.1  li  t,  ..r  n.,n-n,embran<.us  stenosis.     The  chussification  .,f  Dr   Ch' 

1.  (Vatrices  following  the  healing  of  ulcers,  or  the  formation  of 
^^•^ -n^tituti.nai   d.sea..e.  .syphilis,   phthi.sis,   glan.lers,   w.)unds,   or 

'  Buck's  Handbnok  of  Medical  8cience,  vol.  iv. 


868 


SOSE  AM)  THRU  AT. 


2.  Inflamruatiiins,  acute  or  chronio,  rosultinjr  in  ()l)structi(m  of 
larynx,  (toui),  .liplitlicria,  (iMlcnm,  and  iMTiclioiidritis.  Clironif  sten- 
osinp  inflaninialions  arc  also  alluded  to  under  this  head. 

3.  Neoplasms,  hcnign  or  malignant. 

4.  Neuroses  causing  sjuusms  or  paralysis,  iusphyxia. 

5.  Conipres-sion  of  the  laryux  from  external  causes,  which  includes 
fracture  of  the  larynx. 

Symptoms.  The  symptoms  of  stenosis  are  those  of  impaired  voice 
and  laryngeal  breathing,  nuThanically  produced  by  the  steiiosing 
cause,  the  severity  depending  on  the  extent  to  which  the  |)assage  of 
air  tlirough  the  larynx  is  iin|H"ded.  The  symptoms  may  be  progres- 
siv<'  or  come  on  suddenly.  The  exact  nature  and  extent  of  the 
stenosis  can  only  l)e  determined  by  laryngeal  examination,  which  is 
an  absolute  necessity  in  determining  the  mode  of  relief. 

Treatment.  The  treatment  of  laryngeal  stenosis  naturally  resolves 
itself  into,  first,  ronsUtutionnl,  as  indicated  principally  in  cast's  of 
syphilitic  stenosis,  by  the  adn)inistration  of  potash  and  mercury; 
second,  mechnnicni.  the  exact  form  depending  on  the  seat,  nature, 
and  extent  of  the  stenosis.  Under  mechanical  treatment  may  be 
iricludi'd: 

1.  Surgical  removal,  by  external  or  endolaryngeal  measures,  of 
stenosing  growths,  the  liberation  of  binding'  cicatrices,  web-like 
bands,  etc. 

2.  Tr.icheotomy  or  intubation  for  the  inmiediate  relief  of  impending 
suffocati.tn. 

.S.  Some  forms  of  dilatation,  either  iis  a  single  niea.sure  or  in  con- 
junction with  tracheotomy. 

Tlie  surgical  removal  of  stenosing  growths  and  the  performance  of 
tracheotomy  or  inlul)ation  for  immediate  relief  are  metisures  which 
each  instance  will  suggest,  and  need  no  further  description  either  for 
their  indication  or  manner  of  i)erformance  than  has  been  accorded 
them  under  their  respective  diapters. 

The  subject  of  dilatation  of  laryngeal  stricture  has  received  the 
attention  of  laryngologists  for  many  years,  the  procedures  h-ing 
based  on  the  same  general  lines  as  in  tubal  strictures  of  other  portions 
of  tiie  body.  Princijjal  among  those  whose  niunes  are  early  a.'^so- 
ciated  with  the  subject  are  Schroetter,  whose  di.  ,ting  tubes  ano,  mr- 
tallic  i)lug  re(|uired  a  preliminary  tracheotomy  in  order  to  be  retain<Ml 
ii!  the  larynx;  Morejl  Mackenzie,  whose  screw  dilator  was  introduced 
like  l.'iryngeal  forceps,  the  dilatation  being  accomplished  by  means 
of  a  screw  at  the  proximal  end  of  the  instrument;  Wliistler,  whose 
cutting  dilator,  the  ))ortion  entering  the  larynx,  consisting  of  an  olive- 
pointed  [»lug  with  a  concealed  knife.  ,  ..s  princi{)allv  used  for  the 
purpo.se  of  dividing  bands  or  webs  and  obtaining  sonie  dilatation  at 
the  same  time;  Navratil,  whose  dilator,  con.sisting  of  a  four-sectioned 
olive-sh.'ined  plug,  is  i„tr<Hlured  closwl.  and  dilated  liy  mean.s  of  .i 
proximal  screw.  'Ihese  and  other  instruments  ha.sed  on  the  same 
principles  obtained  a  measure  of  success  in  certain  adaptable  cases 


STJ-:X0SIS  OF  THE  LARYSX. 


869 


I'.'t  th.>y  wore  all  „pen  to  the  two  ixjsitivp  ..bjectu.ns  either  of  re 
MU.ru.R  u  primary  traclu.ot..,„y  or  neeessitati.  g  ..ft"epeat'Tl      u   t 
atteiMpLs  at  .lilatation.     The  imtt.re  „f  lurvnReal  stVictur     s  s  nf 
...gether  wth  the  resisting  ,,uality  of  the  larynS  b,  x  ^^t     . ,    t 
o    roduee  prop,.r  .hiatatir.n  s..,nethi,,«  „.u«t  h?^ 
.uu.x  which  u-.II  remain  there  an  indefinite  time.  prcHlueinc  c, 
|".in...s  pressure,  an.l.  if  possible,  allow  breathing    o'  K  cam>d  on 
through  th<.  larynx  without  the  aid  of  tracheotomy.  " 

Fio.  «l. 


i 


Whistler'a  cutting  dilator. 

a>  «i  hmit  mneh  fear  of  contradiction  that  the  i.res;nt-<lav  treat 
"'".t  ..t    aryngeal  ster.osis.  wliatever  its  nature,  coiLii   n    £  I  nil" 
•■ation  of  the  principles  of  intubation.  ^ ' 

N.  strongly  imbued  was  Dr.  (VDwyer  himself  with  his  belief  in 
h-  success  of  intubation  for  this  purpose  that  he  said  '  ''Had  int 
Lation  of  the  arynx  proved  a  comj.lete  failure  in  Z  trea  mem  of 
•rou,.  I  .shoulc  still  f«.|  an.ply  ropaid  for  the  time  and  exnei^e  eon 
sume,l  11,  deyelof.ing  it.  for  I  belmve  that  it  offers  the  mo  t  ation^i 
i^  ':;?' r'  K ■'"  ^^;;'™'' ^-  ^Y  <'^*ation  of  ch^cm'S 
^ubst^ntb^ln^'o-D^lr^'^rK^  '-e,  in  my  experience, 

•d';;; tlw"  ^'""  '"'"^"''""  '"  ''^'•^'"«^«'  ^''^''^^'^  "^^y  be  classi- 

•  necISlvlio!^;?  tf  '"r  '"■  '""  '^'T'^tanding  nature,  not  of 
V    ;     '"'"^\"^'  <lf'f»aiiding  an  immediate  operation 

-'.Acute  stenosis  calling  for  immediate  relief. 'eitt^Mmmarv  in 
.^-nature  or  an  exacerbation  of  an  aln-adv  c.isiing  con.    Sf  " 

•5.  Uhcre  we  wish  to  produce  sufficient  dilatation^to  dispe^e  ^vith 

'  New  York  Medioil  Journal,  March  10,  Ifws, 


.s7(i 


NUHE  ASD  TUHOAT. 


tho  wciiritiK  of  a  traclical  camila,  tlnTchy  establishing  rcspirntiuii 
throiigli  the  iioriiial  cliaiiiicl. 

These  three  jtroups  an-  not  arbitrary  in  their  (Hvision,  and  one 
may  at  times  irierfte  into  another,  ••s|H'('iully  ju*  far  ;us  the  Hrst 
and  se<'ond  are  concerned,  for  we  must  iihcdi/s  remi-mlxr  thai  all  caHfs 
iif  lonimiml  or  traclital  utrnn.-is,  hoin-rer  ijradital,  mai),  at  atiji  moment, 
takf  iiiHin  tfnmxflrt's  a  sudden  exaeerlmtinn. 

before  noinji  furtiier  into  any  detailed  (hsoussion  of  tlie  udupta- 
bihty  of  intubation  in  the  foregoing  ty|M's  of  ciuses,  and  the  principles 
guidi?ig  Ifie  |MTformance  of  the  same,  let  me  say  that  the  fundamentui 
underlying  consideration  which  should  always  guide  us  is  u  /»ro/xT 
diaiinosis.  This  cannot  be  too  strongly  emphasized,  for  I  think  that 
the  failures  and  the  disappointuH-nts  which  may  have  overtaken  us 
have  been  largely  .'ue  to  a  lack  of  appreciation  of  the  exact  nature 
of  the  case  in  hand.  This  discrimination  includes,  among  other 
things,  not  only  an  ai)preciation  of  the  original  cause,  l)Ut  also  the 
nature  and  location  of  the  swelling,  density  of  the  tissue  involvetl, 
whethi-r  or  not  then*  be  ulceration,  and  whether  the  imineiliate 
condition  of  the  patient  is  such  as  to  permit  of  the  extra  exertion 
necessary  for  a  proper  operative  manipulation.  No  one  for  a 
moment  should  think  of  performing  intubation  without  a  previous 
laryngeal  examination,  and  if  a  coinph'te  examination  camiot  be 
maile  and  we  cannot  come  to  a  fairly  accurate  conclusion  as  to  both 
the  cause  ;ind  nature  of  the  obstruction,  the  operation  siiould  give 
way  to  tracheotomy,  with  a  view  to  using  intul)ation  subseiiuentiv 
iiearing  on  this  point  is  .-inotlier  important  consideration,  that  <)f 
always  being  prepared  to  do  a  tr.icheotomy  in  the  event  of  failure  of 
intubation. 

It  is  in  the  second  cla.ss  of  ca.ses  where  intubation  in  compari.son 
with  tracheotomy  is  |)ut  to  its  severest  test,  and  those  of  us  who 
may  be  its  strongest  a<lvoc;ites  niu.st  not  be  s<i  much  prejudiced  in 
its  favor  that  we  (■.iniiot  see  its  impracticability  in  certain  cases, 
remembering  that  no  one  oixTation  is  without  its  limitations. 

It  goes  without  saying  that  in  the  second  cliLss  of  ca.ses,  where  we 
wish  to  clioose  between  intubation  and  tracheotomy,  that  intubation 
.should  be  chosen  if  applicable,  thus  avoiding  the  cutting  operation: 
but  the  decision  should  be  made  only  after  due  consideration  of  all 
till'  contingencies. 

Perhaps  it  is  in  the  third  cla.ss  of  cases,  namely,  where  wo  wish  to 
dispense  with  tlii'  tracheal  (anul:i,  that  intubation  has  its  most  posi- 
tive ap|)li(Mtion  in  adult  stenosis,  being  closely  allied  in  this  n'sjject 
to  the  first  el.iss.  It  is  here  that  w«'  come  into  direct  comparison 
with  the  other  and  older  methods  of  dilatation.  An  intubation  tube 
has  the  advantage  .1  l)eiiii;  tolerated  in  the  larynx  for  an  indefinite 
length  of  time,  thus  |  'oduring  a  constant  ilegree  of  absorbing  pres.sure. 
wiiidi  is  the  main  p-.^liit  !,  h.-.-  gaiiie<|,  i^^n\  Ui'Te  is  an  opjM)rtunity 
offered  for  altering  the  .sizi-  and  conformation  of  the  tubes  to  meet 
the  ciiaiigiiig  conditions.     It  has  been  pi    \cn  by  many  cases  that 


J*. 


mfi/EKLxakifKsi'jfJtriK^^fniPW 


UTESOtHa  OF  THE  LA  K I  .V.V. 


871 


:m  intul.ati<.t.  tulM-  yy  l„.  w„ri.  in,|..finil..|y  with  a  nmitmrativ,. 
«.'Kr...>  of  ,■„„,. .rt.  tl...  pati..nt-s.  i,.  ,„„..,  ,,u^^,  |,.ar„i„«  to  mUust 
lli.'ms.-lvc.s  fo  tlic  ii.-w  riictlicxl  (if  hrcatliiiij?. 

Willi  thf  trarhrotoiny  tiilx-  i,t  .sin,  wv  hnvv  ample  time  and  ()i)tM)r- 
tui.ity  f.  .st.i.ly  tlu'  shaiM.  of  th.-  sfnosis  un.l  to  n.ak..  suHicicnt  trial 

.iinour.t   of  suffocation  or  .-xhaustion.     It  n.av  l.«.  f,.u.sil,ie  in  the 

l..'KinniiiK  to  make  an  explorative,  introduction  wi'th  either  a  Schroctter 
tul.e  or  a  laryngeal  .soun.l  of  some  kind;  hut  I  have  alwavs  hehl  ami 
Mill  do  hol.l  to  tlH'  opunon  that  if  a  SchnH-tter  tulH-  can  he  parsed 
nn  in  uhation  lul„.  o|  ,he  same  or  larger  calil.re  can  Im>  as  w.-ll  pasw-d 
a.i.l  lie  n-tain.Ml,  when  w  then  get  the  a.lvant.ige  of  a  continucMJ 
ineZr.'.  r'\.""'  ;^"''J<'^'<'"K  ""•  patient  to  rcp^'ute,]  and  ..fttimes 
meH.ctual  attempts  at  iH-rmanent  dilatation.  It  is  fre,,uently  the 
.ase  that  u.tulmtion  cannot  !«>  performe,!  as  tin-  primarv  operation, 
and  w,-  miL^t  depend  on  it  only  for  s<.cond,.ry  dilatation  ifter  tlK^ 
.erlorma.u.e  of  tracheotomy.  Inder  these  circunistati.rs  it  is  weH 
n  |H;r<.r„i  the  „ach..,tomy  as  high  up  as  possil.le,  as  it  is  much 

;  I  .,.'!.  «r  '"  T'''.'"'"!  '"!'•<"''"•.<'<'"  a'xl  retention  of  the  intubation 

<l>.'  than  uhen  the  tracheal  o,.enmK  is  low  down  and  po.ssihiy  beyond 

tlH-  reach  of  the  nn\  ot  the  intubation  tul.e.     Intul.l,ti<.n  ..hould  be 

|Hrfornu..l  as  s..on  as  possible  affr  th.-  tracheotomv.  in  order  to 

.Mvn„|  the  .secondary  stricture,  which  is  liable  to  occur  at  the  sinx-rior 

iMarjrin  of  the  tracheotomy  woun.l.  which  s ,.tim,.s  luus  to  be  over- 

••-"„.  before  the  intubation  tube  can  be  pro,,erlv  introdtic-d.  The 
Ini.jrer  a  tnu.he..tomy  tube  remaii  ^  in  ,,n  a.lult  larvnx  th..  more  diffi- 
n.  d..es  1,  become  to  reach  the  larynx  with  the  pnding  intubation 
f.ij..  1  ,.iMl  tube  M>  the  tracheotomy  prevents  the  larvnx  from  rLsing 
"  P  ....lation:  this  di  hculty  is  increased  in  a  very  small  patient,  wh.-re 
tl..'  larynx  is  naturally  l,ey..n,i  the  cmtrol  of  the  introduciuR  (iiiR,., 
">  ol  the  former  objections  an.l  perplexiti.  ^  of  intubation  in 
•I'lul  ,.,ses  was  th.-  uncertainty  as  t<.  the  n-tention  of  the  tub«.  for 
M.v  length  of  time,  and  the  probabilitv  of  its  being  .je,  .ed  in  a  fit 
'.  .•oughing:  tins  objection,  however,  h.ns  been  sMisfactmilv  mc-t  by 
urk"S  ^;"^"""  :'":'  •"-li'i'-ati....  of  Dr.  .Joi..  Uu^.r..  of  New 
,;Jt         1  •  '':'""1"1*^  "^  •'  r..taininK  arm  "l.ich  is  screwed  at 

f  le"!f;"f';'.  "/''r'?'  "I"'.""'«  "•  f'-'-'t  «'f  '<-  intubation  tul^ 
■  t    he  Mte  of  the    nu-heal  op,.nmg.     Jt  is  prevented  from  unscrewing 
^^1"  ."  Ml  position  by  having  a  small  plug  or  pin  inserted  in  a  gr  «  "e 
-n.th"  upper  siirface  of  the  arm.     Thus  the'tube  is  .  asilv    ct^d    • 
res,,.  u,g  ...11  ..fforts  at  expulsion,  and  at  the  .same  time  the  su    i  : 

"r.ito  ,  •„.  the  tube  subse,|uently  removed  in  the  usua  n.ann..r 
'  'M.ght  be  thought  at  first  that  there  would  be  considerable  at  g^^^ 
"•■"  the  pluggmg  up  of  the  tube  by  retain,.!  secretions.  hToZ 
'•'>.ly  liapiMM,.  M,  adult  cases,  and  it  there  be  anv  tend.'iicv  in  th-it 
.  rection  steam  inhalations  may  at  times  be  u.scd,  oV  tt  tu  o'remo^i^ 
l'"">  litne  to  tim,.  for  the  pur|K,.se  of  cl.-ansiiig.  remo%cd 


"^ 


872 


A'OSt:  AM)  UlliOAT. 


TIk'  mii'iJkhI  (if  fiiidiiif;  llu-  |>..mt  in  t||..  intulnilinii  tulx'  f(ir  the 
insertion  of  Mic  iiriii  is  :i>  follow.-,  Tlic  mtiihatior.  ihIm-  Imviiif?  Im-cii 
pi.ici'.l  ii:  the  litiynx  aflrr  llic  tnulii'dloiiiy  i.iIm-  li;i>  Im-i-ii  n'Miovi-d. 
a  iiiiiik  is  niailc  on  the  iiitiil)a  inn  tulx-  iluounii  tlic  traclii'otoniy 
woiiiiil,  liihcr  hy  a  (nic  hot  .^^tifT  niftal  |>rol.c  \v:!i<!  hnrits  a  tM-rriaiicnr 
inarkihjr.  or  liy  srratchinK  tiic  tube  will,  il..'  |,oint  of  ■<  r  /  liaml 
iti-triitni'iit:  then  tlir  intnhation  'iilic  is  rciMovtuI  ami  tin- iiistriim«-ii»- 
tinkcr  fits  flic  tlircadi'.l  arm  at  the  [Miint  of  the  niarlvinj;.  In  the 
Jiiiinuil  iif  Ihf  Amir,,  n  Maltnil  As.'oifialioii.  .Iiiiic,  |<KKI.  I)r.  Ijiiil 
.\ia\cr.  of  New  York,  di'scrilns  a  Imllow   intro.iucinjj  handle  which 

Kill.  Mi. 


Rogere'  Intubation  wi  f,,r  .linnj.i'  stenonu. 

is  continuous  with  tiic  intubation  tube,  a  most  valiiabi,.  device  for 
...tubat.on  m  c-rtain  ca.....  whi.-h  has  for  i,s  obj.rt  tl,c  prc'vcntiou 
nf  till'  cutting  ofl  (,t  the  iur  durmjr  the  operation 

Si.Ai-K.  The  .v/,«/«  of  the  tube  use.|  in  adi:lt  intubati-,!,  i>  the  san.e 
as  that  used  t,.r  the  rel...f  of  en.up  in  children,  onlv  larp.-r  and  lone,.r 
iM.r  Kenera  convemenr...  a  .<et  .f  three  lubes  willbe  f<.u,,d  sufficient 
VIZ. .  a  .small,  m.-duin.,  and  larpe  size.  If  anv  special  form  of  stenosi.^ 
has  t(.  be  overcome  whiTein  the  onlinarv  shaped  tube  cannot  h.e 
use.!,  „  w,  1  be  ,„.c.e.ssary  to  chanRo  the  shape  in  accor.lance  with 
the  ca.-e  ;t.  hand.     I  he  iiitrodiicint;  and  cxtractinR  instruments  should 


U., 


HTKyoa/s  '//•  rnK  L.myyx 


Jh-  lirMvicr  aii.i  stouter  than  tli<.s4'  n.-M  with  tl., 

!'•  I«TIIlit  uf  IlKin-  fnn-.-  ill  li.ssili^  \Uo  .lin,T.'Mt  St 


ic  rn 


«7;i 


«'fi,  ill  ordir 


may  iM-ciihcrof  lianl  rulihcr 


itip  till 
ricturcs.     The  ful.^ 


atlvaiitanciiiis  sdinrtimcf*  in  Miikinc  I 


rniiial;  tin- metal  tiiln'  Ix-iu^  | 


ili  lU'IlVKT,  in 


IK  iii\vi'r(lown  in  the  larynx  ami 


»«•!   risiiiK  up  s<.  far  in  the  act  ..f  (|.-Kliitiii.,M,     Tl 


-Mimcwliat  more  liaMc  ti.ccili.-t 


n  inctal  tiilxw,  althoiiKli  i 


Inr  cither  ti>  JMroine  ohstnier   .1  siifHeieiitlv  to 


le  seeretitiiis  are 
t  IS  unusual 


Altliuutrh  then 


neeessifate  reiimval. 


is  eonsicierahle  .liir.Teiiee  in  the  weight   U-tweeii  tl 


MU'l.il  an<l   liarii-niltlMT  tiilies,   they  se« 

t'll.iatetl.     The  teelini(ju«.  of  intuhat. 

the  saini  :us  when  ijone  fur  eroup  in  child 


ni  to  Ik-  aliout  eipiallv  well 
ion  in  the  adult  is.  in  fheiiiiin 


c.t  fore  is  to  l)e  exerted,  and  wiiere  th 
l)y  the  left  fuietiii^cr,  the  operatic 


rer     and  where  a  ininiii 


e  epiRi 


'  can  hi 


Mini 
ell  iiiatianed 


•n  is  coinpaiativelv  easy  for  th 


ulio  hav..  had  any  .•xperieii.e.     ( ),i  the  other  hand."  wh 
.imoiiiit  n{  force  IS  to  Ix'  exerte 
isily  coiiiriille<|,  the  ojieiation  | 


lere  an  extra 


lind  this  lalt.Tdilliciiltv 


oxerted  and  where  the  epifjlottis  cannot  1 
inoredilficult.     We  are  apt  t( 


)ecoiiies 


wi  ir 


in  very  tall  patients  and  in  tl 


n  a  IracJHa!  ca.iuia  for  a  long  whil(>,  rend 


iose  who  have 


lad 


ei  certain  eircums* 


anc 


lering  the  larynx  inactiv 


\(' 


where  the  entrance  to  the  strict 


>   Mnai    or  situated  away  In.ni  the  median  line,  tl 


ure  i.« 


liie  dilliculty  of  iiisertiiijr  the  tul 


duct 


I'llliTS   I 


ion  with  the  aid  (.f  the  larvnw'al 


I  ill'  In 


to   I 


le  stricture  the  mirror  will  have  to  I 


lus  incrr.i.sinjr 

it  may  he  well  to  try  its  intro- 

igeal  mirror;   hut  as  soon  "as  the  tuhe 


piickly 


Iropped  ;uid 


.■.■l.njrer  of  the  mirror  h.an.l  transfern.l  to  the  head  of ',h,.  ,uIm. 
xer.  thr  profHT  pressure  and  to  hol.i  it   :     place  while  the  intro- 


■] 


ir  Hi  i; 


'liiH.ifi  instruMHmt   is   t.ciMg   withdrawn.     Increase 

l''l  '"'•  to  advis,.  intul..,    .,11  hv  aid  of  the  niirn 

-teiinos,  ,f  possihie  to  do      ..     The  strinir  slwmLI 

until  we  art'  r 

no 

I-  tl 

I. 


The  string  should  heal' 


juite  assured  that  the  hreathing 


liangi-r  of  the  tub.   hecomi 


g  IS  ea.'-' 


ngocclu<led  or  coughed 


^IH-rieiice  ha« 
'  ■'  ■  ■  of  adult 

^'   '  i<     1  'uain 
■nd  i!'>!.'  is 


lis  II.  cessaiy  wh.    e  the  ealihre  of  the  tul 


ol 


uhe  IS  verA 


III 


>ve  the  pati,nt  with  the  string  attache.!,  whici 
an  adult  tluui  in  a  child,  di 


11  we  can  lio  lo 


•ully 
if  we 

jiiger 

,1.11  .>ctions  should  he  given  to  witlulnw 

'  -  tuhe  hj-^  ,„,.an.s  of  the  string  whenever  the  p'th-nt  is  una  It?, 

should  he  cautioned,  however,  not  t<.  act  too  hastily    eLse  it  imp-bt 

HI  st  introduction.     It  is  well  to  u.se  niedicatcl  steam  ii.i.da- 
'.'  MS  in  .  rder  to  prevent  drying  of  .secretions  in  the  tuhe       Pnti     ,s 

t  ^r:'',.;;;:"iriK' '"'  "i"""^  ^^r"^''*'""  '-<'-■"'  ''3-  ^-!^^ 

„  ,';.  f  •'  ."'•■•  i«.'>f'<''">'«'s  Ix'i.er  tolerated  dav  hv  dav.     The  same 

:   1  c,   ;  Tl  "'^T'  *"  '''■«'"^"-"  «•'"-''.  '>-  in  children,  is  tt  ^ 

a  .d  iH   having  the  patient  swall,,-v  while  lying  down    with  the 

-I  ..u  d   i  III  ::Z  TT^""^  *"'"'  '"■  '■"^^••''  '^"""»'='.  «-hich  means 


m 


«74 


XOUE  ASD  THROAT. 


Tlip  removal  of  tho  tube  may  Im'  accomplislied  with  or  without  tlie 
aid  of  the  laryngeal  iuirn)r.  I  think,  however,  the  former  way  is 
preferable,  ius  then  we  can  sec  the  |)oiiit  of  the  extractor  enter  the 
tube,  thereby  lessening  the  danger  of  lacerating  the  mucous  mei  i- 
brane  b\  ineffectual  attempts  at  removal.  While  the  tube  is  in  th;' 
larynx  examinations  shouhl  be  made  to  see  that  its  proper  position 
is  nuuntained  and  that  the  opening  does  not  become  occluded  by 
overlapping  swollen  mucous  membrane. 


i     i 


FOREION  BODIES  IN  NOSS  AND  THROAT. 

Tlie  lodgement  of  foreign  bovlies  in  the  nose  and  throat  is  of  very 
common  occurrence,  the  articles  so  lodged  consisting  of  almost  every 
conceivable  object  large  enough  to  l>e  retained  in  the  various  cavities. 
In  the  UDsc  it  generally  h'ip|Kms  in  early  childhood,  and  is  the  result 
of  their  being  placed  there,  either  by  the  child  itself  or  by  compan- 
ions. When  detected  iinm(>diately  after  their  introduction  it  \)e- 
conies  simply  a  matter  of  examination  and  removal,  generally  without 
any  resulting  harm,  but  very  frequently  they  remain  in  the  nose  for 
a  long  while  without  the  knowledge  of  the  parents,  setting  up  sym|)- 
toms  of  obstruction,  I  pistaxis,  pain,  mucopurulent  discharge,  and  all 
the  symptoms  of  a  decided  rhinitis.  As  a  matter  of  experience,  they 
are  so  generally  placed  in  but  one  .>*ide  of  the  nose  that  it  is  almost 
an  axiom  that  a  unilateral  mucopurulent  san^ruineous  discharge  from 
the  nose  is  always  strongly  indicative  of  a  foreign  body.  When  this 
condition  is  present  it  may  be  recogniz<'d  on  examination  of  the 
nose,  wiien.  if  the  foreign  body  is  low  down  and  not  covered  by 
.•swollen  mucous  membrane,  its  presence  is  readily  determined.  If, 
however,  the  suspected  substance  is  fiirtlKT  in  it  will  !)<>  iKTessary  to  use 
a  blunt  met.'il  i)r()l)e,  passing  it  well  down  in  the  inferior  meatus,  and 
then,  if  undetected,  u|)  into  the  higher  nasal  region,  when,  if  present, 
the  familiar  grating  sensation  of  a  foreign  body  will  be  imparted 
by  the  probe.  It  is  best  to  facilitate  the  manipulation  of  the  probe 
by  the  application  of  cocaine.  Frequently  when  the  foreign  body  has 
resid<Ml  in  the  nose  for  a  long  while,  it  may  lK>conie  encysted  or  cov- 
ered with  lime  salts.  Their  removal  is  best  accomplishf^l  under  cocaine 
and  adrenalin  by  means  of  a  suitable  nasal  forceps,  preferably  one 
with  a  slightly-rounded  olive  point,  .so  tli;it  the  foreign  body  may  be 
securely  gnisped  around  its  circumference.  If  the  substance  is  con- 
veniently situat(Ml  its  retnovid  m:iy  be  effected  by  the  use  of  a  strong 
bent  |>robe  rather  bro;id  .Hiid  in  the  shap<'  of  a  hook.  If  very  loose  in 
the  nose,  and  well  down,  the  foreign  body  may  he  exi)elled  by  forcibli 
blowing  of  the  nose  with  the  unobstructed  side  and  mouth  closed. 
It  may  be  necess.-iry  in  some  inst.'mces  to  push  the  substance  back 
into  the  na.'--.opliarynx:  bnt  I  think  this  should  be  avoided  if  possible 
While,  usually,  removid  may  be  effected  by  local  aria'sthesia.  it  mav 
be  necessary,  owing  to  its  size,  coiiforniatio!!,  and  the  irritability  d 
the  child,  to  employ  general  aiuesthesia. 


unixoLirnn. 


RHINOLITHS. 


875 


In  a  cortam  number  of  cts™  f„roign  h„lios  which  lotke  in  the  nose 
K.m.,u-  ,„cru8teci  w.th  the  .alt.  „f  the  .uusal  s,.creti„n5,  Z   L^Z 
I  Hly  he,„K  the  nucleus,  an.i  the  calcareous  deposit  is  supe   „  3 
I    luT  ,„  a  sohd  mass  or  in  layers.     S<,metimes  on   KiTS 

tHiik  Mtretion.  This  maybe  accounted  for  by  supnosimr  fhp 
or.K,nal  nucleus  to  have  bc-n  a  particle  of  hard  or  inspiS«T^ueus' 
J     a   ..udl    detache,!  piece    of    .lead  bone.     Rhinoli^hs   Ihou^  be 

FnreiKn  substance  of  various  natures  may  become  accidentally 

TT  ".'  ?;.'  (''"'"'"I  ^""'  '"'■•^"•^  '»  «  ^'^"^'tv  (.f  ways  part  el?s 
of  ..o.  and  hsh-bones  during  th.  proces.ses  of  eating,  swailiwi  ,1  ,? 
t'".'thp!ates,  pms,aml  nails  hekl  in  the  mouth  in  vari,u,s    cZ  S^ 

<n.ilklv'yi!'.'t''tl'''.'-V"'''-'*'''"  "^  ^''"  ''''^'•>'"^  '"•  ''irvnx  come  on  so 
<|ui<  kl.  ih at  the  hLstory  is  very  easily  obtained.  Th'ev  varv  act  rd 
n*^  to  the  location  of  the  impaction  and  the  nature  ,.f  tl  .■  f.mU  v 
1  h  l„.,.on.es  in.pacted.  I„  the  pharynx  the  syn.pton.  Se  ge  .^ 
eul.  those  of  pan.  an.l  dysphagia,  and  in  the  lArvnx  ..f  ,  ai„  n  I 
.l.v aphonia,  cough,  excessive  laryngeal  irritati.ui.  and  impai  e  I      .'.t 

t  .>  .  xp  .|i,.d  by  either  coughing  or  vonnting.  and  the  patient  n.ti  us 
'"  '-nplain  with  p<.sUive„ess  that  th,.  fon-ign  bodv  s  sti  It  .  r  ,^ 
son.e  mstanc..s  it  ,s  very  difficult  to  .n,K.s„n.  tit-  patient  ti  a   tl      oreii 

..Miy  has  been  expelled.     The  exact  location 'and  la     n-        turn 
I'.-..;te.|  substance  can  only  be  .iefinit.-lv  n.a.l,.  out  bv  a   ,  ,, per  ev.     ' 

J.  -n  m  U,e  upper  pharynx,  by  .lepn^sion  of  the  tongu "  ^   u':    :: 


W^M 


876 


XOSE  AM)  rnilOAT. 


luxly  mijcli  iiiorc  easy,  l)iit  it  also  will  allay  the  irritation  caused  by 
the  impaction.  If  the  character  of  the  object  is  definitely  known  and 
is  lodged  in  tiie  siil)j;!ottic  region,  the  use  of  the  O'Dwyer" short,  cylin- 
drical foreiftn  ixidy  intni)ation  tubes  may  be  brought  into  reciuisition. 
The  value  of  utilizing  the  tiicthod  of  direct  laryngoscopy  a:-  insti- 
tuted l)y  Kirstein  hax  been  mentioned  as  aflonliiig  assistance  in  the 
search  for  and  removal  of  foreign  bodies  in  the  trachea.  This  metlHMl 
when  practicable  would  .<eem  to  po.ssess  considerable  advantage.  In- 
stances have  been  reported  by  Ingals,'  F.  K.  Hamilton/ and  olhur.s. 


=  New  York  M«<lica:  Joarnal,  .September  17,  18*8. 
*  Auatnllan  Medical  Uazette,  May,  1898. 


;  i 


tj 


CHAPTER    XX. 

NKOPLASMS  OF  THE  NOSE  AND  LARYNX:  THE  LOCAI 
MEDICINAL,  AND  SURGICAL  TREATMENT  ' 

OF  THE  LARYNX. 

By  W.  E.  CASSELBERRY,  M.D. 

NEOPLASMS  OP  THE  NOSE. 

Benign  Neoplasms,  Nasal  Polypus  ((Edematous).  (Edematous 
.  asal  po  ypu«  ,s  :t  tunu.r  of  a  gelatinous  consistency,  m.re  ace  ,rS 
.lescr.lK.1  .is  <r,len.atou«  tibron.a.  which  originates  ro.n  tltJ  mucosa 
.  nucopenosteun.  „.  conse,,uonce  of  chr,M.ie  infla.nn.a  on  espe- 
".  Il>  ..»  the  ethnuml  region.  It  is  .sometimes  designated  as  invxon  a • 
l.u  >  IS  not  identica  with  that  neoplasm,  as  it  occuil'l^v  're  ^i 
. t.l.ne  s  from  It  in  histogenesis.'     The  form,  a.s,,ect,  an.i  coriiitence 

;..,:;. '''"ti;.  ';"""",'  ''^''"'''.^*»  =>  ^^rape-pulp.bu/  scarcely     iZac  u- 
^'.^.     Ihe  iKiturai  shape  is  pyriform,  but  this  is  often  yaried  by 

«...Mt>   a.s  deyeCpnj.-nt  proceeds,  and  the  point  w  u>re  the  ,.e(  icie 
;>  n.n.oun.led  with  the  tissues  of  attachn.,  nt  is  known  a.s  the  ''ro  t  '' 

'n  ;  uiiki!;:  r'?;"./"  ^•^^^r''"'!"'^'"'-  ^^•""  ^'  >-"--h";h;e 

;;    ;  ,      '•"  ,        '"  •  """'  "'^  ""'■^""'  ''^  -^'"ooth  an.i  glistenine      It 

""'I'  tli.it  <>t  a  jK'a  to  a  walnut  or  larger.     When  sinde  it  is  !,.««  ..,.f 
!-vn.raherre„.oyal  or  recurre,K.e  is  longer  de^;:;:'^^^^^^ 
may  he  far  ba.-k  m  the  nn.s.ril,  „r  ..y,.  .roject  int.,  the  .uts.,  >,'  ry  p^ 
;■»  't  's  apt  to  be  M..,re  fibrous,  an.i' is  then  kn.,wn  ^^  Xi    .  al 

"Nt  1  li.,\,   .,i,sery..,|  tli..iu  fr..n,  th.'  age  of  ,>ight  y.>ars  ui.w.rd    .,n, 
a  .-as..  un.l..r  ..„e  year  assume.l  ,..  be  c.,ngenhal  ^  s  iZV^  .^  '  ' 
AI--0  I  hay..  kn.uvn  th.-m  to  .l,.yel..p  at  the  a.ly..n,v.|  age  .'f'^iSlty 

Etiology.     Th<-  mo.si  f,v,|uent  underlying  con.liti..n  is  ethmoi.litis 
I  r...  le  mHanm,at...n  .,f  ih^-    n>u,.„,,erios,eu,n   an.l   bone     ft  hV 
'  """.M.I  labynnth  m.,.1  mi.l.ll,.  turbinnt.' I  b.K|y.     Tl...  n,,lv,    i,|   hick 
;;;""«  a...l  gra.,ulati..„  tissue  fn.n  whi.-h  p..lyps  .le    -1  J  ^^  ^     '^ 
"I   >>i.iple   ,nflani,>,...t..ry  aeti..n   which    yari..s   tow.-ml   .e.ie  n      A, 
anaivs.  ,,  the  ..yi.lenc..^  fayor.  the  yi..v  that  the  i::H;un,;^;;Lmbeg(;.^ 

(877) 


878 


XOSK  ASD  THROAT. 


% 
} 


H 


II 


ill  tln'  iiuin)s:i,  and  tliciicc  is  lial)l«'  to  extend  to  the  periostouiii  and 
l)()ne,  altlioufili  a  few'  contend  that  the  initial  lesion  is  in  the  bone. 
A  disintegration  of  hone,  or  rarefyinj;  osteitis,  is  often  a.ssoeiated. 
There  may  he  actual  curies"  of  hone;  hut  usually  the  condition  is 
iwtter  described  as  a  defeneration,  in  which  state  it  is  etusily  denuded 
and  it.s  trabecuhi'  readily  broken  down.  ZuckerkandlV  observation 
on  cadavers,  that  two-thirds  of  all  nasal  polypi  proceed  from  »he 
middle  meatus  beneath  the  middle  turbinated  body,  is  confirmed  by 
accurate  clinical  examination.     (Fi<;s.  4W  and  444.;     The  polyp  buds 

Via.  u;). 


KepresentlnK  the  outer  bony  wall  of  the  left  narls,  with  the  mKltllo  tiirtiiiiated  body  iiirne.1 
upwani  to  Rhow  Ixjneath  the  hiatus  semlUmaris.  to  the  edges  uf  which  polji*  are  frcquentlv 
attached.    (Author'KR|>eclmeii.) 

proceeding  from  thp  ethmoidal  labyrinth  grow  in  the  direction  ..I 
the  least  resistance  downward  thntiijrh  the  hiatus  semilunaris,  which 
is  the  common  outlet,  and  form  attachincnts  to  its  projecting  lower 
edge  and  to  the  bulla  ethnioidalis  above.  The  point  is,  that  althfiugl 
distinct  polyps  ;ire  found  to  be  attached  to  the  borders  «.f  the  hiatii- 
in  a^  large  firoportioii  of  ca.ses  the  initial  lesion  is  a  diffuse  ethnioiditi- 
-Next  in  fre(juenry  polyps  originate  from  the  free  border  of  tli( 
middle  concha,  then  from  the  superior  meatus,  superior  concha,  an.; 
acces.sor>'  sinuses.     In  typical  form  they  are  very  rare  on  the  iiiferi<!' 

I  lj«mt)ert  Ij«k.    The  Joii.-nal  ..f  I.«r>-nKol.wy,  KhliM.joKy.  and  Otology,  KcLriiary,  liUll,  p.  M 
=  Edmond  W<ialce»     NamI  I'olypu..  etc  .  in  ReUtlon  to  Ethmuiditta. 
'  Zurkrrkandl.     Anatomic  der  Nanenholilc,  S  i'>4  el  «eq. 


SKOPLASMS  OF  THE  S>,SE. 


Hl[i 


=t-:;';:;2-;;Si;-l^^^^^^^^^ 


Flo.  4M. 


Out«r  .VKll  o.  the  riKlu  „u.al  c.vuy,  exhibiting  three  polypi. 


iZuckkrkandl.) 


flu.  445. 


liv.r  may  he  rppar.le.1  as  (.r.p  of  the  prodi.;. 
l-'sing  raiisos  of  othiiioiditis,  for  it  is  a  fro- 
'I'""'  ••<'nr..niitant  in  this  class  of  cases     The 
v.'r.nus  causes  of  a.-utc  an.l  chronic  rhinitis 
'"  ^^l.lch    reference    may  he    made  are   also 
<r"rativ...       Ohstructive   .ieformities   of    th<. 
-•pt.imtPay  encourage  the  formation  of  na.sal 
t'-lyp.,,,  which  case  they  are  often  found  also 
''•''.;'■■;'«;■.'  ''•••'nl.an.i  when  in  the  narrow 
"•still    i,e|„nd   the  obstruction.     (f-V    44^^) 
A  pun.  ent  outflow  through  the  l.iatas  .sen.i- 
"iiarisfrom  ,.mpy<.ma  of  the  antrum  of  High- 
"Tc  ,s  an  ...xciting  cau.se  of  ethn.oiditis  and 

l"'lvpus.  and  the  same  may  l,e  sai.i  of  prim  ,v 
-;;';|""-"""'   "f    the   fn.ntal    a,.,l   .sp,!,.„oii S 

;     'iir    '•""'    ""'.'""'•'    '"•"•^-      Kspecialiv    in 

-'""-t.on  ..f  these  cavities  seems  Lorroft:;;'  to'^^s^'fr;;;;;"!; 


Nttsa!  l>olypuslneunJiiiictl..ii 
with  obstructive  deformlly  of 
the  septum.    (Author's  oas^  i 


I 

i 
I  ■ 

i  i 


I  i 


i  i 


880 


XOSE  AND  TUROAT. 


closure  of  tlu'ir  orifices  by  polyps  which  were  pritnarily  the  outprowth 
simply  of  an  initial  non-suppurutivc  cthnioitlitis.  I  "have  frcHjucntly 
obscrvoil  simple  ethinoidiiis  with  polypus  and,  perhaps,  asthmatic 
symptoms,  hut  without  any  inus  aujjpuration,  and  years  later  en- 
countered the  same  cases  then  affect(>d  by  suppuration  in  one  or 
more  sinuses,  or,  with  bilateral  |)olypi  there  may  be  sinus  suppura- 
tion on  one  side  and  not  on  the  other. 

Pathology.  The  pathogenesis  of  nasal  jM)Iypus  has  Imhtj  outlined 
in  considering  the  etiologj-.  It  Is  further  elaborated  in  the  section 
on  pathological  histology. 

Microscopic  Appearance.'  The  epithj'lium  is  ciliated  colunmar, 
thickened  in  areas.  The  stroma  is  a  network  of  areolar  ti.ssue,  the 
size  (if  whose  meshes  Is  determined  by  the  amount  of  serous  infil- 
traiion.  The  meshes  contain  under  higli  power  granular  coagulated 
fibrin,  cobweb-like  threads  of  fibre  bundles,  and  small  round  cells, 
which  are  more  numerous  in  the  immediate  vicinity  of  the  blood- 
vessels from  which  they  exude.  From  the  round  cells  voung  con- 
nective tissue  is  formed  with  its  branching  cells.  The  senim  contains 
salts  in  .solution  and  nmciii 

Polypoid  Cysts.  Occasionally  a  growth  which  has  the  external 
appearance  of  an  (edematous  nasal  polypus  is  found  to  be  a  cvst, 
the  fluid  contents  usually  (>scaping  as  the  wire  is  tightened  around 
its  pedicle.  It  may  be  small  or  large,  single  or  nmltiple,  and  exist 
alone  or  in  association  with  ordinary  polyps  growing  from  the  sjimc 
situation.  In  one  case  the  c  ^t  that  grew  from  the  posterior  part 
of  the  middle  meatus  twice  r(>curred,  each  time  as  a  cyst.  Again, 
polyps  may  be  partly  cystic,  the  spaces  containing  at  "times  a  yel- 
lowish purulent  fluid.  lioth  are  regarded  as  glandular  retention 
cysts.  Tl»"y  differ  from  cysts  of  the  middh"  turbinated  bone  and 
from  dentary  cysts. 

Symptoms.  Na.sal  obstructions,  excess  of  secretion,  intranasal 
pressure,  and  headache,  defective  speech,  aural  complications,  impair- 
ment of  .smell  and  taste,  and  nasal  reHexes— <■.  7.,  asthma,  migraine, 
cough,  sneezing,  eK-.— are  the  salient  manifestations.  The  tumors 
are  prone  to  swell  in  damp  weather,  thus  increasing  the  nasiil  ob- 
struction. .Mouth-breathing  will  result  in  irritation  of  the  pharvnx 
and  larynx.  Tli(>  .secretion  may  be  simply  mucous,  possibly  excor- 
iating, or  in  case  of  conjoined  sinus  su|)pi"iration  it  will  be  purulent 
and  may  then  be  fetid.  The  spe(>ch  is  "dead"  from  absence  of  nasil 
resonance. 

Impairment  of  the  sen.se  of  smell  may  be  the  first  symptom, 
as  in  one  patient,  a  physician,  who  complained  only  that  he  liai 
lo.st  his  cu.stoniarily  keen  olfactory  sen.se,  and  in"  whom  polvni 
buds  could  barely  be  .seen  jutting  out  from  beneath  the  middle  tur- 
binated bodies.  In  fact,  the  di.sease  iiresents  so  many  import:. :it 
phases  in  connection  with  its  .associated   underlying  and  result!.  SI 

'  Jotuthin  Wright.    TranMctioni of  the  American  Ur)ngologlcal  Aaiocliitloii,  1893,  p.  6» 


liL 


NEOPLASMS  OF  THE  NOSE. 


881 


conditions  that  a  clinical  cliussification,  with  brief  case-descriptions 
and  illustrations,  will  best  i)()rtray  it. 

Nasal  Polypus  with  Simple  Ethmoiditis.  Mr.  li.,  aged  forty  years, 
coinpiains  of  pressure  far  back  between  the  eyes.  The  bas(>  of  the 
nose  ext<Tnally  is  broadened,  and  there  is  infra-orbital  .swelling  which 
simulates  the  physiognomy  of  Hright's  di.sea.se.  There  is  great  en- 
largement of  the  middle  turbinated  bodies,  which  press  hrnily  against 
the  septum  on  each  .side.  They  hav."  a  glistening  a.xpect  and  are 
odi'Miatous,  puitaceous  to  the  touch.  (Fig.  440.)  A  compact  bunch 
of  small  polyps  jut  out  from  beneath  each  middle  concha. 

.Mr.  N.  .\1.,  tiged  fifty  years,  liad  a  few  polyi)s  removed  ten  years 
ago.  Xa.sal  respiration  luis  since  been  free,  but  of  late  years  hi'  has 
suffered  a  seiLxe  of  pressure  far  back  between  the  eyes,  at  thnes  .so 
severe  tus  to  induce  a  high  degree  of  nervous  excitement.  ICnornious 
osseous  overgrowth,  with  polypoid  degeneration  of  the  middle  tur- 
binated bodies,  which  together  with  a  small  i)olyi)us  literally  pack 


Flo.  446. 


Flo.  447 


Fio.  41fi.— Elhmohlltis  with  nami  polypi  and  polypoid  degeneritiim  of  the  middle  turbinated 
Ixidies.    (Author's  c'a.«i!.) 

Kri;.  447  — Kepres.'ntiiiit  oil  one  »idi>  polyps  Rfowing  from  the  ethmoid  n.-){ion.  visible  only  after 
resection  of  the  middle  turbinated  bo<ly.    (Author's  case  ) 

the  upper  channels  of  the  nose.  Resection  of  the  middle  turbinated 
builii's  was  made  which  laid  bare  the  hiatus,  bulla  ethmoidalis,  and 
ill  I'art  the  other  ethmoid  cells,  from  which  i)olyps  could  then  be 
seen  to  protrude,  and  who.s(>  walls  were  in  a  similar  state  of  polypoid 
dcjreiicraticii.  On  the  left  side,  curiously,  no  true  polyps  had  been 
visible  until  after  removal  of  the  middle  turbinated  body,  when  two, 
of  good  size,  but  of  flat  s|ia|)e,  were  exposed,  which  projected  from 
ilir  region  of  the  ethmoid  cells.  (Kig.  447.)  The  term  "intracellular 
polyps"'  has  been  given  to  this  type,  in  which  growths  imiceeding 
Irom  tli.>  ethmoid  cells  are  contained  in  the  middle  meatus  beneath 
.111  enlarged  and  perhaps  excavated  middle  concha.  In  a  study 
iinbracing  a  series  of  forty  cases  of  nasal  polyj)us,  fourteen  were  of 
the  cla.ss  rejireseiited  by  these  two.     In  most  of  them  there  wa.s 


Dosworth.    Transactlous  of  the  Ameiican  Uryiigologioal  Ansodatlon. 
56 


i 

I 


H 


882 


NUHE  AM)  TlHiOAT. 


pdlypditl  transfonnatiim  of  the  Miiddlc  tiirhiiiatcd  body,  and  twn  of 
thciii  li.:d  each  a  lar^c  typical  polyp  dcvclopt-d  fniiii  '"liis  process  of 
the  ctlimoid,  aside  from  the  other  jtolyps  wliich  |,i-oceeded  from  the 
tuiddle  meatus. 

Nasal  Polypus  with  Vasomotor  Ethmoiditis.  This  class  is  introduced 
itirecosiiitioM  of  a  complex  of  symptoms  which  iucludes,  with  varia- 
tions, asthma,  hay  fever,  hypera'sthelic  rhinitis,  intumescent  rhi- 
nitis, and  poIy|)us.  Tliese.  when  occurrinj;  in  the  s.ame  patient, 
imlicate  a  fundamental  neurotic  lialiit.  That  the  neurosis  involves 
all  impairmi-nt  of  the  vasomotor  nerv<>  control  over  the  affected 
areas  is  jiurely  conjectural;  hut  it  is  a  reasonable  h.ypothesis,  and 
one  which  is  intended  to  keep  in  mind  the  .-ixsociations  and  partial 
dependence  of  asthma  upon  ethinoiditis  and  jiolypus. 

Miss  Mc{".  has  sutTered  from  comi)lete  nasal  obstruction  for  several 
years,  together  with  asthma  and  hay  fever.  There  were  multiple 
polypi  which,  after  removal,  would  ra|)idly  redevelop,  jjrowinji  in 
profusion  not  only  from  the  middle  meatus,  hut  also  from  the  superior 
meatus  posteriorly,  and  from  both  the  middle  and  superior  turbinated 
bodies.  TIk'  (-ntire  nii-sal  mucosa  w;is  in  a  state  of  (I'dematous  tume- 
faction, as  if  devoid  of  vasomotor  control.  The  hiatus  and  ethmoid 
cells  just  alM)ve.  when  exposed  by  resection  of  the  middle  concha, 
wore  found  covered  with  |)olyp  buds  and  jiranulation  ti.ssue  which 
were  curetted  and  picked  off  by  cutting  forceps.  Intermittent  intu- 
mescence of  the  nasal  tissues  contiiuies;  she  is  comparatively  but  not 
absolutely  free  from  a.sthma,  and  the  hay  fever  is  mitigated. 

Out  of  a  .series  of  forty  ca-ses,  this  case  is  rpi)resentative  of  a  group 
of  nine.  Asthma  Wius  a  universal  symptom:  four  of  the  nine  had 
hay  fever,  and  the  others  were  es|)ecially  susceptible  to  dust,  coal 
smoke,  fog.  aroma  from  horses,  etc.,  which  sufficed  at  any  season  to 
excite  tumefaction. 

Nasal  Polypus  with  Suppurative  Sinusitis.  This  class  is  repre- 
sented in  the  series  of  forty  by  a  group  of  twelve.  Nearly  .all  had 
empyema  of  one  or  both  maxillary  sinuses.  Two  had  in  addition 
empyema  of  the  frontal  simises,  and  one  of  these  conjoined  suppura- 
tion of  the  ethmoid  cells.  Two  others  h.id  sup|)urative  ethinoiditis 
without  involvement  of  the  other  simi.ses.  Curiously  enough,  onlv 
two  of  these  sujipuralive  cases  suffered  from  astliin.,.  and  they,  while 
having  polyps  on  both  si<les,  had  supixu-ative  maxillary  sinusitis  on 
only  one  >ide.  and  in  both  of  them  the  ethinoiditis  |)ulyps  anda-sthma 
seemed  to  precede  the  suppuration. 

.Mr.  McC.  aged  fifty  years,  has  sutTered  from  nasal  i)olyi)i  for  ten 
years.  <  die  year  ago  intense  pain  commenced  over  the  left  frontal 
siiii'--,  then  supra-orbit;il  bulging  and  tumefaction,  and  finally,  after 
months  of  intense  suCfering,  spontaneous  disch.arge  of  pus  occurred 
from  the  frontal  sinus.  The  left  middle  turbinated  bone  was  enor- 
mously enlarged  and  in  an  advance(l  state  of  jiolyjioid  degeneration, 
the  whole  mass,  together  with  some  small  jiolyps,  being  pack<'d  in  place 
.so  firmly  a.s  to  obliterate  the  middle  meatus  and  to  press  the  septum 


MM 


.\EOPLASMS  Ol-  THE  SOSb'. 


««3 


Inwar.l  tlic()|)|)(.sitcsi.|c.  The  removal  of  lliis  mass  exposed  pulypoid 
.■\crese<'nres  aii.l  sii|)piiralioii  of  the  ,  tliiiioid  eells.  wliicli  were  then 
M'laped  ami  drained.  He  Jmd  also  empyema  of  th<'  maxilla  y  iinlrum 
Miss  1'.,  a;:e.l  twenty  years.  The  rij;til  middle  tiirl.inated  l,o,Jv  j^ 
eiilarfr.'d  and  pres.^ed  against  the  septum.  The  hulla  ethmoidalis  is 
also  e.ilarjreil,  the  two  top'ther  presenting;  the  deeeptive  appearand 
•  if  a  double  turbinated  l.ody  or  one  that  has  wnd<-rp)ni'  apMurenl 
eieavafre.  i  !■  ijr.  44N.)  From  the  ii.s.^ure  protrude  .several  small  polvps 
and  a  jMirulent  seerelion.  wliieh  in  the  ahs.M/ee  of  maxilla!  v  and  frontal 
MiHisiiis  musi  proeeed  from  the  ethmoid  cells.  .\  fine  piolie  inserted 
iiiio  the  li.ssnre  .leterts  denuded  hone.  |{eseeti(,n  ol  the  middle  tur- 
I'Uiated  l)ody  and  eureliin>i  of  the  bulla  and  vieinitv  resulted  in  a 
cure. 

Diagnosis,  It  is  usually  only  neee.s.sary  to  look  -vith  a  good  lipid 
and  l-i'l  with  a  probe  in  order  to  establish  eorres,,.,nde::re  with  the 
l.hNsical  characters  described,  but  more  rarely  an  accurate  knowledge 


Flu.  44S. 


fir,.  HU 


<it  ail  patholojri.Ml  states  i.s  essential  to  a  precise  diagnosis.  Polypus 
H  '..  be  distmjruish.'d  from  mere  Ivperfn.phic  rhinitis,  and  septal 

■  v  HM-ence  by  the  fact  that  the  turbinated  bodies,  although  sivollen 

■  nul  the  s-ptum.  althou.iih  deformed  (  p.ui'v  their  natural  po.sitions' 
\Uiile  a  polypus  occupies  one  of  the  spaces  beneath,  between  or  beside 
tliese structures.  .  Fig.  4  K).  1  It  i>.  moreover,  movable,  and  jrenerallv 
"f  .1  paler  color.  Sarcoma  should  be  carefully  exclud.  d  by  micid- 
-■■'•I'ir  .'xammation  m  any  case  in  which  the  clinical  aspVcts  ap- 
.''■'.icli  malignancy. 

i  li.-nv  obser\ed  polypus  .and  sarcoma  side  by  side  in  the  same 
ii'Mnl,  .-md  I  ••im  mclmed  to  share  the  widespread  belief  that  ordinary 
pnlypus  m,y  m  ceriam  subjects  become  the  site  of  .sarcoma,  although 
it  i^ditiicultol  absolute demonstralion. 

So-called  '■  i,je,>di.,jr  tuiiiors  of  the  .septum,-  if  not  simple  vascular 
iivpertroi.hy  oi  svphilitic  gumiuata,  are  usually  angioinatti,  telaii- 
i^i'ctuiMata.  or  s.ircoinata. 


t^^ur 


IM4 


SaSK  AMf  TllHO.iV. 


Progi    4ii.     Tliif  i>     •.ctlliiit   if  tlic  di^iiw  'm>  crtcctivcl     trcatfil 
otherwise  rcciiiTciKM'  is  iif<uai. 

Treatment.  The  Im'sI  means  fur  tlir  r(iii()\.il  nf  ty|)ical  polypi  is  the 
cold  wire  simrt',  suppit'iiicntcd  l)y  sharp  cutting  forceps,  aiii!  ix-ca- 
sioiially  a  sliarji  curette.  Tiie  tcdiiiijUe  is  di  scrilM-d  in  another  ciiap- 
ter.  I.ocai  tnediciiial  measures,  ^Mcll  as  the  injiTtion  into  the  polyps 
of  perchloride  of  iron  solution,  chromic  or  IrichlorMcctic  a<'ids.  are 
inferior  modes  of  treatment.  \\Vakcn(  il  alcohol,  etc.,  to  di.-'  an  i;e 
their  growth,  is  of  i|uestionalile  utility.  \\KiT\  from  the  removal  of 
the  polyps  an  important  part  of  the  treatment  consists  in  the  estab- 
lishment of  free  nasal  passages  for  respiration,  drainap  ,  visinn.  and 
instrumental  manipulation,  for  otlier\\i.<e  the  polyps  can  Ik-  hut  mi- 
perfeclly  removed,  and  are  certain  to  recur.  To  this  (>nd  hypertro- 
jihied  turl)inat<'d  liodies  and  septal  .spurs  should  he  reduced  and 
wcriou.**  detlections  of  the  .septum  straightened.  I  iirthermore.  in  iSiM, 
in  a  piiper  liefore  the  .Vmerican  Laryiipological  A.ssociation,'  I  i>r()posed 
:i.s  part  of  tlu'  radical  treatment  of  iia.sal  polypus,  the  resection  of  the 
anterior  part  of  the  middle  turhinated  hone  in  order  to  facilitate 
acc«'8s  to  the  jioints  of  development,  liiRli  up  in  the  middle  mcatas. 
The  method  has  al.>*o  Iwen  advocated  hy  ( Jriinwald,'  Haji-k,'  and  others. 
.Vssociated  sinus  supi)uration  should  receive  appropriate  treatment. 

Intranasal  and  Retronasal  Fibromucous  Polypus.  This  nra- 
plasm,  al.so  called  myxohhroma,  contains  a  variahle,  often  u  large 
proportion  of  fibrous  tissue  which  gives  it  a  firmer  con.-iistenpy,  denser 
structure,  and  somewhat  darker  color  than  the  onlinary  mucous 
polypus.  It  is  more  .ascular,  and  the  intranasal  ;;rowth  remains 
sessile  longer.  It  is  |iroiie  to  originate  toward  the  rear  of  th<>  na.sal 
fo^su,  the  median  and  posterior  a.-in'-ts  of  the  mi<ldle  utrhinated 
body  or  adjoining  ;';'rt.-  iif  t'nr  cilimoid  and  sphenoid  bones  being 
.-^cat-  of  att;;clinic!!t.  Tlicnce  it  m.'iy  project  forward  or  backward. 
It  is  attached  fa.iiin  Kirward  than  a  regul.-ir  nasopharynge.il  fibroma. 
In  diagno-is  one  should  be  c  tri'fiil  to  exclude  sa''.'oma.  The  symp- 
toms and  treatment  of  the  intranasal  growth  are  the  sanu'  iis  for 
ordi'iarv  nasal  jxilypus.  The  symptoms  and  treatment  of  retntnas:il 
fibri.nmcous  polypus  cannot  be  better  described  than  in  relatiin: 
the  follow inu  case: 

Mr.  M.,  agcil  about  forty  years;  increasing  nasal  obstruction  for 
years.  The  ;:;!M\vtli  actv  like  a  valve,  permitting  a  slight  ingre.ss  of 
air.  but  closing  the  clioana'  upon  e\])iration.  an  action  which  is  par- 
ticularly noticeabl(>  and  distmbing  during  sleep.  ,\t  first,  if  he  won!  1 
lie  upon  the  right  side  the  tumor  would  gravit.ate  so  a>  to  free  tin' 
other  side;  but  iatterlv  it  has  growii  {t^>  large  to  afford  even  tlii- 
relief.     On  examiualii  n  po^teriorl\  the  tumor  is  seen  to  project  fro'i 


'  Oih^'lberr)"-    TraiLsartions  of  the  American  Ijiryn«ol(«;ici"!  Asaoolatlon.  1X91. 
-  (iriinwiilil.    Iiiu  I^bre  von  ilen  Niuenel'tTiingvn,  1S9,1.     Milnohcn  und  Leipzig,  Verlag  ^  a 
J.  f.  I.shmMi: 
«  H.  Ji'l.      ..:.  hlv  r.  Lar,.  n;?ulogle  und  RbiuoloRie,  VS\  Band  It.,  Heft  3. 


SEOI'LASMS  OF  THE  XOSK. 


88S 


the  rijriil  nostril  inti)  Hit-  iiiis<.|tliaryn.\,  whicli  it  nearly  fill;*.  ( Fin.  4.'»<).) 
It  i-  liarfly  visihlf  liy  anterior  ins|)cciiun,  iM-cause  adi'tlcftcd  wptiini 
limits  the  vi.vv.  An  cfTort  tu  nnarc  I'roni  in  front  failiMl.  A  loop  of 
No.  ."»  piano  win-  carricii  l>y  a  curved  catiula  through  the  niontli  and 
lias. .pharynx  enveloped  part  of  tin-  Krowlli,  hut  Im-mI  the  caiiulu  Ix'foro 

\\un   {Urmifrh,  and   had    to   Im- 
.1.  laclM'd.     A  cautery  snare  siini-  no  mo 

lariy  a.i;  isled  ilivided  part  of  the 
tuiiior,  permitting  the  reiimant  to 
>lip  forwanl  so  iluit  it  could  he 
snared  anteriorly. 

Intranasal  Fibroma.  rnderthi> 
title  it  is  proper  to  include  only 
jiwre  or  nearly  pure  tihroinata 
which  orijiinat!"  in  the  musal  fos.sa- 
anterior  to  the  nasopharynx.  They 
are  rare.     Schmidt'  oh.served  two  _ 

among   .'J.'MKH)   palients.      The    UU-      Uetronawl  nbmmucoup  polypiw.    (CoHlN.) 

tlior  has  re|iorted-'  a  typical  case 

ol  strictly  na.sal  hhroma  of  dense  cnn.«istpncy.  niicroscopipally  pxani- 
iiied,  which  originated  from  the  vault,  and  -.vhicli.  pri'.ssinR  the" septum 
to  ihi'  o|>positc  side,  had  cau.sed  absorption  of  the  middle  turbinated 
i"  y,  the  trahecuhr  between  the  ethmoidal  cells,  and  part  of  the 
anterior  wall  of  the  sphenoidal  .sinus,  the  nostril  after  its  removal 
presenting  a  large  cavernous  juspcct  with  smooth  walls.  It  was  re- 
iiiovi-d  in  fragments  by  the  galvanocautery,  and  has  not  recurred 
during  tliirte<'n  years.  Iti  the  nasopharynx  pure  fibromata  an- 
coiiip.-irativcly  conmion.  and  some  of  the  nasal  cases  have  originated 
from  parts  bordering  upon  the  iia.sopharynx— c.  »/.,  the  walls  of  the 
posterior  ethmoidal  cells  and  .sjihenoidal  sinus,  the  posterior  edges  of 
the  septum,  and  the  rear  ends  of  the  turbin:it<"d  bodies,  since  here 
is  foimd  in  greater  .abundance  the  fibrous  stratum  from  which  they 
■lie  assumed  to  develop:  but  no  part  of  the  no.se  is  exempt,  for  welf- 
.■iutlieiitic;it''d  cases  are  recorded  in  which  the  origin  was  from  the 
.•Ulterior  wall  of  the  sphenoidal  sinus,"  the  rear  of  the  vault*  as  demon- 
>tratrd  by  an  jiutoiisy:  the  middle'  .and  inferior  turbinated  bodies, 
I'le  n.of  uf  the  nasal  fossa,"  the  cartilaginous  sepfinn.'  and  the  na.sal 

Etiology.  ( )iic  ca.se.  involving  the  septum,  was  directlv  attr;buta'>le 
to  a  blow  on  th.-  nose:  in  another  it  followed  some  years  after  the 
leiiioval  of  a  mucous  jiolyp  from  the  same  site,  and  hence  is  attrib- 

'  .Sohmldt.     Die  Krmikhcltfn  deroln'reii  Lunwegc,  1S!V|.  S.  4'4ci 

•  (  mwll  .-rr)-.     NNsul  KiliroiimtM.    Jdiimal  of  Ameriraii  Medical  .A^sl«■iallon,  April  21,  IHiw, 
'  I'luwelbcrry.    .Inur:^  1  uf  Ameriean  Mollcal  As.xx'iatlon,  April  ■.'!,  Isw. 
'  lieMy.    (iiixi  by  .Muckenzle.     I)i.-e«M>«  of  the  Tlirout  aiul  S.w,  vol.  il.  p.  37.>.  Am.  cd. 
■■  e.  II    KniRlit.    .loiirnal  of  I,ar>  ngnlony,  Rhinology.  and  Otolosry,  March.  18S«,  p.  l.V!     New- 
'•niiib     Tliv  UrynKiisco|>e.  July.  I9()l.  p.  TO. 
^  ^;«ckeii2ie.    l)ioi«p«  of  the  Throat  and  No«e,  vol.  II.  p,  376,  Am.  eU. 
'  BuchaiiHn.    (ilaairow  Medical  Journal,  1S82,  p.  JU. 


MICROCOPY    RESOLUTION   TEST   CHART 

iANSI  and  ISO  TEST  CHART  No    2' 


1.0 


I.I 


If  ■- 

I—   1^ 
I-    1^ 


IIIIM 

[12.2 
[2.0 

1.8 


1.25 


1.4 


1.6 


A     APPLIED  IfVVIGE     Inc 


"fe)    .-flS       '■^.^■i 


■-609       ■wi* 


:     I 


8«6 


A'OAi,'  AXD  THROAT. 


utal)lc  to  ii  porvcTsioii  of  the  cliroiiic  liypcrtropliic  iiiflaiimialory 
jiroccss  similar  to  tliat  wliicli  rcsuits  in  iiuicoiis  polypi.  Both  scx('s 
and  al'  ajri's  sccin  (Miwally  liahic. 

Pathology.  Fihrous  tumors  in  this  situation  present  the  ordinary 
pathological  characters  of  hhroniata  in  general.  In  con.sistency  they 
vary,  heing  sometimes  very  dense,  and  at  other  times  softer  and  more 
succulent.  The  fibrous  tissue  which  constitutes  the  chief  part  of  the 
growth  is  grouijcd  in  Innidles  of  various  sizes,  or  is  simply  do.selv 
interlaced  and  devoid  of  <lefinife  arrangement.  A  few  minute  cells, 
either  round  or  spindle-shaped,  may  he  |)resent  among  the  fibres  or 
in  large  numbers  around  the  bloodvessels.  A  smooth  fibrous  cap.sule 
usually  envelops  the  whole.  The  following  is  Dr.  .Jonathan  \\'right's 
description  of  sections  from  the  author's  speciiTien:  The  sections 
are  largely  made  up  of  fibrous  conne<-tive  tissue  whose  outlines  do 
not  show  very  clearly,  owing  p'robably  to  the  long  time  the  six'cimen 
has  been  kejjt.  I  presume  you  are  justified  in  calling  the  growth  a 
fibroma,  although  thei  >  are  a  number  of  (edematous  areas  in  it.  as 
well  as  the  evidences  more  commonly  regarded  as  those  of  chronic 
inflanmiation.  "     (Fig.  4.51.) 


Fio.  451. 


IntninaMil  tibnima 


(.\utbor'H  s|n;t*imen.) 


Symptoms.     The  early  symptoms  are  tlioso  of  a  catarrhal  nature, 
followed  by  obstruction  and  distention  of  the  fos.sa.     Its  develo])ment 
continues,  to  th  •  deiriment  of  bones  or  cartilages  that  mav  be  in  the 
rhes  


*ay. 


L'se  aie  absorbed,  enveloped,  and  rent  asunder,  the  neoplasii 


yiyjPLAS3lS  OF  THE  yusE. 


887 


p.-notrating  into  fissures,  accessory  sinuses,  and  neighboring  cavities. 
Tlif  l)riilf;e  of  the  nose  is  ffatteiied,  the  eyes  bulged  forward,  and  tiie 
(•lieei<  swollen,  th(>  whole  constituting:  the  hideous  deformity  known 
as  "frog-face."  Fre(|uent  and  dangerous  attacks  of  e])istaxis  may 
|ii()ceed  from  surface  ulcerations.  Kxiension  upward  may  open  the 
cranial  cavity. 

Diagnosis.  A  ])robal)Ie  diagnosis  is  not  diliicult.  Its  appearance 
//(  f^itii  differs  mucli  from  that  of  the  mucous  polyp.  It  is  not  mul- 
tiple, but  may  be  lobulated.  The  ba.se  is  broad.  Ihe  color  is  tlark 
red,  tliere  is  no  translucency,  and  it  is  firm  and  resistant  to  pressure 
by  a  i)robe.  It  is  more  difficult  to  distinguish  it  thus  from  fibro- 
sarcoma. Microscoi)ic  examination  is  the  only  means  of  positive 
diagnosis. 

Prognosis.  There  is  a  tendency  to  recurrence  after  removal, 
although,  if  thoroughly  extirpatetl  and  ihe  base  cauterized  to  the 
bfine,  the  prognosis  should  be  good.  Intranasal  fil)roma,  like  fibro- 
iiuicous  polypus,  appears  to  form  a  fa\'orable  nidus  for  the  develop- 
ment of  sarcoma. 

Treatment.  If  small  it  could  Ix'  removed  in  lolo  by  the  galvano- 
cautery  snare.  When  large  and  confined  by  adhesions  it  is  necessary 
to  resort  to  the  author's  expedient  of  dividing  it  into  two  or  more 
tongues  or  fragments,  over  which  tlie  snare  may  then  be  more  easily 
adjusted.  Repeated  sittings  may  be  necessary,  and  if  profu.se  hemor- 
rhage be  excited  an  iodoform  gauze  packing  sliould  be  inserted.  In 
cutting  operations  there  is  great  danger  from  hemorrhage,  Grrdy's' 
and  HeilerV  cases  having  termin,"  d  fatally  from  this  cause.  Never- 
theless, in  long-continued  neglected  cases,  wl'Pre  the  neighboring 
cavities  are  encroached  upon,  it  may  be  necessary  to  make  an  external 
operation,  such  as  von  Brun's,  OUier's,  or  Rouge's,  or  a  resection  of 
the  sujierior  maxilla. 

Intranasal  Papilloma,  (a)  Fibroma  Papillare.  (6)  Adenoma  Pap- 
illare.  The  true  papilloma  or  i)apillary  fibroma,  conmionly  called 
a  wart,  is  often  found  in  the  vestibule  of  the  nose  at  or  near  the 
jimctiou  of  th(>  skin  and  mucous  membrane,  and  is  then  usually  of 
ti\e  hard,  scpiamous  variety,  as  it  develops  fron>  the  cutaneous  struc- 
ture. 

Strictly  within  the  nose  true  papilloma  occurs  but  rarely,  but  still 
it  does  occur.  It  may  also  be  of  the  s(iuamous  ty])e,''  as  are  the 
w.trts  of  the  ])harynx  and  larynx,  or  it  may  he  soft,  ((uite  va.scular, 
and  composed  primarily  of  colunmar  epitheliiun*  which,  however, 
nay  degenerate  in  places  into  Hat  cells.  Whether  the  ephhelium  is 
of  tiie  columnar  or  s(|uamous  tyi)P  the  branching  ])ediclc  or  central 
tissue  is  fibrous  and  without  glands.     It  may  be  pedunculated  or 


'  'iertly.     Loc  cit. 

-  Soiler,  TraiisHirtloiis  of  the  PRtholiiglcal  Society  of  Philadelphia,  18*4,  p.  126 :  cited  by  Bosworth, 
lMsea«es  nf  N<mh;  and  Throat,  vol.  i. 

'  Hillman.  Archiv  f.  Uryngolruie  und  Rhinologie,  Band  Ti.,  Heft  2,  8.  171 ;  Douglass,  New  York 
Mnlicai  Journal,  J.intiary  7,  ISini.  p.  6. 

'  Jonathan  Wright.    Transactions  of  American  Liryngological  Association,  1896,  p.  177. 


888 


yoUE  AM)  Til  HO  AT. 


i"i 


1       1 


H 


!    J  I 

■    I  I 


(liffusoly  sessile.  The  favorite  sites  are  tiie  cartilaginous  septiini  and 
the  floor  of  tiie  nose. 

Sjmiptoms.  The  salient  symptoms  ,••'•'>  nasal  ohstnictions  and 
epistaxis.  cither  of  which  may  l)e  ahscn*  >  the  jrrowth  he  tiuite  small 
or  not  vascular. 

Dia.H'nosis.  The  jjapillomata  would  he  distinguished  from  malig- 
nant neoplasms,  especially  epithelioma,  hy  microscopic  -xamination 
coupled  with  the  clinical  aspect  and  course  of  the  disea.se. 

Prognosis  It  tends  to  recur  unless  thoroughly  removed:  but 
complete  removal  is  usually  i)ossil)le  in  the  nose. 

Treatment.  They  may  he  removed  hy  the  cold  or  hot  snare,  or, 
if  accessible,  iiy  knife  or  sharp  forceps.  Hemorrhage,  if  persistent, 
may  he  controlled  hy  an  iodoform  gauze  tamjion.  Chromic  acid  is 
best  adapted  to  the  cauterization  of  the  base,  which  is  oft(>n  indicated 
to  prevent  recmTcnce,  although  unnecessary  irritation  by  repeated 
aj)plications  of  caustics  or  inefficient  operative  measures  is  to  be 
avoided.  For  inveterate  recurrence  it  is  said  the  local  and  systemi" 
use  of  the  tincture  of  thuja   occidentalis,'  ajjplied   on  cotton  for 

enty  minutes  twice  daily,  and  a  tcasjjoonful  taken  thrice  daily  is 
.if  service. 

Adenoma  Papillare.  In  addition  to  true  i)ai)illoma  or  papillary 
fibroma  there  are  not  infre<|uently  found  in  the  nose  glandular  over- 
growths, ])a|)illary  hyi)ertrophies,  and  inliamini.tory  thickenings  which 
present  to  tlie  naked  eye  a  papillary  surface,  and  some  confusion  has 
arisen  by  naming  these  also  ])apillomata  or  warty  growths.  Ho)i- 
maim's"  so-called  ]iai)illomata,  which  are  implante(l  usually  upv)n 
hypertroiihied  turbinated  bodies,  contain  glandular  elements  sulficient 
to  .justify  till'  term  "adenoma  papillare."  Others  are  mucous  |)<)lj'])i'' 
with  a  papillated  surface,  and  still  others  are  to  be  regardetl  merely 
as  localized  inflammatory  overgrowths. 

Intranasal  Angioma.  Bleeding  Polypus  of  the  Septum.  Si/notuiws. 
.\ngiotibroma,  fibroangioma.  fibroma  angiomatoides,  telangiectoma, 
{■avernous  angioma,  bleeding  |iolyi>us  of  the  .<e|)tuni. 

Tlii>  I  iimor  is  probal>ly  not  so  rare  as  li:is  been  represcMited,  being  de- 
scriiicd  under  various  names.  S<'ver;il  papers' have  recently  aitjjearec I 
in  (ierman  literature  under  the  title  of  "bleeding  iioly])us  of  the  sep- 
tum," and  I'tliers  in  .\nierica  under  the  titles  of  telangiectoma''  and 
cavernous  angioma.''  The  detailed  pathological  description  of  all 
these  tallies  I'loselv  with  each  other  and  with  the  case  below  described. 


'  K  F.  Ingalls.    Transactions  of  AinerM'Hi  Laryiiijolonioal  ,\s<<i)Ciaiion.  1**'.J0.  p.  .'»J. 

>  UopiiuiiMi.  Arihlv.  I'.  i«th.  Anal.,  rhysiol.  niul  Me<l..  ISKl.  Nci. ',i:i.  p  :Jl');eiteil  by  Joiiullmu 
Wrinht,  rraiisaction"  of  Aniurican  I.aryiiK"IOKicai  Asscx-iution,  1>*91,  p.  14. 

=  Xo.iuet.  Rev.  de  laryiiBolORic'.  etc.,  July,  iswi.  ami  June,  1"*91 ;  citeil  by  Jonathan  Writjhi. 
loo.  ('it. 

*  Victor  Ijin;re.  Internationales  Centralltlatt  fur  Laryn.  und  Uliinot..  June,  lsy;i.  p.  .V.HI , 
Schadewaldt.  Arehiv  f.  i,arynifol.,  Bani  i.  S.  'ii'A) ;  Alexallier.  ibid. :  Sclieier.  iiii'i  ;  Heymann,  ibid. 

f"  Cierce,    'I'ransaction.'s  of  Ameneau  Medical  Association.  Section  of  lAryntfology  and  UtoloKy 

Ju.ie  1,  Iv.iT. 

'  Cobb.    Trausactioiu  of  the  Paii-Amvrican  Medical  ConKren,  1X93,  vol.  ii  p.  I.MO. 


NEOPLAHilS  OF  rilK  S</>,E. 


889 


111  tlic  cMily'  litoraturo  sovorul  cases  are  reported  uiulcr  the  name 
ansiioiiia,  Imt  some  of  them  ar<>  eoiifused  with  other  neo])hisms,  c.  r/., 
anjiiosareoina.  angiotihroma,  etc.  About  thirty  oases  in  all  are  re- 
|iiirteil. 

The  exact  site  on  the  se])tum  hii-s  varied,  hut  all  were  toward  the 
anterior  part,  and  several  at  the  l)as(\  Tlie  size  is  from  that  of  a  pea 
tip  a  hazelimt;  if  much  larger,  one  should  strongly  suspect  sarcoma. 
The  siu'face  is  no(lulat(>d  or  furrowed,  !)ut  may  he  smooth,  the  color 
a  mottled  l)lue  or  red,  and  the  pedicle  either  narrow  or  hroad. 

Cavernous  anjiioma  is  also  described  as  occurring  on  the  anterior 
and  median  portions  of  the  inferior  turbinated  body.  In  this  situation 
dill'  mu^t  avoid  confusing  mere  hyi)erplasia  of  the  normal  cavernous 
structure  with  a  neophism,  although  the  latter  does  occur,  the  illus- 
trations^ and  pathological  descriptions  siiowing  it  to  conform  closely 
to  angioma,  as  it  occurs  on  the  sei)tum. 

Etiology.  They  are  more  freiiuent  in  females  than  in  males,  in  the 
proportion  of  three  to  one.  The  lymphatic  temperament  seems  to  be 
a  I iredis] losing  condition. 

Pathology.  The  vascular  tumors  whicli  grow  upon  the  septum 
iiarium  do  not  conform  exactly  to  either  the  tj'pical  amjioma  mnplex 
iir  the  (Uhiioma  ravcnwsum.  They  contain  both  bloodvessels  and 
blood  spaces,  thus  far  representing  rather  a  combination  of  the  two 
ty|>es,  and  they  contain  also  a  larger  jiroportion  of  reticular  connective 
tissue,  with  either  round  or  sjiindle  cells.  In  some  this  reticulum  has  a 
lilirillary  "liaracter,  justifying  the  term  angiofibroma.  If  composed 
entirely  of  dilated  pre-existing  vessels  rather  than  newly  formed 
vessels,  the  term  relaiigiectasis  or  telangiectoma  is  by  some  preferred. 

.Mil  noscoi'ir  Ai'i'KAKANCK.  In  the  ca.se  below  mentioned  the 
tiinmr  was  compo.sed  largely  of  bloodvessels  and  blood  spaces.  The 
bloodvessels  vary  in  size,  and  most  of  them  contain  more  or  less  blood. 
.Smieof  the  v^'ssels  are  collapsed.  The  blood  spaces  are  partly  lined 
with  epithelium.  Hetween  the.se  ves.sels  and  blood  sjiaces  is  connec- 
livf  tissue  ill  which  are  lumierous  round  cells  and  young  connective- 
tissue  cells.  ( )n  one  side  of  the  tumor  is  a  remnant  of  mucous  nieni- 
lirane. 

Symptoms.  Attacks  of  bleeding  are  fre(|ueiit  and  severe,  especially 
if  the  tumor  is  located  near  the  orifice.  The  degree  of  obstruction 
dr]iends  ujioii  the  size  of  the  tmiior. 

The  condition  is  exem|ilitied  in  the  following  ca.se: 

Mis.  T.,  aged  about  thirty  years,  married,  pregnant.  Has  been 
.iniii  .I'd  for  the  past  few  months  by  fre(|ueiit  bleeding  from  the  rigl.i 
ii"-tiil,  and  gradually  increasing  obstruction.  Kxaminatioi.  d'  I'l  ised 
:i  soft,  reddish,  irregularly  nodulated  tumor,  the  size  of  a  smail  bean, 
.ittached  by  a  rather  broad  pedicle  to  a  small  excrescence  of  the  se])- 
tiiiii  at  the  point  of  junction  of  the  cartilaginous  .segment  with  the 

I  lloswiirth.    Discuses  of  the  Niise  atiii  Thrmit.  vol.  li.  p.  431 ;  Schwager,  Archlv  f.  l.ar)'ngol.  und 
ia.ni.ii.,  r>„u.l  i.  ,>.  lo-'i. 
-  Jurasz :  cited  by  Scbwager,  lac.  cit. 


890 


XOUE  ASD  THROAT. 


1. 


w 


■ 


Kio.  I5i 


septal  process  of  the  suixTior  maxilla,  therefore  just  within  the  nostril 
and  dose  to  the  Hoor.  It  bled  ejisily  on  contact  with  a  pro!)e.  I  re- 
moved it  with  a  cautery  snare,  and  cauterized  the  l)ase  with  chromic 
acid.     Three  weeks  later  one  small  vascular  i)oint,  still  unhealed  and 

disposed  to  bleed,  was  again  cauter- 
ized with  chromic  acid.  No  recur- 
renc(>  during  three  years. 

Diagnosis.  The  tumor  may  j'ulsate 
if  connectt  '  with  an  artery,  and  the 
color  is  tluw  more  red;  but  if  chiefly 
venous  the  color  is  bluish.  Sarcoma 
should  be  excluded  by  careful  micro- 
scopic examination. 

Prognosis.  If  well  removed  it 
shows  little  tendency  to  recur. 

Treatment.  The  growth  may  be 
rei.inved  by  the  cautery  snare,  very 
slowly  by  a  cold  wire  snare,  by  silk 
ligatures,  or  by  electrolysis.  The 
ba.se  should  be  cauterized,  preferably 
by  chromic  acid. 

Intranasal  Adenoma.  A  pure 
of  gland  structure,  having  its  type 
Obstruction  of  tii(>  ducts  may  lead 
u  ^vstic  formation.  More  often  it  contains  considerable  fibroas 
conruH  tive  tissue,  when  it  becomes  in  reality  an  adenofibroina.  Such 
a  neoplasm  occasionally  originates  from  the  glandular  structures  in 
the  posterior  surface  of  the  velum. 

In  the  nose  i)ure  adenoma  seems  to  occur  but  very  rarely.  Certain 
mucous  polyps  may  contain  adenomatous  elements,  .\denoma  pap- 
illare  receives  reference  under  intranasal  ])apilloma.  It  is  usually 
imp-lanted  upon  hyi)ertroi)hie(l  turbinated  tissue,  contains  glandular 
elements,  and  has  a  jiapillated  surface. 

Adenosarcoma  is  encountered  in  tiie  nose,  and  is  included  in  the 
chapter  on  sarcoma.  Rarely,  the  sarcomatous  element  has  Ix'cn  so 
slight  as  t'l  induce  the  reporter  to  cla.ss  it  as  adenoma,  in  accordance 
with  the  i)renonderating  tissue,  for.  while  semimalignant,  it  is  less 
so  than  the  average  sarcoma.  In  Harris''  case,  after  six  years'  suf- 
fering from  asthma  and  nasal  polypi  many  times  removed,  he  expc- 
ri>nced  an  inveterate  rapid  recurrence  of  the  poly])i,  which  finally 
became  soft,  necrotic,  and  friable,  packed  the  maxillary  and  ethmoid 
sinuses,  and  terminated  fatally  eight  years  after  the  commencement 
of  the  asthma  and  poiypr-. 

The  structure  o'  this  growth  a.s  described  by  .lonathan  Wright- 
may  serve  to  exemplify  the  class:  Comi)osed  principally  of  glandular 


1  Harris.    Ijincet,  January,  1896.    Reprint. 
•  Wright.    Quotsd  by  Uarris,  loc  cit. 


Intrana»l  angioma.    (Author's  case.) 


atlenoma  is  a  benign  hyperpla.'^' 
in  the  acinous  or  tubular  gland: 


SE0PLAS31S  OF  THE  XOSK. 


Sl»l 


culuninar  opitlu'liuin  regularly  formed  into  acini  and  ducts,  in  some 
pints  involution  of  the  epithelium  wjis  surrounded  hy  a  framework 
of  new  connective  tissue,  which  in  a  few  places  is  ma(ie  up  of  spimlle 
cells,  and  in  considerable  areas  is  densely  crowded  with  round  cells, 
some  of  both  the  rounil  and  spindle  cells  being  so  arranged  as  to 
suggest  sarcomatous  tissue. 

Adenocarcinoma  receives  reference  under  carcinomata. 

Symptoms.  These  would  depend  upon  the  exact  character,  situa- 
tion, and  size  of  the  growth:  but  the  symptoms  likely  first  to  attract 
attention  would  be  those  incidental  to  lui-sal  obstruction. 

Diagnosis.  Adenoma  is  prone  to  develojj  in  middle  and  advanc(>d 
life,  ttbroma  in  the  scond  or  third  decade.  A  careful  micro.scojjic 
examination,  considered  in  connection  with  the  clinical  aspects,  may 
be  necessary  to  exclude  sarcoma. 

Prognosis.  This  is  favorable  when  there  is  an  entire  absence  of 
malignant  elements. 

Treatment.  When  strictly  licnign  there  is  little  difficulty  in  its 
eradication  by  the  means  enij)loyed  for  other  nasal  neoplasms.  If 
there  is  a  malignant  tendency  the  treatment  would  be  in  accordance 
with  the  principles  enumerated  in  the  .section  on  .sarcoma. 

Intranasal  Osteoma;  Chondroma  and  Odontoma.  O&teoma.  Sipi- 
(imims:  lixostosis,  enostosis.  The  term  exostosis  hius  also  been  aj)})iied 
to  excrescence  of  the  sejjtum,  but  is  not  now  generally  so  used. 

.\  form  of  exostosis  which  constitutes  an  osseous  tumor  somewhat 
rarely  develo])s  from  the  walls  of  the  ethmoidal  cells,  frontal  or  max- 
ill.'iry  sinus,  and,  while  occupying  to  some  degree  the  nasal  fo.ssa,  it 
u>ually  encroaches  upon  surrounding  parts,  especially  the  orbit. 
^\  hen  it  develops  in  the  diploe  the  cortical  substance  ex])ands  and 
envelo|)s  the  osteoma,  and  \'irchow'  draws  a  distinction  between 
these  which  he  names  enostoses  and  exostos(>s  pro])er,  which  originate 
from  the  periosteum.  Bornhaupt,'  in  reporting  a  case  of  frontal 
siinis  osteoma,  gathered  from  the  literature  .'iO  cases,  "i.'J  of  the  frontal 
sinus,  12  of  the  ( *hmoidal  cells,  10  of  the  antrum  of  Highmore,  and 
•")  ot  the  s])h(>noiil,  sinus;  87  per  cent,  oi  the  whole  number  occurred 
before  the  thirt  eth  year. 

Osteomata  ar  •  described  as  living  and  dead,  the  latter  when  they 
li.ive  undergone  spontaneous  loosening  from  their  point  of  attach- 
ment. In  btein's''  ca.se  the  osteoma  wa.s  .symmetrical  aii<l  double, 
causing  the  a])pearance  of  "frog-face"  and  complete  nasal  obstruc- 
tion. 

In  FengerV  case  thi'  large  osteoma,  partly  living  and  partly  deail, 
s]ir;ing  from  the  ethmoid  bone,  filled  the  na.sal  chamber,  and  en- 
croaciv'd  upon  the  orbit.     It  followed  a  fracture  of  the  nose,  trau- 


'  Virchow.    Cited  by  Fenger,  Journal  of  American  Medical  Association,  188S.  p.  185. 
■  Bomhaupt.    I.angenbeck'8  Arehiv  f   kliniache  Chirurgie,   18S1,  Band  i»vl.  p.  5S9;  cited  by 
Feuifer,  Inc.  clt. 
'  ".  J.  Stelii.    IjirynKOScnpe,  July,  1900,  p.  2:*. 
*  Fenger.   Journal  of  Americau  Medical  Awociatlon,  1888,  p.  186. 


mi 


yosi:  A^     rnito.iT. 


w 


! 


I 


(I 


inuiisin  l)cin^  rcfianlfM  !is  !i  (•oiiiiiion  cxcitiiip  cawso.  Nassil  poly])! 
(•(M'xistcd,  (loiilitlcss  excited  l)y  tlic  irritation  and  supjuiration  inci- 
dental to  the  |iresence  of  tiie  osteoma. 

Chondroma.  Intranasal  chonilronia  is  rare  if  the  term,  together 
with  its  synonyms— enchondronia  and  echondroma— he  properly 
restricted  to  a  real  neopla.-m  t)f  cartilagi',  and  not  loosely  a|)plie'  to 
inflammatory  sjuirs  and  deflections  of  the  septum.  A  true  dion- 
dronia  usually  ilevelops  dininp  adolescence,  springinfi  from  the  .sejjtal 
or  alar  cartilages,  or  at  the  inferior  junction  of  the  two.  It  varies 
in  size  from  that  of  a  hazelnut  to  an  orange,  and  is  round  or  nodu- 
lated, closely  resembling  a  dense  fibroma.  It  is  composed  of  hyaline 
cartilage  with  perhaps  tihrous  tissue  near  the  st'rface.' 

The  diagnosis  would  licst  he  confirmetl  l>y  Toscop'c  examina- 
tion, for  which  purpose  a  segment  could  he  .cd  by  means  of  a 
rotary  knife  trephine.  One  would  wish  to  .de  chondrosarcoma. 
From  osteoma  it  is  distinguished  by  its  peneirability  by  a  needle. 

Chondroma,  if  not  too  large,  can  be  removed  by  a  cold  snare;  the 
iiemorrhage  is  slight,  and  it  .shows  no  tendency  to  recurrence.  Hence 
the  importance  of  ;m  early  recognition,  for  when  (juite  large  an  exter- 
nal operation  becomes  necessary." 

Odontoma.  Odontoma  is  a  neo])lasm  which  arises  from  the  germs 
of  teeth,  and  which  is  composed  of  dental  ti.ssues,  cementinn,  dentine, 
and  enamel,  one  or  all  in  varying  i)roportion.  The  tumor  may 
contain  a  mniiber,  even  as  many  !is  Hfty  denticles  or  tooth-like  bodies 
composed  (if  either  cemeiitum  or  dentine,  as  the  case  may  be,  or  even 
ill-shaped  teeth  comjiosed  of  all  three  elements.-'  The  number  of 
such  denticles  in  the  human  may  reach  fifty  or  more.  Odontoma 
involves  the  no.se  only  by  extension  from  the  alveolar  process.  It 
encroaches  first  u])on  the  antrum,  filling  and  distending  that  cavity, 
thence  possibly  'Vojecting  into  the  hnnen  of  the  nose.*  It  arises 
only  in  youth,  before  dentition,  a  ])oint  of  value  in  distinguishing  it 
from  osteoma.  It  shows  no  tendency  to  recurrence  if  well  enucle- 
ated, for  which  ]iur])ose  a  subperiosteal  partial  resection  of  the  maxilla 
through  the  mouth  may  be  reijuireil. 

Lipoma.  While  lipomata  are  not  uncommon  on  the  external  surface 
of  the  nose,  they  are  not  encountered  within  the  nares. 

Malignant  Neoplasms  of  the  Nose. 

Intranasal  Carcinoma.  Carcinoma  occurs  less  frequently  in  the 
nose  than  sarcoma,  but  many  well-authi'nticated  cases  are  recorded. 
It  is  rarer  in  the  nasal  cavities  than  in  other  ]iarts  of  the  upper 
respiratory  tract,  the  larynx,  for  instance;  hence  the  more  dotailcii 

'  Mackenzie.    Piseaso  nf  the  Thnwit  ttiid  N'ose.  Aiit.  e<1.,  vol.  ii.  p.  .3S0. 

-  Veriieuil  ;  cited  by  Boswnrth.  PiaeaRes  of  the  Nose  aurl  Thix>at,  vol.  if.  p.  4:l'>. 

'J.  lllaiid  Sutton.    Tumors.  Innocent  and  Malignant,  IH93,  p.  .W:  cited  by  A   W.  de  Roa'.dcs, 

*  A.  W.  de  lioaldes.    Tran»actinn8  of  Ainericun  Laryngological  Aitaociation,  1894,  p.  91. 


NEOPLASMS  OF  THE  yoSE. 


^J3 


(l('S(Tii)ti(m  of  tlio  (lisoiiso  will  be  found  under  i-urrinonia  of  tlic  larynx. 
Si|\iani()us-c('ll(>(l  raroinoniii  (cpitliclioinai,  cylindrical-celled  caicin- 
oiiia,  and  glandular  carcinoma,  soft  (encephaloidl  and  hard  {scirrluis), 
appear  in  point  of  frequency  in  the  order  nanieil.  Favorite  sites 
are  the  vestilnile,  cartilaginous  septum,  middle'  and  inferior"  turbin- 
ated bodies,  ethmoid'' region,  anil  posterior  edge  of  the  vomer.*  It 
oiijjinates  more  often  in  thi'  antrum  of  Hifrhmore,  and  extends  thence 
to  the  no.se.  It  develops  usually  aft(>r  forty  years  of  age.  Hilhotli 
has  described  a  "glandular  carcinoma"  or  "cylindrical  epithelioma" 
of  less  disposition  to  recurrence,  in.stances  of  which  occur  in  the  nose. 
The  .same  is  known  also  as  adenocarcinoma''  or  malignant  adenoma, 
and  con.sists  of  a  stroma  of  young  connective-ti.ssue  cells,  lying  in 
which  is  an  aggregation  of  tubuli  lined  with  a  cylindrical  non-ciliated 
e|)ithelium. 

Symptoms.  In  addition  to  nasal  obstruction  and  distention  pain 
of  a  lancinating  character  is  a  prominent  .symptom.  Invasion  of 
the  orbit  will  cau.se  exophthalmos  and  blindness. 

The  diagnosis,  especially  from  sarcoma,  will  depend  upon  micro- 
scopic examination.  It  does  not  always  involve  the  neighboring 
lymphatic  gland.x.  The  prognosis  is  exceedingly  unfavorable,  excjit 
in  "glandular  carcinoma."  The  principles  of  treatment  are  the  same 
as  for  sarcoma. 

Intranasal  Sarcoma.  Nasal  sarcoma  is  rather  frequent.  Nine 
cases  have  pas.sed  under  the  author's  observation,  mo.st  of  which 
have  terminated  fatally.  Each  had  long  jjersisted  in  the  hope  that 
ill'  suffered  merely  from  a  polypus.  A  better  comprehension  of  the 
disease  in  its  early  .stages  is  to  be  desired.  The  cartilaginous  septum 
is  a  fa\orite  site  for  sarcoma.  Of  41  ca.ses  tabulated  by  Bosworth 
in  9  ii  originated  on  the  .septum.  This  fact  is  the  more  important 
since  >n  this  situation,  if  recognized  early,  it  is  accessible  for  thor- 
'•■  -ition,  even  by  hitranasal  methods.  This  was  exemplified 
uthor's  ca.ses,  a  man  aged  fifty  years,  who.se  right  nostril 
■ed  by  a  rather  firm  neoplasm  which  projected  slightly 
II  ..is  and  .sent  tongue-like  prolongations  backward  into  the 
»;■  the  nasal  fossa,  but  which  on  removal  was  found  to  l)e 
attached  only  to  the  upper  jjart  of  the  cartilagincms  septum  bv  a 
pedicle  2  cm.  in  diameter.  Its  i)rojecting  lobule  w;is  abraded  and 
Med  freely  on  slight  contact;  but  its  larger  part  was  covered  by  a 
thin,  smcoth,  capsular  membrane.  After  complete  removal  I  cauter- 
ized the  base  with  such  thoroughness  as  to  produce  a  large  perforation 
of  the  sei)tum,  and,  although  metastasis  in  the  ethmoid  region 
iiccurred,  it  did  not  redevelop  at  the  original  site.  The  microscopic 
findings  are  given  under  pathology. 

Other  points  of  origin  are  the  ethmoid  region,   the  turbinated 

•  Robert  Crieu.    Atlas  der  Nasenkrankhelten,  1901.  Plate  XXXVI. 
=  Krteg.     Loc.  clt.  3  Kriee.    Loc.  cit 

'  schmirtt.    We  KraiittheltenderOberen  Luftwege. 
'  Thoruer.    Medical  Record,  September  10, 1898,  p.  367. 


or. 
ii.     ' 

i'niiii 
CK  '-ice 


S<J4 


yo.SE  ASO  riUlOAT. 


Iiiiilics,  and  (lie  iiaMiil  llimr.  Tlie  aiilniiii  is  pniiif  t"  involvciiu'iit, 
I'df  it  is  an  avaiial)lc  spacf  into  wliicli  llic  tumor  expands  midcr  the 
pi'i'ssuiT  ol  ils  ^lowtli.  Less  often  the  nroplasm  urijiinates  in  tl.e 
antiuiu  and  e.Npands  into  the  nose.  In  advanced  e.i.-es  it  may  be 
dillienlt  lo  determine  which  course  lias  l)een  pursued:  l)Ut  the  aiitrinn 
and  the  other  acce-sory  simises  should  l)e  kejit  in  mind  in  connection 
with  |)os>ihlc  reineihal  ineasun- 

Cases  reporteil  include  all  af;e>  I'roin  four'  to  seventy-<'ifjht  years,- 
although,  in  comjiaiison  with  carcinoma,  e;irly  afies  preilominate.  My 
youngest  case  was  a  hoy  of  ten  years,  whose  rijriit  nostril  was  packed 
with  a  fungoid  mass  of  a  few  months'  development,  which  proved  to 
Im-  rouiul-celled  sarcoma.  l']xteriial  o|MTation  was  declined,  and  the 
patient,  witliout  treatment,  had  still  survived,  hut  was  fast  falling, 
a  year  afterward. 

The  oldest  of  my  series  was  a  man,  a>;ed  sixty-hve  .vi  :<.  who  had 
an  imm(>nse  growth  of  three-ye.'irs"  development,  wilii  )jronouiiced 
exoplithalrnos  and  swelling  of  the  whole  side  of  the  face.  It  pro- 
truded from  the  anterior  iiari.-,  projected  somewhat  into  the  naso- 
pharynx, and  involved  the  aiitnuii. 

Etiology.  The  still  unsubstantiated  microhic,  that  is,  the  protozoan 
infection  tlieory  of  carciiKJina,  isapplicahli'  a'  >  to  sarcoma,  the  organ- 
isms supi)osedly  exciting  a  proliferation  of  coimective-tissue  cells. 
.•\lso  the  Cohnheitn  theory  of  an  excess  of  emhryonic  cells  in  pre- 
viously ((uiescent  ej'elets  ma.v  he  U'entioned.  Schmi<lt  ascribes  sar- 
coma to  a  perverted  or  atypical  syphilitic  iiiHuenee.  Trauma  i^ 
re))Uted  to  Ih-  a  pre(lisposing  condition  to  sarcoma.  Without  implv- 
ing  a  change  of  type  of  tissues,  it  is  clinicallv  observed  that  benign 
growths  occasionally  become  the  site,  that  is,  furnish  a  suita'^le  nidus 
for  the  development  of  malignant  tumors,  and  the  same  is  true  of 
inHammatory  tissue.  Tims  is  explained  the  rare  development  of 
s.arcoma  in  connection  with  UMleniatous  nasal  polypi  which,  for  want 
of  a  better  name,  is  termed  "myxosarcoma."  This  tyjie  usually 
grows  from  the  ethmoid  ri-gion,  since  that  is  a  favorite  site  for 
(edematous  polyps.  It  is  exemplified  by  2  cases  in  my  s(>ries,  one 
a  man  aged  hfty  years,  who  had  been  subject  to  nasal  i)olypi  which 
had  iK'cn  periodically  removed  during  several  years,  (iradually  they 
assumed  a  cauliflower  aspect  and  a  mottle(l  hemorrhagii  hue.  Bleed- 
ing liecame  continuous  and  at  times  profuse.  He  persistentl.v  de- 
ferred external  surgical  measures  and  ))asse(l  tinally  from  observation, 
being  then  in  an  advanced  state  of  exhaustion. 

Pathology.  Both  the  round  and  sj)indle-celle(l  ty])es  iire  encoun- 
tered, and  either  may  be  of  the  small  or  large-celled  variety,  tin 
smal!  rouiid-celled  nas,-'  sarcoma  beuig  es|)ecially  malignant.  (!iant- 
celled  or  inyeloiil  sar  .aa  also  occurs  in  the  nose,  one  of  the  writer"-^ 
cases  being  of  this  form.     When  truly  pigmented  it  is  known  as 

1  BlisB.    Transarti.-.ns  .-.f  '.tnsiiror,  [,Hryngol.-igica!  .A=50clat!t>n,  I".*,  p.  16. 
•  ButUn  ;  cited  by  H.swDrth,  loc.  <;lt. 


yEOPLA.SMH  OF  THE  AOAA'. 


8!)o 


tiictaiinsarconm.'  also  a  very  inaliu'iiaiit  type;  hut  iiasal  cases  dc- 
s(iilic(lasiii(laiMiticari'n()talwa>>  n-ally  such,  the  discoldiatidii  Ix-inj; 
ilui'  to  l)lu(»l  cxtravasiitioii.  An  .ihcr  couiltiiiatidti  is  lilirnsam.tiia, 
uhirh  is(.|ic<)uiitcn'<l  in  all  (ic};ivis  of  Mialij;iiancy,  In.tii  the  tiijruuia 
uilh  which  there  are  mixed  only  a  few  round  ci'll.s,  and  which  may 
not  he  malijrnani,'  to  the  sarcoma  which  has  simply  a  larger  amount 
than  usual  of  tilmius  connect  ve  tissue  minjricd  with  it.  Angiosar- 
coma' is  encount<Ted  es|M'cially  u|)<)n  the  cartilaginous  -.ptum,  where 
It  constitutes  one  of  the  forms  of  "  1)1. -ding  polypus  of  tJie  septum." 
Microscopic  Appearance.  In  the  author's  ca.se  1.  ahove  mentioned, 
small  round  cells  i)redominate(|.  In  case  2.  "  my.xosarcoma,"  tiu' 
M'ction  showed,  ui  addition,  areas  of  ci'deinatous  p(»lypoid  tissue.  In 
i-ase  ;{  the  .-ection  showed  large  nuinlH>rs  of  small  multimideated 
round  cells  lioiuid  together  hy  hhrous  connective  ti.ssue,  also  an 
aliiindance  of  mucous  ti.s.sue. 

Symptoms.  Nasal  obstruction  and  distention,  leading  to  headache 
and  other  pre.v-ure  manifestations,  .such  as  exophthalmos,  "frog-face," 
and  local  par.  lyses,  an-  .symptom.s  wliich  vary  in  degree  acconlii'ig 
to  the  extent  of  the  growth.  To  these  is  commonly  ad<led  re|)eated, 
easily  e.xcited,  and  s()metimo,s  severe  l)l(H'<ling  attacks  and  discharge 
which  may  he  fetid  or  excoriating.  The  cervical  lymj)hatic  glands 
are  not  usually  involved  until  late,  and  cachexia  al«)  mav  be  absent 
until  exhaustion  is  manifest. 

The  growth  is  originally  encap.sulated  and  pedunculated,  although 
the  parts  which  i)resent  anteriorly  are  oft.-n  .so  broken  down  and 
excoriated  as  to  a.ssume  a  granulated  cauliflower  a.sjject,  and  with 
closely  packed  large  growths  it  may  not  he  possible  to  distinguish 
the  [MMlicle  until  after  removal.  More  than  one  point  of  attachment 
may  he  anpiired.  or  the  growth  may  become  a  diffused  fungoid  mas.s. 
The  surface,  if  unbroken,  is  a  mottled  bluish-gray  or  yellowi.sh,  and 
thi'  consistency  soft,  although  in  two  of  my  ca.s^'s  it  was  so  firm  as 
to   suggest  ti!)roma. 

Diagnosis.  The  presence  of  the  symptoms  deserilK'd  would  Ije 
■strongly  suggestive  of  sarcoma,  although  confirmation  should  inva- 
riably he  sought  by  microscopic  examination  of  a  fragment  removed 
tor  the  purpose.  Kven  then,  for  diagnostic  pi  poses,  a  degree  of 
harmony  between  the  microscopic  findings  and  the  clinical  aspects 
should  he  established,  for  micr()scoi)ic  errors  do  occur,  and  in  the 
nose  the  normal  lymphoid  structure,  inflanunatorv  and  svphilitic 
infiltrations,  and  adenoma,  may  all  sinmlate  sarcoma.  Carcinoma, 
.■iltlioug!i  more  rare,  is  also  encountered. 

Proposis.  If  early  recopiized  and  thornughlv  extirpated,  the  prog- 
nosis IS  fairly  good;  but  if  long  established  or "incompletelv  removed 
<  IS  very  bad,  for  diffusion  •     the  cells  to  a  distance  in  surrounding 

>  Mlphael.    Annaies  des  Maladies  .le  fOreille.  du  Larynx,  etc.,  1890,  p.  6S8;  Lincoln.  New  York 
\lu<lical  Journal,  October  10.  l)«i. 
-  Schmidt.    Die  Krankheitpn  der  .".hprpr,  T.uftwege. 
'  Scndzlak.    Journal  of  Laryngology,  Khinology,  and  Otology,  March,  1896,  p.  104. 


Hi»G 


so.si:  A\j>  riiii'iAT. 


H 


\  ; 


t 


I 


1! 


tissu.'-i  :m<l  inctastiisis  occur.  An  iiiiiilysis  of  sixty  tiiluihitnl  cases 
woiilil  s...|n  to  iii.licatc  that  al.uiit  lialf  tin  I>alicrits  ,i|M;ratc.|  on 
rccovcriMl,  vet  if  one  cxclutlcs  cases  in  wliicli  no  report  is  jjiven  alter 
six  months  or  a  vear,  the  minilter  of  rec.iveries  will  Iw  rediice.l  to 
abont  IV)  i>cr  cent,  lioun.l-celled  sarcoma  ami  true  melaiiosareoma 
are  es|KM-iallv  malicnant.  iM'inji  liahie  to  very  rapiii  growth  ami  .lii- 
fusioii.  yet  one  certain  recovery  from  the  former  ty|M'  ami  one  trom 
the  latter  are  re|iorte(l.  Myxosarcoma  is  much  less  malignant  ami 
furnishes  a  numl-er  of  recoveries.  The  ihiration  of  life  in  unoix-rated 
cases  ami  in  those  which  recur  is  from  two  to  six  years. 

Treatment.  First  must  Im'  deciiled  whether  it  is  an  oin-raMe  or 
an  inoiH-raltle  cas«',  and  if  o|M'ral)le  whether  inlraiia.sal  or  e.xti-rnal 
methods  should  In-  pursued.     To  aiil  in   the  determination  tif  the 

first  iM)int  .su< lata  may  Iw  (livided  inio  Inur  jjroups.^     The  first  Lh 

that  of  pedunculaled  tumors.  The  .-second  >;roup,  which  comprises 
tumors  with  a  limited  hase  ..•  implantation,  is  less  fa^•or!ll)le  than 
the  tirst  for  surgical  intervei.iion  :  but  when  situat<'d  near  the  anterior 
nares  their  ablation  is  relatively  ea.sy.  DiH'use  tumors,  on  the  con- 
tniry.  which  form  the  third  griaip,  when  they  extend  either  sui>er- 
ficially  i>r  deepiv,  perhaps  sending  prces.ses  into  the  underlying 
iMuies,  necessitate  ftrave  and  ditlicult  optTations.  Only  a  (|uestion 
of  degree  .separates  tlxMu  from  lho.se  of  the  fourth  group,  which  are 
situated  in  immediate  proximity  to  vital  parts,  and  so  far-rcachinn 
fis  to  Im>  (luite  iiioiM-rahle.  To  decide  iietweeii  the  third  and  fourth 
group  may  call  for  judgment.  It  may  Im-  impos.sil)!e  prior  to  an 
oi)eration  "to  determine  the  extent  or  attachments  of  the  growth,  in 
which  case  an  external  o])eratioi\  may  he  justified  in  the  hoiK'  that 
it  inav  prove  to  he  erai'.icahle. 

The  decision  between  intr.anasa!  methods  and  an  external  op-ration 
will  deixMid  upon  the  accessibility  of  the  base  of  the  growth  through 
the  natural  pa.s. ,  ges.  When  circumscribed,  and  esjiecially  when 
originating  from  the  cartilaginous  sejjtum,  thorough  intrana.sal  mean> 
are  to  be  preferred.  If  i)edunculated  and  iilion  the  external  wall, 
the  same  mav  be  s;iid:  but  if  difluse  and  rimning  n\>  Ix'neath  the 
mi<ldle  turbinate(l  bo.ly  into  the  ethnioitl  cells  or  into  the  antrum 
or  si)henoi(lal  sinus,  the  only  hope  of  eradication  lies  in  a  formidable 
external  operation  to  give  access  to  tlie  parts,  ''"'le  nature  of  this 
will  depend  u])on  the  site. 

i'.vt-n  f  '•  circumscribed  easily  accessiiile  tumors  it  is  sometime- 
urged  that  extirpation  w.iuld  be  more  certain  through  the  simpler 
external  incisions--( .  (/.,  -.'w  reparation  of  the  ala  by  an  incision  in 
the  nasogenal  fniTow  with  or  without  temponiry  resection''  of  the 
nasal  bones— but,  by  reason  of  convenience  or  prejudice  agair\st  faci:il 
<lisHgurement,  intranasal  methods  are  usually  giv<'n  a  first  trial. 
The  incandescent  snare,  wlien  it  can  be  caused  to  envelop  the  growth 

1  Biiylan.    Transaclions  "f  American  iJiryngolopMil  Association.  1S'J6.    Bosworth,  loc.  cit. 
:  Plicqiiu.    Aniialea  des  .M»l.  liu  ion-illf,  tlu  Laij  ..a,  etc.,  Murctl.  in'JO. 
s  Maekenjle.    Discussion,  American  Laryngological  Association,  1«9". 


KEOPL.f^lS  OF  THE  LARYSX. 


807 


with  amiracy,  is  to  Ik-  pn-fcnrd,  hut  the  cold  wim  Hiiare  catj  1«' 
used  and  is  often  iiKiri'  coiivctiiciit  f(ir  fniKiiifntiil  n-movul.  I  huvc 
IdiiihI  I'riiicf  s  turliiiiiitoiiiy  f(irc«'|w  wTviccahlo  f.  the  rapid  clearing 
away  i>l'  large  caiiiiHower-like  niai*^^.  Hemorrhage  is  controlled  hy 
i.MJotorni-gauw!  |)acking.  For  destruction  of  the  l)ii»«>  I  have  used 
llic  gaivanocauter\  <ui)|)leniente  I  liy  chromic  acid,  and  if  preventiil 
i)y  bleeding  I  have  deferred  this  procedure  until  the  next  Hitting. 

NEOPLASMS  or  THE  LARYNX. 


Benign  Neoplaanu  of  the  Larynx.  U'ith  reference  i  he  symp- 
toms, diagno.-is,  and  treatment,  the  ()enign  neoplivsm:  .  the  larynx 
have  so  much  in  comnum  that  they  may  Ih>  considered  collectively 
under  the  heading  of  their  chief  repn'sentative,  {)apilloma,  leaving 
only  liricf  individual  descriptions  for  the  rest  of  the  group. 

Papilloma.  The  most  frerpient  and  clianicteristic  type  of  jia))- 
ilioma  in  the  larynx  is  that  v..'  h  resemlilcs  to  the  naked  eye  a  cu- 
taneous wed-wart.  The  neoiiiasm  with  its  hy|)ertrophied  papillie 
may  In-  plush-like,  foliated,  i  'mhlhig  a  cock's  cotnh,  of  a  cauli- 
t'owi  r  aspfct,  or  nmlherry  form.  The  growth  as  a  whole  is  of  ru'lier 
tirm  consistency,  although  the  surface  is  soft.  It  iscommonly  c. .  .il  or 
scmiglohular,  but  may  be  irregular,  e\<'n  angular  in  contour.  In  size 
they  vary  from  1  to  10  nun.  or  more,  in  long  diameter.  The  color 
grades  from  i)ale  gray  to  pink,  and  they  may  l)e  single  or  tnultiple. 
T!ie  smaller  growths  are  usually  se.ssile;  hut  with  greater  develoijment 
they  are  prone  to  liecome  jiodiculated.  The  |M'(licIe  may  jxTinit 
considerable  moliility,  as  in  a  n-cent  cii.se  of  »he  author's,  in  wh'ch 
a  papilloma  the  size  of  a  bean  attached  to  a  vocal  cord  hung  below 
the  glottis  during  (juiet  respiration,  but  rose  between  and  alw     the 


FlO.  4V) 


"n   -IM. 


PHpllloma  of  the  larjuz. 

vocal  cords  on  phonation.  The  site  is  nearly  always  the  vocal  cord, 
•  ■■specially  at  or  near  the  anterior  third.  I  have  observed  the  warty 
U'luwth  to  spread  around  the  free  edge  of  the  cord,  involving  both 
till-  u]ii)er  and  lower  surfaces,  also  to  spread  from  the  upper  sur- 
iace  into  the  ventricle,  and  from  the  anterior  commissure  dowTi  the 
tracheal  wall.      (Figs.  453,  454,  an<l  455.)      The  vc)  'ricular  band, 

ft" 


%^-'><J« 


«!I8 


XOSE  AXI>  TiriUKlT. 


I 


; 


Flii.  4'm, 


Papilluinu  of  lilt'  Iiirynx. 


aryopifllotlic  fold,  ami  cijislottis  arc  rarer  sites.  The  iiiterarytenoid 
folil  is  stat('(l  to  he  exempt  from  true  pai)illoma,  hut  1  have  notes  of 
two  cases  in  wliicii  it  was  involved  together  with  the  vocal  cords. 

.\  .second  form  of  laryngeal  papilloma  is  characterized  hy  a  more 
ditTu.s'cl  distrihution,  wide  areas,  any  or  all  parts  heing  covered  hy 
till'  growth  which  may  lead  to  ohliteration  of  the  lumen  of  the  larynx. 

This  diffused  ty]K'  is  prone  to  affect 
young  children;  hut  the  author  has 
oh.served  some  |)ronounced  instances 
of  it  al.so  in  adults. 

In  the  case  from  which  Fig.  4.55  is 
drawn  tlie  larynx  at  first  sight  was 
fillecl  withamassof  papillomata,  \\'iich 
on  Ix'ing  in  ])art  cleared  out,  were  i>  aid 
to  sj)ring  like  a  fringe  from  the  entire 
length  of  the  vocal  cords  and  the  iii- 
terarytenoid  fold. 

A  third  type  of  laryngeal  ])ai)illoma 
is  descrihed'  as  ijuite  small,  .sessile,  and  smooth :  in  fact,  indistinguisli- 
ahle  from  a  lihroma,  I'xcept  hy  inicroscoi)ic  examination. 

Etiology.  Little  is  known  of  the  etiology  of  this  and  the  other 
henign  n(>oplasins  of  the  larynx.  I'redi.sjxisition  is  evidenced  hy 
papillomata  apjx'aring  on  various  surlaces  and  at  times  hy  a  family 
tendeniy  thereto.  Males'  are  affected  in  the  i)roportion  to  females 
of  three  to  one.  Chronic  laryngitis  and  the  congestion  which  is 
incidental  to  overu.se  of  the  voice  have  heen  apparent  causes  in  a 
few  of  the  author's  cases.  Two  were  singers,  one  a  hoard  of  trade 
operator,  one  a  campaign  orator,  one  a  lawyer,  etc.,  yet  in  most  of 
them  the  voice  was  not  overtaxed  and  the  larynx  not  independently 
infiamed.  Four  were  young  children,  a  much  higher  percentage 
than  is  indicated  liy  Fauvel's''  ;J0()  cases,  of  which  only  ")  occurred 
in  the  first  ilecade  of  life. 

Pathology.  The  essential  elements  of  a  papilloma  are  a  connective- 
tissue  stroma,  hypertrn|)hied  iia])illa'.  and  prolifer.-ited  epithelium. 
The  stroma  may  he  soft  and  sparse  or  the  compact  form  may  pre- 
dominate, the  latter  conditicms  especially  ju.stifying  the  term  papillary 
fihroma.'  The  hypertrophied  pa])illa'may  he  very  few  and  simple,  each 
composed  at  thi'  has(>  of  a  central  core  of  connective  tissue  containing 
a  vascular  loo|)  and  covered  hy  layers  of  epithelitil  cells;  hut  usually 
the  pajjilhe  are  multijjle  and  hranchecl,  each  terminal  rep'-esenting 
one  of  die  small  hulhous  or  jiointed  jirotrusions  of  the  surface  of  the 
tumor.  The  epithelium  is  stratified,  hut  may  he  thin  or  very  thick, 
often  constituting  much  of  Ijie  growth.  It  hoth  covers  ;t"nd  dips 
between  the  papilhe.      It  grows  kihui.  hut  not.  as  in  carcinoma,  ititc 


'  Oertel ;  riiwl  hy  Jiirnpz     lleynmiiirs  lliuvltjiich,  Haml  i ,  s  syi. 

'  .Inni«7       HpyTt!H!!!r<  !lsi!!!'!ieh. 

■I  Kaiivtl ;  oital  by  H<«uiirtli   I>iK<>ii»'s  iif  Ihe  Tlirdiil  nilil  N\«e. 
*  Zli'gler.    Lvbrbuch  iler  palh.  Anatomie. 


Xi:orLA^.M^  OF  THE  LAItYXX. 


81(1) 


the  iiiiilcrlying  tissue.  In  the  ilcpths  the  of)itholial  cells  are  polyg- 
<iii;il.  hut  near  tlic  surfaoe  they  assume  the  pavement  form.  tlie 
tcnii  pnrhijdrrmin  rnrurosa  (Virchow)  is  applied  to  tliis  tyj)e  of 
papilloma  iti  coutradistinetion  to  imclii/dcrmio  diffusa,  in "  which 
there  arc  ehronic  inflammiitory  changes  in  the  deeper  sulx-pithelial 
layers. 

The  res|)iratory  trad  heing  derived  from  the  epihlast  its  papillo- 
in.it.t  are  classed  with  skin  warts  of  the  hard  type  in  contradistinction 
1(1  soft  warts  of  organs,  like  the  bladiler  and  intestines,  which  are 
derived  from  the  hypoblast. 

Symptoms.  The  disahility  occasioned  by  any  benign  tumor  of  the 
larynx  consists  mainly  of  an  interferen  e  with  the  functions  of  phona- 
linii  and  resjjiration.  The  voice  first  iires  easily,  then  grows  st(>adily 
hnarse,  and  finally  is  reduced  to  a  husky  whisper  as  the  growtji 
impinges  more  and  more  upon  the  glottis."  Kfforts  at  talking  when 
the  larynx  is  thus  disabled  are  ajit  to  maintain  congestion.  Dyspncea 
iiccins  when  the  neo|)lasm  attains  .-JufHcient  size  to  occlude  the  glottis. 
It  i-<  common  in  young  children  from  laryngeal  papillomata,  because 
the  larynx  is  |)roportionately  small.  It  usually  necessitates  tra- 
cheotomy. Diffuse  papillomata  may  interfere  with  res])iratioii  also 
ill  adults.  Other  benign  neoplasms  which  may  grow  large  enough 
to  obstruct  res])iration  are  fibromata,  chondromiita,  lipomata,  adeno- 
mata, cysts,  and  thyroid  tumors.  On  the  other  hand,  any  (tf  these 
growths  when  small  and  favorably  situated  may  be  devoid  of  symp- 
toms. Cough  is  rare,  but  may  be  severe  and  lead  to  suffocative 
attacks.  Laryngeal  .spasm  is  ob.served,  especially  in  childhood,  in 
the  form  of  nocturnal  exacerbations  of  tlie  dyspnu'a. 

Diagnosis.  The  differentiation  of  benign  pai)illoma  from  carcinoma 
of  the  larynx,  which  may  present  a  papillom.atous  surface,  is  dwelt 
u|)on  in  the  section  on  carcinoma.  Papilloma  occurs  at  any  age, 
favors  the  anterior  }K)rtions  of  the  vocal  cords,  is  not  painful",  does 
not  bleed,  and  is  distinctly  superHcial,  not  impairing  the  motion  of 
the  cord. 

'aicinoma  favors  mafin-e  age,  often  begins  on  the  posterior  part  of 

i;  cord,  may  ulcerate,  bleed,  and  infiltrate  the  depths  of  tissue,  im- 
pairing in  l.ihty.  \  microscopic  examination  of  a  fragment  from 
ill'-  depths  of  tSe  neoplasm  should  be  conclusive:  but  it  is  a  safe 
mic  to  insist  upon  harmony  between  the  microscopic  findings  and 
ilic  cliiiical  aspects. 

SiiKin-s  iKules  (lifTer  from  ordinary  pajiillomata  in  being  svmmet- 
iic.illy  i)il;iteral,  usually  (piite  minute,  and  of  simple  in'lammatorv 
origin.  They  consist  of  a  hyperi)lasia  either  of  th<>  epithelium  o'r 
'■'■niicctive  tissue,  which  forms  a  minute  nodule  on  the  free  edge  of 
each  vocal  eord  at  about  the  middle  or  near  the  junctitm  of  the  ante- 
rior .and  middle  third. 

l-'ihmmn  is  distinguished  from  papilloma  ))v  its  smooth  -urface. 
"icimisciilxMJ  form,  firmer  consistency,  redder  color,  and  bv  inicro- 
■^copic  examination. 


ii( 


yoo 


yUSE  AM)  THROAT. 


i    i 

{ 


I 


\ti 


Myxoma,  so-culled,  in  the  hirynx  is  probably  an  (Edematous  or 
degenerated  tibroina,  and  its  exact  nature  would  be  determined  only 
by  niicroseopic  examination. 

Cynts  also  have  a  smooth  surface,  and  their  litjuid  contents  may 
be  (lemonst rated  by  i)uneture. 

Lipoma  is  rare,  occurs  usually  on  the  aryepiglottic  folds,  falling 
into  the  pyriform  sinus,  and  not  on  the  vocal  cords. 

Amiioma  may  have  a  rough  surface  not  unlike  a  papilloma:  l)ut 
its  vascular  or  red  raspberry  aspect  will  usually  indicate  its  nature. 

Chondroma  is  dense,  hard,  anil  immovably  attached  to  one  of  the 
cartilages. 

Adenoma  is  very  rare,  but  when  it  occurs  it  might  readily  be  mis- 
taken, without  microscopic  examination,  for  a  large  papilloma  of 
the  mulberry  type. 

Prognosis.  \Vith  respect  to  the  voice,  the  prognosis  is  good  in  the 
circumscribed  type  of  papilloma,  provided  the  tumor  be  skilfully 
and  promptly  removed.  Recurrence  is  freiiuent,  but  is  due  only  to 
the  (lifhcuity  of  thorough  extirpation.  Dyspncea  is  an  evident  menace 
to  life,  and  tracheotomy  should  not  be  too  long  delayed.  This  is 
especially  true  of  children  who  are  liable  to  die,  as  in  two  ca.ses  of 
the  author's,  through  nocturnal  exacerbation  of  the  dysj)n(i>a,  perhaps 
excited  by  crying,  temper,  and  fright.  The  liability  of  a  papilloma 
or  other  benign  neoplasm  to  become  the  site  of  a  malignant  growth 
is  also  a  consideration. 

Treatment.  The  treatment  of  laryngeal  ])apilloma  and  ol  the  other 
benign  neoplasms  of  the  larynx  is  mainly  of  a  surgical  nature,  and 
the  techni(|ue  is  considered  at  length  in  the  chajjter  on  intralaryngeal 
o|)erations.  A  few  principles,  however,  may  be  heie  expressed. 
Nearly  ;ill  benign  neoplasms  of  the  larynx  in  the  adult  are  amenable 
to  intralaryngeal  methods,  which  should  be  skilfully  and  persistently 
attempted  before  resorting  to  an  external  oj)eration.  Laryngotomy, 
however,  exceptionally  may  l)e  justihed.  even  in  adults,  for  instance, 
when  till'  throat  is  very  intolerant,  the  larynx  very  deeply  placeil, 
and  the  neoplasm  very  imfavorablv  situated — r.'j.,  at  or  Ix  low  the 
anterior  coiiimissure,  a  combination  of  conditions  which  has  occurreil 
in  the  author's  experience.  Thyrotomy  has  been  many  times  resorted 
to  for  papilloma  in  childhood,  but  is  not  in  as  much  favor  as  it  should 
be,  for  the  reason  that  re"urr(>iice  of  diffused  growths  is  the  rule,  while 
cicatrici;il  stenosis  has  occurred,  and  there  is  an  appreciable  risk  from 
jineumonia  (.'{.o  per  cent.).'  Delay  may  be  afForded  by  a  low  tri- 
cheotomy,  and  in  rare  instances  spontaneous  recovery  has  thereafter 
•■nsued,  encouraged  by  enforced  rest  to  the  larynx:  but  indetinite 
delay  becomi's  far  more  dangerous  than  tliyrotoniy.  becau.se  of  tli;' 
many  accidents  which  liMj)peii  to  traclie()t(imy  or  intubation  tube^, 
and  the  liability  to  sudden  death  before  assistance  can  be  rendere'l. 
In  botii  children  and  adults  with  obstructive  iieoiilasms  tracheotomv 

'  M»nierrc.    etiicBuo  Mclii'iil  Recorder,  January,  1895,  p.  35, 


XKOI'LAHMS  OF  THE  L.lHiyX. 


901 


m;iy  Ix'  an  csspiitiii!  a'nl  n  ♦  only  to  respiration,  but  to  subspciucnt 
inlralarynfical  removal  of  tlu   L'rowtli. 

Fibroma.  'I'lie  coMneetive-tissu  *'bres  may  be  closely  interwoven, 
constituting;  the  hard  fibroma,  or  they  may  Ix-  loosely  arranjiei I,  with 
spaces  containinf'  serunr  when  it  is  known  as  a  soft  or  (edematous 


lilimnia.     iietween   the  two  are   found 


T 


degre<'s  of  consistency. 


wise   W 


iiich  approximate  the  former  ty])e  are  most  connnonly  de- 


sciiiu'd  under  the  name  of  fibroma,  while  the  latter  are  collo(|uially 
spoken  of  as  polyps  or  incorrectly  named  inyxomata.  In  the  larynx 
fibroma  occurs  next  in  frequency  to  paoilloma,  the  usual  location 
lieinj;  one  of  the  true  vocal  cords,  pretVrabiy  its  anterior  i)art,  aldiouph 
any  feature  of  the  larynx  may  be  the  site.  The  author  has  recently 
observeil  one  on  the  arytenoid  eminence,  which  was  large  and  firm, 
beini;  distiiifjuisluMl  from  a  cyst  by  puncture.  On  the  vocal  cord  it 
is  usually  small  (2  to  5  nun.),  semiftlobular  or  oval,  broad  based, 
circumscribed,  single,  smooth,  and  of  a  reddish  color:  but  there 
■Iscwhere    it    may  become  ipiite    large,  lobulated,  exceptionally 


mu 


lti|ile,  pedunculate<l,  and  gray  white   in   color.     The  .sym[)t( 


)nis. 


and  treatment  are  considered  in  common  with    those  o 


nillon 


Fig.  i'il. 


Fig.  Vo\ 


Fiu.  4. j»i.— Fibroma  of  left  vocal  cord.    (Cohen.) 

Flo.  4.'»7.~Fibroina  of  right  vocal  cord.    (Cohkn  ) 

Fio.  4V*.— <FAlematoU8  tibmtna  or  polyp  {tnyxomu)  of  rijrht  vot-al  curd 


Myxoma.  Certain  growths  which  spring  usually  from  the  edge  (  f 
the  vocal  cords  and  resemble  nasal  polypi  in  their  lustre,  seinitrans- 
hiccncy,  and  .soft  consistence  are  variously  termed  myxomata,  polypi, 
oijematous  fibromata,  and  degenerated  fibromata.  Like  iia.sal  poly])i 
they  may  be  of  inflammatory  origin,  yet  they  assume  the  distinctive 
characteristics  of  a  tumor.  Whether  they  can  with  propriety  be 
separately  cla.ssed  as  myxomata  would  seem  to  deix-nd  upon  whether 
their  gelatinous  or  mueo.s(>rous  intercellular  sul)stance  is  the  same  as 
the  gelatin  of  Wharton,  which  is  \'irchow's  prototyi)e  for  myxomata. 
Tiie  tendency  in  recent  pathology  is  to  regard  them  as  crdeniatous 
libroiiiata.     (Fig.  458.) 

Cysts.  Cysts  of  the  larynx  are  usually  of  the  mucous  retention 
t>|ie.  They  vary  in  size  from  that  of  a  millet  seed  to  a  walnut. 
Ihey  are  apt  to  be  semitransjiarent  when  possessing  a  clear  li(iuid 
cont(>nts,  but  may  be  opatiue  from  thickness  of  the  wall  or  opacity 


!  1 


902 


yosi:  AM)  TlUiOAT. 


of  tlic  (•(intents.  TIloy  tire  niuiid.  ov:il,  or  siiiiidlc-sliapcil,  anil  aro 
located  ill  tlie  (inlei'  named  on  the  epifilollis,  especially  its  anieiinr 
siiil'ac<'  and  I'lee  ed<;e.  vocal  cords,  ventricles,  aryepifrlottic  folds,  and 
arytenoid  region.  When  projeetinf;  from  the  ventricli  they  may  lie 
mistaken  for  Mi-calleii  prolapse  of  tlie  ventricli-.  A  cyst  is  not  always 
a  mere  distent 'm  of  a  previously  e\istin;t  structure;  liut  its  wall  may 
aci|uire  a  <;riiwih  of  its  own  and  its  multiplied  endothelium  continue 
to  elahora  '•  the  contents.  Such  a  <'ysl  is  a  veritable  neoplasm,  and 
may  he  properly  de-;ij;nate(l  cystoma. 

Lipoma.  Stricdy  inlralarynjieal  fatty  tinnors  are  exceedingly  rare, 
iiut  a  few  c;i>es  are  recorded.'  -  They  frrow  more  often  from  the 
aryepijrlottic  folds'  ;ind  epifjlottis  anil  fall  uiitwardly  into  the  larynx. 
However  these  may  attain  a  size  sullicient  to  ohslruct  the  larynx. 
Thev  mav  lie  sin;;le  or  multiple,  smooth,  lirimched,  or  loliulated. 

Ang'Oma.  The  characteristics  of  ihis  .uiowlh  are  descrilied  in 
connection  with  intranasal  anj;ii>ma  or  lileedinjr  polypusof  the.sejituni. 
It  is  comiiaratively  rare  in  the  larynx,  the  author's  ex|ierience  iH'injj 
re]iresented  liy  a  siii<;le  case.  In  this,  as  is  usual,  the  <;riiwtli  was 
located  on  the  vocal  cord,  (iverlaiipinfr  the  free  eiljre:  it  was  bright 
red  in  color,  .•uid  i's  surface  was  roughened  liy  tortuous  l)liiodvessel>. 
It  was  raised  liut  little  above  the  sinface,  and  would  be  clas.sed  as 
angioma  simjilex.  It  was  destroyed  by  a  single  ajiplication  of  the 
gai^anocauterv,  tin  patient's  singing  voice  being  restored.  (Plate 
XXVIII.,  I'ig!  1.) 

Angioma  cavernosum  apiears  more  like  a  raspberry,  either  sps.sile 
or  pedunculated.  I'lither  lorni  may  occur  at  any  other  site  in  the 
larynx  than  the  vocal  cord— c.  </.,  the  ventricular  band.*  Kithcr 
form  may  be  nuiltiple.  or  indeed  ijuite  diffused,  perhajis  involving 
other  parts  of  the  throat  and  moutli.  .\  laryngeal  tumor  described 
miller  the  name  of  cunriKiiis  pdpilluuKi  is  doubtless  an  angioma'  with 
a  thick  epithelial  covering.  Lymphangioma  eavernosim  of  the  larynx 
is  I'epresented  in  literature  by  a  single  case." 

Chondroma.  Chondroma  ajijiears  '.n  the  larynx  as  a  conical,  round, 
or  nodulated  hyperplasia,  usually  of  the  cricoid  cartilage,  which  forms 
a  sessile  tumor,  sma.ll  :it  l:r-t,  but  of  slow,  pei'sistent  ilevelo]iment  to 
the  point  of  occlusion  of  ihe  larynx.  The  thyroid  cartil.-ige  is  a  rarer 
site,  and  still  more  larely  are  the  arytenoids  and  epiglottis  the  scat. 
The  structure  is  that  of  hyaline  cartilage,  in  which  will  be  spots  of 
chalkv  degeneration  ;uiil  ossJIicMiion.  In  diagnosis  it  may  be  dis- 
tinguished fiom  perichondritis  by  its  circumscribed  t'ormation.  abseiiir 
inflammatory  conditions,  ;mil  ledeina  .and  absence  of  the  usu.i! 
cau~es  of  jiericliondritis.     The  priigno--is  is  go(,,l  if  well  removed. 


1  Bruiis  ;  liti'c!  li.v  ScliniclkT,  KmiikliclliMi  ili's  KiOilkuiiles,  l*'.':i,  S.  iw. 
-  K'tiilor  St'ifert :  ritt^l  h.v  Jiini>z,  MeyinHiid's  HaiKlhiich.  Itutul  i.,  s.  s!0. 
'  J(H».'^:  (Mti*"l  by  hirasz,  !<«■.  rit. 
1  N.riii-  \v..ircri.liii.    .I.rfuiia)  ut  I..iryni;nloBy  .iHil  Itnin.ihcy,  I-<m.  p.  ■-->;. 

Fl'ioiwr.  r.  n.    TmiiBiictidiis  of  Anu'ricHii  l.nryii(!nti.i:iinl  .\sscici«tiiin,  iss|.  p.  6,3. 
•  K.wehler;  cited  liy  Junsz,  Ileymann's  Uandbueh.  llHinl  i  .  S  Mil. 


~'?S.:lilli 


LATE   XXVIII. 


Angioinn  or  the   LpM   Vo.al  Cord.     lAuUior's  Case.) 


H.'i.urrenie  ol  Smiomu  in  ilio  Larynx. 


f^r-rM-'^w 


I 


I 


XEOI'LASMS  OF  THE  LARYSX. 


yoa 


When  not  tod  largo  iiitralarynp.'iil  iiiethodrt  arc  hoiH'ful. 
1  cautrrizatioii  by  chromic  aci(l=  liavo  each  been  suc- 


Treatment. 

The  snare'  anci  cainfiiiimvni  •>..  i... -  ••■,-:•.  — ,  ...   ., 

c-sfullv  uscl.     (iulvan<.caut(>rizati..n  an.l  l-Uinj:  f<.rcc])8  inij?ht  b.' 
utiiizc.f.     If  of  nn  at  bulk  larynK.)toniy  may  be  p.ec«"ssary 

Adenoma.  B.-niKn  adenoma  of  the  larynx  i.,  represen  e.l  m  l.teu.- 
,„n  bv  l>ut  three  well-..ubstantiat,..l  ca..e..-;  I..  -'•IVl-J;':;;:;: 
,.,aine.l  a  size  ..utlicient  f.  occlude  the  larynx,  luul  a  p-anu  ar  sur  a.-e, 
a,..|  clor  varying  In.n.  gray  to  r.,1.  The  type  of  nasal  neup  asnj 
;ics.Tib.-.l  as  adenonu.  papiUare"  po.ssibly  ..ccurs  n.  the  larynx  cloaked 
under  the  name  of  i)ai)illoma  and  carcinoma 

Thyroid  Tumors  of  the  Larynx  and  Trachea     The   ,««  rec.r.  ed 
instances  of  thvroid  tis.sue  in  th.-  larynx'  have  been  subglottic,    h 
„„„efac.i..n  exiending  from  just  bel.w  the  voca!  cords  to  th'"  ^••j;-'  '•  ■ 
,l,inl,  or  fourth  tracheal  ring.     In  two  .t  occu,>H"d  t''''  I'-  ;; 

chcal  wall.     The  thvroid  tissue  enters  the  larynx  not  b>  abenation 
„f  ,l„.  eu.hrvonic  elem..nts,  pro.lucing  an  acc.-ssory  thyroid  gland 
.u.i.  a<  is  f.mnd  at  the  base  of  the  tongue,  i.ut.  as  demonstrated  m 
,„„.  case  by  post-mortem  dis.section,"  the  thyroi.l  tis.-^ue  grew  mto 
and  between  the  traclu-al  rings,  fornnng  thus  a  ^''''''^j''^'''"  l";;';!;^ 
1...  intralarvngeal  tumor  an.l  the  ti.yroul  gland.     The  author  has 
iS'served  o,.;.  ca.se,  reporte.l  by  Freer,"  in  which  there  was  .pronoun-l 
subglottic  inhltration  surroun.ling  the  .nter.or  of   he  cnco.d  ca  t.l,  ^e 
and  a  large  tumor  on  the  posterior  tracheal  wall  at  about    he  tlnrd 
,i      Microscopically  this  ma.ss,  after  removal  by  a  snare  an.l  cuttmg- 
i;.p;  prove.l  f.be  tvpical  thyroi.l  tis.sue.    Nevertheless    I  am  m- 
for.n.'.V  that  symptom's  uulicating  malignant  disease  subse<iuently 

'  ''prolapse  of  the  Laryngeal  Ventricle.    The  mucosa  which  lines  the 
vntSes  ..f  Morgagni  is  attach.-d  t..  the  inner  surface  -t  t lie  thyroid 
til  i.     Looseniiig  ..f  the  attachment  gra.lually  ..r  b>  violent  cough 
n'uiv  iH.rmit  an  evers^.n  or  turning  outw.ml  ..f  the  pouch.    Thij^   s 
„.,f  a'  ne.,plasm;    but  is  considere.l  m  this  sect  urn  a.s  a  ->«'-;  ;f 
,.„nv..ni.>n.r  with  ivspect  t<.  .Iiagn.is.s  an.l  treatment.     It  is  s.,  r.  re 
,l,at  its  <>xist<'nce  is  ,l..ubted  by  .-ertam  autlmrs  wh..  '":">';>'"<''•»' 
v.Titabl..  nc.plasms,  as  well  as  syphilitic  an.l  tubercubus  mf.l  rations 
l.ave  !......,  mistak.Mi  for  it.     The  latt.>r  are  certainly  predispos.  ,g 

!;  .ditions.  siife  most  .>f  the  rep..rte.l  cas..s-  "  have  b.;."n  either  syph- 
ilitic ..r  tul.ercul..us.    Lefferts'=  ma.le  a  thyrotomy  m  his  case,  abscis.-.l 

.  Asch     Traii«i.-tir.ns  of  A.nericai.  LarynKoloxical  Awoclalion.  1SH4  p.  .56. 
«  insals.    Transar.iun.s  or  American  I.ar.vnKol<«i..al  ,||H«H.l,.t.on   1««.^.  P.  U6. 

.  PaLuf.    /.legler's  B..,.r.K..  1S9-.'.  Band  .v..  S.  7, ;  oited  by  Bav..»v.c,.  !.«_  cu. 

■>  Freer     Journal  of  tl.e  Araeri<»..  Medical  A9!«ciatlon,  March  30. 1891.  P-i*?  ■ 
.'.  Mai.ir.    Tran«.ruon!.Americ«..I.ar>„«.,logical.\sHat:mtmti  iw.,p  II. 
n  ,i„iKenhelm.    Inleruat,  .cntralblau  f.  Laryngol ,  Rhlnol.,  etc..  vol.  Till.  p.  127. 
1=  l.ca'ert».    Medical  Record.  ISTti,  p  3.W. 


!»(I4 


sunt:  AM*  TlIltU.lT. 


r- 


! 


; 


llic  priiji'ctin);  iin'inbrMiic,  and  fouinl  it  Id  he  an  everted  ventricle, 
so  that  tlie  |i(issil)ility  tiiiist  lie  admitted.  Mlsl'erj;'  and  Colien-  also 
report  cases.  l)ys|ilionia  and  moderate  dyspiid'a  are  the  salient 
symptoms.  Temporary  replacement  of  the  ventricular  membrane  by 
a  probe,  and  its  rounded,  soft,  smooth  contour  jiroject in j;  from  tiie 
position  of  the  ventricle  are  the  chief  diajinostic  features.  The 
treatment  is  by  ab.scission,  evulsion,  or  cauterization,  the  same  a.s 
for  a  real  neo|ilasm. 

Malignant  Neoplasms  of  the  Lar3nix.  Carcinoma  of  the  Larynx. 
Caicinoina.  win  ii  orijiinatinji  and  confined  strictly  within  the  frame- 
work of  the  larynx,  is  termed  iiilriiisir  or  endol;iryn>ieal  cancer. 
When  it  attacks  even  the  superior  border  of  the  larynx,  so  as  to  in- 
volv<'  necessarily  p.arts  of  the  lower  pharynx,  and  when  it  extends 
from  the  tonsil,  lin>;ual  base,  or  pyriform  sinus,  it  is  termed  exlrin.-^ic 
or  pharynpilarynjieal  carcinoma.  This  distinction  is  of  im])ortance, 
because  the  intrinsic  type  is  more  amenable  to  ojx'rative  treatment. 
It  is  much  slower  to  inv(»lve  the  cervical  lymphatic  fjlands.  ( »f 
Hutlin's'  14  cases  the  frlands  were  affected  in  but  2  at  the  time  of 
operation.  This  is  explained  by  the  fact'  that  the  lymphatic  ves.sels 
within  the  larynx,  while  present,  are  much  attenuated,  so  that  at  the 
level  of  the  ventricular  ban<ls,  and  especially  the  vocal  cords,  it  is 
difficult  to  inject  them. 

Etiology.  As  with  cancer  elsewhere,  the  direct  cau.se  is  unknowni. 
The  microbic,  that  is,  the  protozoan  infection  theory,  while  plausible, 
is  not  y(>t  wholly  substantiated.  (Jeneral  pre(lis])osin<i  conditions  are 
iH'redity,  which  is  traceable  in  about  one-fourth  of  the  ca.ses,  the 
male  sex  in  the  i)riii)ortiop  of  four  to  one,  and  mature  ajjc,  an  analyses'' 
of  4S{\  cases  showing  40  per  cent,  between  fifty  and  sixty  years,  and 
S4  per  cent,  between  forty  and  seventy  years,  with  but  1,)  per  cent, 
between  twenty  and  forty  years.  Larynjjeal  sy])hilis,  tuberculosis, 
and  chronic  laryngitis,  includinR  pachydermia  laryngis,  by  maintain- 
ing Ideal  irritation  seem  to  act  slightly  as  pi-eitisposants.  Tobacco 
and  alcohol  figure  only  ina])preciably.  Witisout  implying  a  change 
of  tyjie  of  tissues,  it  is  clinically  observed  that  benign  growths  and 
inflammatory  tissue  occasionally  become  the  site,  that  is,  furnish  a 
suitable  nidus  for  the  development  of  malignant  tumors.  Thus  is 
exi)lained  the  so-calle<l  transformation  of  benign  laryngeal  neoplasms 
into  malignant  ones."  which,  however,  is  so  rare  that  the  alleged 
influence  of  intralaryngeal  ojx'rations  must  be  practically  nil.' 

Pathology.  The  most  fre(|uent  tyjK'  is  sciuamous-celled  carcinom.n 
(epithelioma),  although  cylindrical-celled  carcinoma"  is  encountered 

'  Eblwrg.     Arc:hlvi'«  of  l.aryiiKoloKy,  vol.  ill..  No.  1.  p.  66. 

-  Cohen.    Archives  of  LaryngoloKy,  vol.  ill..  No,  1,  p.  67. 

»  Butlin  ;  citiMi  liy  Bosworth,  Diseases  of  the  Nose  and  Throat,  vol.  11.  p.  7.'S1. 

<  ."appey'a  Atliis.    Valswaiix  Lyniphatl(|iies  <hez  I'Homme.  Paris,  l«9.i;  cited  by  Lennox  Browne. 

'■  s<'ndzl»1(,    i(.isiiriiKe(!i.«chw«l«te'1e!  Kehlkojifs. 

«  Ward.  M.  K.     I'itlsburK. 

■  Seraon-Sammelfcin.chiiii|{,    nuernatioiwlw  Cenirulblati  f  LuryiiKologie,  etc..  Idlilt. 

"  Seudziak.    Op.  ell.,  S.  I». 


L 


yEOl'LAfiMS  OF  Tin:  lmiysx. 


Jt05 


witli  nirity.     ( )tlifr  types  about  in  the  onlcr  tiaiiicil  an"  soft  ulaiulular 
irciiioiiia  (<'iicc|ilialni(l)  and  hard  n'!"idular  carc'moiiia  (scirrlitis) 


\\  licii  intriiisic,  favuritc  sites,  prii 


irilv.  are  tiie  vocal  nird,  veiitrie- 


iilar  liaiid.  and  ventricle.  It  is  primarily  un'lateral,  l)iit  may  JM'come 
asymmelricaily  bilateral  by  contact  infection  or  otherwise. 

Symptoms.  \'ocal  impairini-nt,  a  sen.se  of  laryngeal  discomfort,  and 
sii};iit  couffh  are  tin-  tirst  and  perhaps  the  only  symptoms  for  months 
or  years.  Later  dyspiuia  and  hemorrha>;e  ensue,  the  latter  when 
the  ulcerative  .stap-  is  i-eached;  at  the  same  time  the  secretion,  [kt- 
haps  previously  aufrmenteil,  becomes  more  cojiiows,  thi<'k,  \iscid,  and 
U>\\\.  imparting  to  the  breath  the  peculiar  odor  of  malipiant  disease, 
bi  extrinsic  cases  |)ain,  e.'^pecially  on  deglutition,  and  reflected  toward 
the  ear,  is  a  prominent  symptom. 

0/(  (wamiruiti'in  in  the  more  common  difTused  form,  the  carcinoma 
is  ol)ser\  (I  to  spread  over  and  through  considerable  surface,  at  first 
a  mere  thickeniiift  of  the  ti.ssue,  later  becoming  irregularly  nodular, 
.iiiii  of  mottled  reddish-yellow  hues.  Kxceptionally  the  surface 
appearance  is  ])ai)illoniatous,  chalk-liko,  or  snow-white,'  or  it  may 
lie  (luite  smooth,  londhig  to  a  tumor  of  reddish  hue  the  apiM'arance 
of  .1  fibroma. 


Fill  im. 


Flu.  4.')0,— Siiiiamims  celliKj  carcinoma  (epithelioma)  of  the  larjriix.    iCuHis  ) 
Fill,  -ifii).— MtHluUary  can'iiioina  of  the  larynx.    (Cohen.) 

The  so-called  cnrcinnma  pnlypnidts^  primarily  affpcts  the  vocal  cord 
only,  and,  while  not  circumscribed  nor  sujjerficial,  like  benign  neo- 
plasms, has  a  broad-ba.sed  elevation  of  more  or  less  limited  contour, 
bate  cases  which  have  extended  from  one  part  to  another  present 
advanced  degrees  of  distortion,  tumefaction,  and  ulceration  of  the 
parts. 

Diagnosis.  Renign  neof)Iasms,  especially  papilloma  and  fibroma,  if 
not  pedunculated,  are  superficially  situated,  not  interfering  with  the 
free  motion  of  ti.e  cord,  while  in  carcinoma  the  substructure  is  infil- 
trated and  swollen,  causing  a  "lazy"  motion  of  the  cord,  which,  how- 
ever, is  not  invariably  observable.  It  may  be  situatcMl  at  any  point,  but 
is  the  more  suspicious  when,  in  an  elderly  individual,  it  is  found 
upon  the  posterior  third  of  the  vocal  cord.    The  carcinomatous  sur- 


<  <•'     ^mann.    Transnctinnn  of  .\merican  Laryngolngical  Aiisociatlnn.  1896. 
■  Fi  iiikel ;  cited  by  Sendziak,  op.  clt. 


IKMi 


.\USi:  AM)  TltllOAT. 


i  I 


t  i 


fact'  wIk'I)  siiinil;iliii<^  papilloma  is  softer  ami  inoro  vascular.  A 
microscopic  cxaniiiiatiMii  of  a  frajrm<'iit  removed  when  it  exhibits  a 
positively  careiiioiiiatoiis  structure  is  conclusive,  hut  a  nejjative  result 
does  not  with  certainty  exclude  carcinoma,  for  tin  reason  that  tin- 
frajiment  may  represi-nt  only  a  papillomatoid  >urface  of  an  under- 
lyiufT  carcinoma.  This  is  ohvi.ated  hy  sulimittin;;  a  fragment  from 
tliede|)tli()f  the  neoplasm:  hut  still  other  histolojiical'  -  errors  are  po.s- 
sihle,  so  tliat  for  a  final  diagnosis  it  is  a  safe  rule  to  insist  upon  a  dejjree 
of  harmony  hetween  the  microscopic  (indiiijrs  and  clinical  as|M'cts. 

I'lichililiriiiid  is  usually  synnnetrically  bilateral  and  af'IVcts  the  vncal 
processes  jiarticularly,  witli  an  oval-cupix'd  infiltration. 

S!ii>lillis,  when  not  characteristic  or  distinjiuishalile  hy  concomitant 
symptoms,  may  Iw  clitTerentiated  from  carcinoma  hy  the  thera|K'utic 
elTect  of  |)otassium  ioiliile,  it  Ix'iri);  remetnhered  that  cancerous  infil- 
tration will  also  recede  at  first  under  this  dru^',  hut  only  sli<;htly  and 
for  a  brief  ]M'riod. 

Tiihrmiliisis  enters  the  (|uestiori  only  in  atypical  cases  when  devoid 
of  concomitant  jmlmonary  symptoms,  bacilli,  .and  local  pallor.  It 
may  be  unilateral,  but  is  prone  to  alTect  lirst  the  arytenoid  eminence 
ami  posterior  part  of  the  vocal  '•ord.  Tin  ulceration  ajJiH-ai-s  earlier 
and  is  of  the  mouse-nibbled  type. 

It  is  possible  for  ciircininia  to  d<'velop  in  a  tuberculous  larynx,'  al.so 
in  coimection  with  lonn-standin}i  chronic  laryngitis'  and  in  syphilitic 
.subjects,' conditions  wliich  render  the  diagnosis  the  more  diflicult. 

Prognosis.  The  natural  course  toward  a  fatal  termination  is  com- 
paratively slow.  Kijiht  years  is  not  an  unusual  jieriod.  An  early 
(liajiiK'i^is  and  promjjt  operative  interfv  rence  afford  a  chance  of  recov- 
ery, but  at  the  expense  of  deformity  of  the  throat  and  some  imme- 
diate risk  to  life. 

Treatment.  Xotwith.standinj;  occasional  cases  reported"  favorably, 
endo'.'rynjreal  operating  is  suitable  only  for  diagnostic  and  palliative 
|)urpoM's,  tlu>  exception  being  v  n  the  tumor  is  strictly  circum- 
scribeil,  "•polypoid"  in  formation,  superficial,  and  accessible,  very 
rare  conditions,  even  in  the  earliest  stage.  It  is  justifiable  to  remove 
-egments  l)y  the  cutting-force])s  or  double  curette  for  microspo]iic 
(•x.amination.  and  in  inopenitile  cases  the  hm.en  of  the  Larynx  may 
be  kept  clear  in  like  manner,  but,  as  a  rule,  one  of  the  ext(M'nal  vipera- 
tions  should  be  urged  early.  It  is  inipossible  to  determine  b^-  the 
mirror  the  extent  of  cancerous  infiltration,  certain  recesses  are  inac- 
cessible to  intralaryngeal  methods,  and,  besides,  one  is  without  means 
of  controlling  possible  hemorrhage.'  .\  false  hope  is  engendered  b> 
repeate(|   in;id<'i,-iate  removals  which  delay  radical   measures  uuti! 


1  rhlari,  O.    Archiv  f  f.arynj^IoBie  unrl  RhinoUtRie,  Bund  viii.,  Ht'fl  1.  S.  t'A. 

s  Frnnkel ;  citetl  by  clilHri.  (ip.  cit. 

3  Chiari.    A-chiv  f.  LHryrmolOKie  und  khinoloRio,  Banil  viii  .  Heft  'J. 

<  rhiarl.    Lw.  cu..  Fall  \\.  ■  Cliiiiri.    I.oc.  cit..  tall  xl. 

»  Krknkel,  B.    Areliiv  I.  I.aryiitfrilcmie  uiul  Rhiiiologio,  Band  vl.,  s.  3«i. 

:  Ndltenin!.    Op.  cit.,  llanil  viii.,  S.  lin. 


.\j:i)rLAsMs  or  rni:  lauysx 


1K)7 


tfxi  l;itc  or  until,  lii'.'iii-iick  hy  liopr  drfcrrctl,  iIh-  imticiit  rcjciiH 
further  opcrjilivc  aiit. 

Tlnintlonn/,  tin-  least  fDriiiidalilc  "f  the  external  niMTatioits.  is  the 
hest  when  the  earcirKinia  is  wjinlly  within  'lie  larynx,  cdntihed  ehielly 
|((  one  vocal  eurd  or  ventricular  hand,  and  without  extending  so  d'-epiy 
••IS  to  involve  the  cartil.'ij:''-  Also  as  a  iliaj;nostie  nietlmd  it  may 
ininiediately  precede  total  or  partial  larynp'Ctomy  whenever  there 
i>  the  least  (joiilit  of  the  necessity  of  such  upeiations. 

Modern  statistics'"  an-  favorahio  to  this  o|M<nitioii  for  early  cases 
limited  to  one  Mn-al  cord  or  ventricular  hand.  showiuK  U  to  14 
per  cent,  of  ahsolute  recoveries  (thu..  years),  i;{  to  4:.'  per  cent. 
aililition:il  of  relative  recoveries  (one  year),  with  !>  to  IS  per  cent, 
of  d(  aths  from  the  operation. 

I'liiiiiil  risirtiiDi  i>j  Ihi'  Itirj/iix,  meaning  the  removal  usually  of  a 
lateral  half  of  the  thyroid  and  cricoid,  is  ad;ipted  only  to  strictly 
ininilarynjiejil  and  iniilatenil  carcinoma.  It  has  heen  soufrlit  to  suh- 
stitute  it  for  complete  laryngectomy  when  these  conditions  jiermitted, 
JH'cause  the  risk  of  .-jeptic  pne'.nnoni.-i  is  le.-;s.  .•md  dcfihititii'M.  respira- 


tior 


nd  I'ven  voca 


Ii7.ati( 


111  are  resumed 


It  can  he  iitilizeil  for  case: 


slifthtly  more  extensive  than  those  suitahle  for  tliyrotoiny,  hut  should 
not  he  relied  ujion  where  there  is  any  suspicion  of  invo^-einent  of 
hoth  sides  or  in  larynfiopharynp-nl  ca.ses.  One  hundred  and  ten  cases 
tabulated*  since  iNTti  show  9  [mt  cent,  recoveries  (three  years),  \2 
per  cent,  relative  recoveries  (one  year),  2S  jxt  cent,  recurrences,  and 
■Jfi  per  cent,  of  deaths  in  conseiiueiice  of  the  op<'ration.  Two  latci 
series,  one  of  57  cases'^  and  one  of  .50  c.ises,"  since  1,S((0,  piv<»  an 
improvement  showiiif;  12  to  1(5  per  cent,  recoveries,  :i2  per  cent, 
ri'lative  recoveiios,  3<)  per  cent,  rt'currences,  and  16  to  28  ixt  cent, 
of  operative  fatalities. 

Liiriiniitrtomj/,  or  complete  oxtirjiation  of  the  larA-nx,  is  indicated 


when  the  carcinoma,  while  confined  to  the  larvnx.  involves  so 


much 


of  that  orjran  that  no  part  can  lie  saveil  w'»hout  risk  of  recurrence. 
If  the  epiglottis  is  |)ositively  he.'ilthy  it  can  he  retained  and  utilized 
hy  Swain's'  methoil  to  form  an  anti>rior  wall  to  the  (I'.sonh.'ipiis  aid 
close  the  pharynx  from  the  windpi])e.  The  greatest  danj;er  of  lary- 
Kcctomy  is  septic  pneumonia  from  the  inspiratioi;  of  discharfjes  froi  i 
the  wound  and  secretions  of  the  throat,  and  this  is  prevented  hy 
leaving  no  openiiifi:  hut,  as  a  rule,  the  retention  of  the  epiglottis 
favors  recurrence  (2()  cases,  2  recoveries)."  and  the  same  end  can  he 
accomplished  as  in  Cohen's  ca.se"  and  others'"  hy  stitchinjr  the  upper 


'  St-iidziak  ;  cited  by  Chiari.  np  rit.  -  schinleKclon  ,  iMe<l  by  ('hi«ri,  op  olt. 

^  lielavan.    Transaption;*  nt"  American  IjirynenUiKial  Associalion,  liHH),  p.  71. 

*  Seiiiizirtk.    Kiisartige  (icfichwiilste  ile.s  Kehlkoples.  ISIIT. 

'-  IviavHii.    Transactions  of  American  l^tryngological  Aosnclation.  1900.  p.  71 

^  SclnnicKclow  :  cited  by  Chiari.  loc,  cit. 

■  Swain.    Transactions  of  American  Lan-n(Coln«ical  Association.  l«tt|.  p.  U.i. 

~  rxMuizialc.     BnsyirtiKe  tieccltwulfte  <ies  Keiilkopfs.  S.  171. 

"  1.  Soils  Cohen.    Archiv  f.  Laryngitlouie  nnii  Khinologie.  Band  i..  S.  ;*7S. 

"'  i;iuck.    Berliner  klin.  Wochenschrifl.  1S97.  9. 1K2. 


iXM 


.vo.na;  .I.N7)  Tiii;o.\r 


oikI  of  tlu'  tniclicii.  slit  (i|Mii  ill  Innit,  l<.  tlif  xkiii  i.f  the  neck  iit  the 
hotldiii  of  the  iiiiisioii.  This  |iicclu'li's  rt'-piratifin  liy  tlic  iiioiith  iiiul 
Ihi'  'vcariiiK  of  jiii  arlilici;il  larynx,  Imt  If.-scns  tin'  ilaiip-r  and  condutrs 

t.i  ( ifoit  Ity  iioii-iiitcrfcri'iicc  with  tli'Klutilioii.     A  luiccal  voice  is 

ptotic  to  (l(  vdop.  which  ciialiN  H  the  palicnt  to  make  hinwif  uinl«T- 
stood. 

Till'  stati.-itics  of  total  extirpation  of  the  larynx  have  improved  with 
iiiodeni  iiielhods.  Kifly  eases  talmlaled'  since  ISiM)  ^ive  it)  iht 
cent,  recoveries  (three  yearst,  fs  per  cent  relative  reenvcries  lone 
vear),  Jl»  jx-r  eeiit.  recurrences,  and  2'2  per  cent.  o|H'rative  fatalities 
I  two  inoiihs).      Delav.'iirs-  >eiies  of  .U  ca.ses  from  seven  operators 

sii IS'.M)  -jives  *>  per  cent,  of  recoveries,  mid  -'(>  |x'r  cent,  of  o|M'ra- 

tive  deaths. 

Sources  of  danp  'dier  than  pneumonia  are  shock,  damaKi'  to 
luaiiches  of  the  pneriii  i>r;istric  nerve,  alTectinj;  the  heart  and  cirni- 
lalion:  exhaustion,  and  ,ieiiiorrliaKe.  It  is  still  a  hazardous  o|M'ration 
tln' advantages  nil  disadvantages  of  whieh  sliouhl  be;  fully  explained 
to  the  patient. 

Siihli fluid  i>liiiriin<iiiti»n!i  is  indicated  only  for  tumoi's  of  the  cpi- 
fjtottis,  iiyriform  sinuses,  or  lower  pharynx  when  not  properly  re- 
movalile  throujili  the  mouth. 

Tr<ulni>li)tn>i  alone  serves  to  proloiip  lift-  in  iiioperahio  cases,  those 
in  which  the  pathological  process  is  too  widely  distributed,  or  the 
patient  in  an  enfeebled  state,  and  in  those  in  which  a  radical  opera- 
tion is  declined.  ( )f  six  cases  seen  by  the  author,  in  four,  two  intrinsic 
and  two  extrinsic,  this  la.st  resort  was  the  only  suitable  remedy  at 
the  time  they  Hrst  a]>|M'ared.  late  in  the  course  of  the  disea.sc.  It  is 
often  thus.  Usu.'illy  the  canula  should  be  insi  rted  Ix'low  the  isthmus 
of  the  thyroid  gland,  in  order  to  escape  the  descending  laryngeal 
infill  ra I  loll,  and  f"r  permanent  use  a  tnichiHitoniy  tul)e  of  soft  rublier 
is  iietter  tolerated  than  the  customary  metallic  one. 

(lastrt)st(iiiiii  may  prolong  life  a  trifle  when  exhaustion  is  iimninent 
because  of  dysphagia. 

I'nllidtirc  Mtiistii-fs.  .\n  alkaline  antise|)tic  spray  may  be  prcccdc'd 
by  a  1  per  cent,  cocaine  spray  and  sii]ipleniented  by  additional 
sedatives  and  emollients.  Orthnforni  applied  as  in  laryngeal  tuber- 
culosis gives  the  most  enduring  relief  from  pain.  Fotiussium  |)ernian- 
gaiiate  in  1  per  cent,  solution  is  an  ethc'  'iit  deodorizer. 

Sarcoma  of  the  Larynx.  Much  that  has  been  said  with  reference  to 
carcinoma  ajiplies  also  to  sarcoma  of  the  laryiiX.  The  c'lnical  course 
is  similar.  It  is  more  rare,  in  the  proj/ortion  of  one  to  twelve.  The 
com[)arison  with  all  other  laryngeal  iiei  .iilasiiis''  is  three  to  five  hundred 
and  forty-eight,  nevertlieless.  a  series  of  .jO  ca.ses  or  more  is  readily 
collected  from  modern  literature.  The  author  has  observed  but  one 
<'a.sp,  that  of: 


I  RchmM-Kclow  ;  oiled  by  O  chlari.  liic  clt. 

t  DelBVRn.    Tr»t!sHclion«  nf  AmcrioBH  Ijir-ngnlnglcal  Aaaoclatlon.  19U0,  p  72. 

"  McriU-Schmidt ;  cited  by  Sendilak.  op.  clt..  p.  194. 


yKOI'LASM.S  OF  Tilt'  LAHYSX. 


9W 


Mr.  ().  H.,  of  Seattle,  WoxhinKton,  forty  yean*  of  age,  ujwn  wl.nii 
Halm  liail  jHTformed  thyrotoiiiy  in  Kurojx'  six  months  pn-viou-ly 
tor  the  puriMiM'  of  extirpating  a  malignant  growth  whieh  proved  to 
Im-  spiiuile-eelled  nareomu.  At  the  time  of  my  examination,  while 
on  hi."  way  home,  a  reeurn'tice  had  already  taken  place,  a  graimlo- 
M'atous  ma«M  oeeupying  much  of  the  lumen  of  the  larynx.  He 
< '••(lined  anoiK'ration  in  Chicago,  and  continueil  hi.«t  journey  in  despair. 
(.'ate  XXVni.,  Kig.  •-'.) 

^'nrvimit  may  originate  in  the  order  nanunl  from  the  vocal  cord, 
epi^liitti>,  aryepiglottic  fold,  false  cord,  ventricle,  and  pyriform  sinus. 
.\lso  from  the  subglottic  region  and  trachea,  or  it  may  l)e  extrin.sic, 
having  ext.'iided  to  or  from  the  pharynx.  The  usual  tyiK'san-spintlie- 
filled,  ngmd-celled,  and  alveolar  .sarcoma,  although  every  possible 
.su'comatous  combination  has  Imh'ii  reeorded.  For  a  further  drscriji- 
tion  of  thes<^,  and  for  the  etiology  of  sarcoma  in  g.-neral,  references 
I'lay  1m^  made  t(»  the  chapter  on  intrana.sal  sau'oma.  It  is  more 
litciuent  in  (•••irly  life  than  carcinoma,  but  tho.m'  of  mature  age,  thirty 
til  >ixty  years,  funii.sh  the  majority  of  ea.s«'s,  projKirtionately  increa.s- 
iii);  ill  each  decade.     -Men  are  affected  in  the  ratio  of  three  to  one. 

The  sjilient  .symptoms,  such  as  cougli,  hiar.seneas,  and  es|M'cially 
pain,  are  less  pronounced  than  with  carcinoma,  ami  the  glands  are 
<'vcn  less  likely  to  Iw  affected  until  late. 

On  examination  one  finds  u.sually  a  diffused,  smooth,  nodulatetl  or 
warty  tumor.  .More  rarely  it  is  circumscrilK-d,  even  |M'dunculated, 
and  tlien  proceeds  from  the  vocal  cord.  The  color  runs  from  i)right 
red  through  yellowish  tints  to  gray,  and  the  consistency  varies  accord- 
ing to  the  tyjH',  fn)tn  a  creaking  hardness  to  a  cauliflower-like  for- 
mation.    It  is  usually  single,  but  may  Ik'  multiple. 

Diagnosis.  Carcinoma  can  l)e  excluded  only  by  a  microscopic 
examination.  The  polyjM)id  or  jjcdunculated  type  may  simulate 
tihroma.  but  can  1k>  differentiated  in  the  same  way.  Not  so,  however, 
with  syphilis,  for  gimunatous  infiltrations  in  section  resemble  uid- 
i'flled  sarcoma.  The  effect  of  pota.*.sium  indido  should  be  noted  and 
a  degree  of  liiirmony  esta'  'ished  iK'tween  the  microscopic  ftndings 
and  the  clinical  course  and  as|)ects. 

The  prognosis  is  less  unfavorable  than  with  carcinoma;  but  it  all 
di'lK'iids  u|M>n  the  |K)ssibility  of  an  early  and  thorough  extiq)ation. 
.\ii  analysis  of  50  ca.ses'  shows  12  f)er  c  :  t.  recoveries  (three  years), 
and  '1\  ])er  cent,  relative  recoveries  ((me  year),  with  fewer  immetliate 
fatalities  from  tli,'  various  operations  than  with  carcinoma. 

Treatment.  The  principles  underlying  the  selection  of  an  opera- 
tiiKi  and  the  techni(iue  are  the  .same  :i.s  for  laryngeal  carcinoma,  to 
wliich  subject  reference  should  be  made.  Medicinal  means  esjH'cially 
adajited  to  inoperable  cases  are  there  mentioned.  In  addition  injec- 
tions of  mercury  bichloride,  2  [H-r  cent,  solution  in  olive  oil,  and  1 
per  cent,  pyoktanin  cxtrnially  have  been  co:.    u'tidcd. 


Sendzlak.    Op.  clt.,  S.  ii 


910 


AOA/v  AXJ)  THROAT. 


i 


THE  LOCAL,  MEDICINAL,  AND  SUSOICAL  TREATMENT 
OF  THE  LARTNX. 

McdiciiKil  substances  may  1»'  aj)|)lio(l  to  the  larynx  in  the  form 
of  sjiray,  medicated  air,  vapor  or  t'nmes,  pigment  or  ))aint,  powder, 
syrinfjed  (luid,  and  suhmucoiis  injection.  The  larynx  may  i)e  sprayed 
hy  tiie  ordinal y  straif;lit-tip|)ed  atomizer  by  taking;  forced  inhala- 
tions while  the  head  is  thrown  backward,  the  tonjiue  protruded,  and 
the  nose  closed.  Nei)uli/,eil  oil  is  readily  inhaled  thus,  while  a(iueous 
s]irays  soon  excite  coiifih  which,  however,  is  evidence  that  th(>  spray 
lias  actually  entered  thi'  larynx.  The  short  aiiKtilar  downward  atom- 
izer-tip is  sometimes  of  sei-\ice,  but  l'"reer  has  devised  a  cnrvecl  attach- 
ment for  the  Daxidstin  spray  tulx',  suiliciently  lonf;  to  acfuMly  enter 
the  larynx,  which  in  skilful  ham  Is  is  still  more  useful.     (Fig.  4()1.) 

Vh,.  4f.l. 


Shitwin^  KrytT's  liiryngeiil  sprHv-tnte  atlached  to  ft  Davidson  atomizer. 

For  a  decided  emollient  elTect  the  actual  atomization  of  oils  by 
means  of  a  powerful  double-ball  hand  atomizer  of  the  Davidson  tyjM', 
or  one  operated  by  machine  compre^-iil  air,  is  prefer.able  to  the  more 
finely  divided  oil  vaporization  which  is  furnished  by  sjK'ci.Ml  "oil 
atomizers,"  "oil  nebulizers,"'  and  "inhalers."  The  latter  cla.ss  of 
inhaler  of  the  <;lobe  |)attern  is  now  arr;ui>;ed  in  multiple  for  attach- 
ment to  the  com|iressed  air  tank.  Its  actual  usefulness  seems  to  me 
(juite  limited,  perhaps  beinj;  beneficial  in  acute  larynjiobroncliial 
intlamm.'itiou  and  as  an  occasioii;il  means  of  inducinj;  respiratory 
frymnasiics.  (Fiji.  4fi2.)  The  "atomiziiij;  vaporizer"  of  Thomas  is 
more  efficient  because  the  spray  is  more  copious.  (I'ifi.  4().'{.)  The 
steam  .atomizer  is  at  present  little  used.  A  hot  laryngeal  spray  is 
objectionable  before  froinj;  out  in  the  cold,  but  may  be  serviceable 
for  the  first  stajje  of  acute  laryngitis,  when  the  patient  is  confined, 


MEUICISAL  AND  SURGICAL  TREATMENT  OF  THE  LARYNX.     ()H 


iiiid  for  cvciiiiif;  a])|)lic;iti()ns. 
Till'  same  may  be  said  of  iiicdi- 
ciiially  iiiiprcftnatcd  hot-water 
(ir  steam  vapor  inhalations. 
The  latter  can  I)('('Xtem|)orized 
liy  tlie  use  of  a  friiit-jar  half 
tilled  witli  water  just  short  of 
a  i)()iliiij;  temperature,  and 
covered  with  a  glass  funnel. 
Tiie  sedative  properties  of  tlie 
\apor  itself  ill  tlie  e.irliest  stage 
111  an  acute  inllaniniation  of  tlie 
liirynx  and  contiguous  ]»arts 
will  he  intensified  hy  the  addi- 
tion, for  instance,  of  thirty 
^'lains  of  hipuliii. 

Swahliing  the  Larynx,  that 
is,  the  application  of  a  pig- 
ment or  medicinal  paint,  is 
made  hy  a  pledget  of  cotton 
lirmly  secured  to  an  applicator. 
Hruslies  are  no  longer  used  for 
lliis  |)iirpose,  l)(>cause  they  ean- 
niit  he  rendered  aseptic.  The 
applicator  should  he  sutti- 
cieiitly  ^^trong  to  maintain  u 
fixed  angular  bend.  Cohen's 
t'orcv'iis  (Fig.  404)  and  Freer 's 


Fill.  462. 


Traux  multiple  nebulizer. 


Fia.  463. 


Tlionius'  utouuzing  vtiiKtiizur 


912 


NOSE  AND  THROAT. 


steel  rod  are  satisfactory.  The  hitter's  firmness  is  an  ai'vantage 
in  applying  lactic  acid  with  friction  for  laryngeal  tubeicnlosis. 
There  is  less  resort  to  painting  tlie  larynx  than  formerly,  since  it 
is  recognized  that  the  impact  of  the  swab  is  in  itself  an  irritant; 
nevertheless,  the   process   is  very  useful,  with   astringents  and  re- 


i 


I  \ 

■    I 

\ 


Coben's  laryngeal  cotton-ii  Ming  forcep*. 


solvents,  for  certain  forms  of  sul)aeute  and  chronic  laryngitis,  also 
with  lac'ic  acid,  etc.,  for  tuln'rcu'-i'^is,  and  witii  cocaine  for  the  pro- 
duction fit  local  aiue.-ithesia.  Tin'  swab  is  applied  under  laryngo- 
sco[)ic  ob.servation  at  the  moment  when  the  epiglottis  is  raised  by 
phunation. 


FlO.  465. 


Shurley's  powder-blower. 


The  insufflation  of  powder  into  the  larynx  is  accomplished  by  means 
of  a])owder-l)lower.  ( Figs.  4G5  antl  466.)  Itshould  have  a  detachable 
end  for  sterilizatio". 

The  insufflation  i  -nade  under  laryngoscopic  ol).ser\-ation  and  while 
the  patient  phonates  to  raise  the  epiglottis,  the  powder  being  blown 


FlO    166. 


fireene's  powder-bUiwer. 

from  behind  forward  and  downward.  This  method  is  useful,  amonr 
other  conditions,  for  persistent  subacute  laryngitis,  alum  diluteil 
with  an  e(|iial  part  of  acacia  being  insufflated. 

Oils,  especi.'dlv  "oil  v.nseljnn"  jind  other  petroleum  products,  c.-m 
be  slowly  syringed  into  and  through  the  larynx  without  provokinr 
much  spasm.     From  2  to  0  gin.  of  an  antiseptic  or  stimulating  einol 


. 


MEDICINAL  AS  It  SURGICAL  TREATMEyT  OF  THE  LARYNX.     913 

licnt  inixturc  iiiay  be  thus  injected  at  a  dose.     A  syringe  with  a  long 
aiigiihir  hiryngeal  tube  is  requisite.     (Fig.  467.)     The  larynx  should 

Fio.  407. 


Moreau  Brown's  laryniieal  syringe. 


first  be  sprayed  with  a  2  per  eent.  cocaine  solution.  Even  afjueous 
solutions,  i"  bland,  can  be  injected  after  cocainization.  The  method 
is  useful  ioi  chronic  tracheitis  and  laryngitis  sicca  and  for  fetid  bron- 
chitis. 

Subimicous  injection  in  the  laryn.x  is  employed  for  the  production 
(if  thorough  local  ana-sthesia  by  cocaine  preceding  certain  endolaryn- 
fieal  oi)erations  and  to  promote  absorption  of  tuberculous  infiltration 
by  creasote,  guaiacol,  etc.  ChapiK'H's  .syringe  is  well  adapted  to  the 
latter  purpose.  The  needle  shank  is  six  inches  long,  and  may  be  given 
suitable  curves;  the  needle  itself  is  half  an  inch  in  length,  with  the 
opening  close  to  the  point.  The  piston  can  l)e  disengaged  byathumb- 
button  when  it  is  automatically  pushed  home  by  a  .spring.  A  set- 
screw  regulates  the  do.se,  usually  one  droj).  Heryng's  sjTinge  is  an 
excellent  instrument  without  the  automatic  piston. 

Fio.  m,. 


Anthar'8  laryni;eal  pnrte  caustlque  adapted  to  Schroetter's  handle. 

ChrmirnI  Cnuteriznfinn.     For  the  application  of  either  chromic  acid 
or  solid  nitrate  of  silver  to  a  circumscribed  spot  in  the  larj'nx  these 

68 


914 


SOSJ-J  AM)  TIJJiOAT. 


sul>stiinc('s  sluuiM  he  fused  in  a  small  ix'ad  upon  the  cikI  of  a  shicldoil 
applicator.  The  tubular  shield  should  cover  the  head  during;  the 
introduction  of  the  instrument,  heins;  withdrawn  to  exjxjse  the  caustic 
{H>int  only  when  the  latter  has  reached  the  exact  spot  to  bo  cauterized. 
(FifTs.  4i)S  and  4()!).)  This  method  is  properly  available  only  in  a 
tolerant  locally  ana'stlietize(l  larynx  and  under  perfect  laryngoscopic 
oi)servation.  It  is  exceptionally  u.sed  for  the  destruction  of  small 
benijrn  neoplasms  or  for  the  cauterization  of  the  base  after  tlit- 
removal  of  a  fjrowth  by  force|)s.  Ingals'  reports  favorable  results  in 
a  case  of  chondroma.  As  a  rule,  the  galvaiiocuutery  is  a  liettcr 
means  to  the  same  end. 

Fvj.  401). 


Mc('(iy'«  laryngeal  potte  cuusti«iue. 


Surreal  Methods.  l-jidolaryngoal  surjiical  procedures  include 
scarification  and  incision,  curettement,  evulsion  and  abscission  by 
forceps,  ecrasement,  jrah'anocauterization,  and  electrolysis.  The 
appliances  are  most  employed  and  best  described  in  connection  with 
the  treatment  of  benifjn  neoplasms,  larynfreal  tulx^reulosis,  cicatricial 
stenosis,  foreiii?)  bodies,  etc. 

Local  Anssthesia.  Before  the  introduction  of  cocaine  it  was 
necessary  to  train  the  larynx  to  tolerate  instrumental  manipulation 
by  a  course  of  daily  contacts  with  a  ])robe.  Cocaine  amesthesia 
obviates  this  necessity,  if  not  wholly,  then  in  part.  The  degree  of 
anaesthesia  obtainable  depends  in  a  measure  upon  the  nK'thotl  of 
application.  The  cocaine  solutions,  it,  10,  and  20  per  cent.,  should 
he  freshly  prepared.  The  '■)  per  cent,  solution  is  sprayed  sparingly 
first  from  a  straight  tij)  through  the  ])harynx,  being  forcibly  inhaled 
into  the  larynx,  and  after  an  interval  of  three  inimites  again  sprayed 
din'ctly  into  the  larynx  by  Freer's  nozzle.  The  10  per  cent,  solution 
is  a]>plied  by  a  cotton  applicator  after  a  second  interval  of  about 
four  minutes,  and  the  20  jwr  cent,  solution  is  used  in  like  manner 
after  a  third  interval.  Including  a  fourth  period  of  rest,  the  whole 
time  consumiMl  aggregates  about  fifteen  minutes.  The  patient  pre- 
viously should  have  been  tested  for  supersensitiveness  to  cocaine. 
Very  strong  solutions  will  occasionally  irritate  more  than  ana'sthetize, 
in  which  event  the  limit  sl;:Mild  be  from  o  to  10  per  cent.  Swabbing 
also  must  excf^ptioiially  Ik-  avoided  ff)r  the  same  rta.son.     For  dvc\ 

'  Tmnsaclioris  of  AmtTloaii  Ijiryngnloglcal  AwDclatioii,  18S.S.  p  i;.Vi. 


Mi:iin/.\AL  AM*  SVIKIIVAL  TREATMEST  OF  TIIK  LAHYSX.     91,j 

(■iircttciiiciit  and  for  I  lie  excision  hy  tlio  double  curette  of  tuixTcuIous 
sites  tile  iii!inediate  area  is  further  aiuestlietized  l)y  sui)niucous  injec- 
tion of  a  dro])  iiere  and  there  of  a  2  to  4  per  cent,  sohition. 

The  Removal  of  Papillomata  and  Other  Benign  Neoplasms. 
Foreign  Bodies.  Singers'  Nodes.  Pachydermia.  Tlie  patient  pro- 
trudes iiis  tongue  and  steaihes  it  witii  a  nai)kin  between  the  tiiunib 
and  first  fiiifier,  while  the  surgeon,  seated  soinewiiat  iiigher  tlian  ti;o 
patient,  hoi<is  tlie  tliroat-tnirror  in  position  with  one  hand,  and  with 
tiie  other  passes  the  forceps,  snare,  or  cautery  electrodi'  around  tlie 
epiglottis  without  touching  it,  and  well  downward  and  forward  to 
tlie  site  of  the  growth.  The  forceps  is  ([uickly  o})ened  and  the  growth 
lirnily  grasiM'd.  .lust  at  this  inoinent  or  before  the  larynx  is  apt  to 
close.  If  the  force[)s  is  aln'ady  in  exact  [Hisition  this  spasm  will  not 
prevent  the  gras|)ing  and  withdrawal  of  the  neoplasm,  but  if  not,  one 
iimst  desist  and  try  again:  the  attempt  niaj'  be  made  either  during 
respiration  or  on  phonation.  I  have  been  more  successful  in  the 
former  position  of  the  larynx,  l)ut  an  overhanging  epiglottis  must 
often  be  pres.sed  forward  by  the  forcejjs.  The  latter  position  is 
adapted  to  growths  which  ri.se  well  above  the  glottis  on  phonation. 

The  forcejjs  are  of  two  general  types,  bladed  pivot  forcei)s  and 
tubular  forcejjs.  In  the  former  the  laryngeal  bend  may  be  ajiproxi- 
inately  a  right  angle  or  a  curve.  Hlades  are  constructed  to  open 
both  antero-posteriorly  and  laterally,  the  latter  motion  being  very 
important  for  growths  at  the  anterior  commissure  and  for  foreign 
hiidies  in  certain  positions.     The  grasping  ends  are  made  with  cutting 

¥'.!..  470. 


Hackeniie'ii  cutting  forceps. 


edges  and  with  simply  serrated  surfaces.  Dundas  Gratit  has  modi- 
lied  the  j)ivot  forceps  by  hinging  together  the  distal  ends  of  the 
rutting  blades.     fFig.  472.) 

The  obstruction  to  vision  by  tubular  forceps  is  less;  but  the  move- 
ment of  the  blades  is  limited  and  they  are  suited  rather  to  (juite  small 


i   1 


916 


XOSE  AXI)  Til  HO  AT. 


growtlis.     TIkiso  of  Sclii"      cr,  Stoork,  Soilor,  and  Krause  are  most 
favorably  known.     Seilor's  tube  is  flexible,  and  is  therefore  adaptable 


Fia.  471. 


Coaco'a  laryngeal  forcepa. 
Fig.  472. 


Dandas  Grant's  guarded  forceps. 
Flu.  473. 


SchnHjtter's  handle,  contAining  serrated  forceps.    Two  stienthed  kTiives  and  a  sheathed  caustic 
api'Iicator  are  also  shown. 


Mi 


m 


MEDICISAL  ASD  SURdlCAL  TREATMESr  OF  THE  LMlYSX.    917 

for  i)r'ii<'liial  and  (rsophaRoal  uses— r.  f/-.  the  removal  of  a  foreipn 
body  through  a  tracheal  oix>ning.     (Fig.  474.) 

Fia.  471. 


Seiler'K  tubular  forcepi.  guillotine,  and  lancet. 


A  small  guillotine  which  forms  part  of  the  tubular  outfit  is  suitable 
for  the  removal  of  readily  encircled  tumors.  A  laryngeal  lancet  also 
convenientlv  forms  one  of  the  tubular  attachments.  The  tube  acts 
as  a  shield  within  which  the  small  knife  is  concealed  during  passage 
into  the  lar-nx,  to  be  protruded  at  will  when  the  desired  spot  is  reached. 
It  is  employed  for  scarification  and  puncture  in  a'dema  of  the  larynx 
and  for  the  division  of  adhesions. 

The  '■  double  curetten  "  of  Krause  and  Heryng  are  in  reality  sharp- 
cutting  and  punch-forceps,  which  operate  on  the  tubular  plan.  They 
are  availalile  foi  the  removal  of  neoplasms,  although  they  were  de- 
.-^igiu'.l  for  the  eradieation  of  areas  of  tuberculous  infiltration,  a  subject 
which  is  considered  in  another  chapter. 

Laryngeal  forceps  are  emploved  also  for  the  removal  of  foreign 
Ijotiies  both  from  the  larynx  and  laryngt>pharynx.     These  objects, 


Foreign  bodies  in  the  larynx. 


including  coins,  fish-bones,  pins,  tacks,  cockle-burs,  buttons,  nutshells, 
beans,  jackstones,  teeth,  etc.,  being  of  all  shapes  and  sizes  and  in 
varying  situations,  one  selects  whatever  implement  seems  best  adapted 


yi» 


snsi;  .[.\h  rmioAT. 


t"  the  individual  case.  The  iiictlmd  ;is  r<%'irds  local  aiia'sthcsia  and 
the  introduclinn  of  ilc  forceps  is  the  same  as  for  tlic  removal  of  neo- 
|)lasiMs.     I.ivinj;  objects,  such  as  luiubricoides.  hydatids,  and  leeches, 

occ.'tsionally  \p\\u  access  to  the  air  pas- 
sap's,  Larpe  ohjects,  such  as  apple- 
cores,  pieces  of  meat,  and  tooth-plates 
may  occlude  the  larynx  i)y  hecomiuK 
impacted  in  the  pharynx.  Tiiey  can 
usually  he  dislodp-d  hy  the  hnjicr,  hut 
laryn<;eal  forceps  may  he  re((uired.  In 
children  extraction,  e\-en  from  within 
the  larynx,  may  often  he  made,  puided 
hy  the  tinfjer,  under  jjeneral  ann'sliiesia. 
Foreijin  bodies  which  are  lodjjed  in  the 
trachea  or  in  one  of  the  main  bronchi  can  usually  be  j;ras|)e(l  by 
straii;ht  or  slightly-curved  forceps  introduced  throufili  a  low  trache- 
otomy wound. 

JM'rasement  or  the  use  of  a  cold  wire  snare  is  best  adajjtod  to  pe- 
dunculated neoplasms  of  good  size,  especially  jtapillomata,  fibromata, 
and  cy.sts.  X  camila  with  a  laryngeal  curve  can  be  adapted  to  a 
nasal  snare.     (Fig.  47S.) 

Flo.  478. 


Kiiri-i|{h  Uiily  til  thi'  Ihtviix. 


Cas8e'.t«rry's  mudilieil  Allen  > 


When  a  papilloma  is  broad-based  and  deeply  inserted  in  a  situation 
rather  m;icce.ssihle  to  forceps,  as  in  part  beneath  a  vocal  cord,  it  may 
be  destroyed  in  sllii  by  the  galvanocautery.  The  author's  experience 
nicluiles  several  cases  of  this  sort  in  which  the  forceps  oper.atioii  seemed 
like  pulling  pieces  from  a  cutaneous  "seed  wart."  The  more  one 
pulled  th(>  faster  it  grew.  The  accompanving  figure  -epresents  an 
electrode  which  is  well  adajited  to  this  purpose.  Its  j)latinuni  loop 
is  turned  to  one  side  or  the  other,  which  renders  umiece.-sary  a  shield 
to  protect  the  opjx.site  cord.  The  p!;itinum  tip  while  cold  is  pressed 
l.'iterally  ui)on  the  growth  and  then  c;msed  to  glow  for  a  .second  only 
Sajous'  handle,  which  is  light  and  has  the  cords  su.speiided  from  i"t.- 
middle,  has  the  best  b.alance  for  laryngeal  u.se.     (Fig.  470.) 

Sc.-,Mle  aiigiomata.  small  iibromata,  polyps,  cysts,  and  tuberculous 
granulomata  can  be  destroyed  in  the  satue  way  by  an  expert  han(' 
Persistent  singers'  nodes,  especially  tho.se  which  air  too  miimte  and 


Mi:i)l(l.\.\L  A.\l>  SVRdlC.XL  TREATMEST  OF  illE  LAUrSX.     !»l!l 

tdii  iiitiriiatcly  l)l('ii<lcil  with  the  .''uljstam'c  <if  the  vocal  cords  t<i  he 
(Ictaclicd  l)y  forceps,  may  Ix'  treated  by  the  cautery  electrode,  althougli 
extreme  care  is  recjuisite.  Tliose  nodes  which  project  siiliicieiitly 
and  tlie  larjjer  iioihiles  of  cliorditis  tuherosa  can  l)e  detached  by 
ciittiiift-forceps,  esiM'ciaily  tJrant's  guarded  forceps. 


fffiilVnittaiii 


Flo.  479. 

iiiiiitiiiiiii'lliiiiiBi 


Casselberrj'B  laryngml  electrode KiiU  Sojoiis'       udle. 


Curettement  of  tlie  larynx  is  employed  chiefly  in  the  surgical  treat- 
iiH'iit  of  tuberculosis  and  receives  ai>])ropriale  mention  under  that 
heading.  Heryng's  single  curettes  are  suitable,  In'ing  well  made, 
sharj),  and  of  varyingsizes.  P;i])illomata,  when  diffused,  and  when  in- 
accessible to  forceps,  ean  occasionally  be  effectually  curetted.  Simple 
inflammatory  and  .syphilitic  infiltrations,  and  p'lchydermia  laryngis 
■AW  somewhat  rarely  amenable  to  the  same  treatment.  In  pachy- 
ijirmia,  curettement  is  usually  supplemented  by  chemical  cauteriza- 
liiiii.  either  by  lactic  acid  on  a  cotton  swab  or  chromic  acid  fused  in  a 
bead  on  a  porte  causti(|ue.  Salicylic  acid,  10  per  cent.,  in  alcohol 
anil  water,  is  also  comtnended. 

Electrolysis  by  th,'  bij)olar  method  is  recommended  by  Chiari  for 
pachydermia  diffusa  (JournnI  of  Lari/nnoldi/i/,  May,  1S94).  The 
irido|)latiinnu  needles  designed  by  the  writer  for  nasal  use  are  suitable 
if  given  th(>  laryngeal  angle.  A  current  of  from  eight  to  twelve  niilli- 
aniperes  is  adcfjuate.  ("upric  electrolysis  applied  by  a  bulbous 
positive  electrode  of  cojjper  with  a  current  of  five  niillianip<Ves  is 
advocated  by  Scheppegrell  for  laryngeal  tuberculosis.  Oxychloride 
of  copper  is  liberated  in  the  tissues. 

Injuries  of  the  Larynx.  Injuries  of  the  lar^'nx  may  occur  in  con- 
s(i|uence  of  either  internal  or  external  violence.  Traumatistn  from 
witliiii  can  result  from  extreme  muscular  action,  the  ini])action  of 
I'nreign  bodi(>s,  the  application  of  surgical  ap])liances,  either  inten- 
tionally or  unintentionally — c,  r/.,  the  false  ])assage  of  an  intubation 
tube,  the  swallowing  of  corrosive  li(|uids,  and  the  inhalation  of  scald- 
ing vapor.  Injuries  from  without  include  gimshot  wounds,  incised 
"(lU'ids  as  in  cut-throat,  punctured  wounds  as  in  sword  and  hay-fork 
thrusts,  fracture,  dislocation,  and  contusion  as  from  throttling,  hang- 
ing, and  accidental  blows. 


»20 


A'UHE  A.SD  THROAT. 


\'i()l«'nt  couRliiiiR  and  shouting  sonidinios  injures  oiif  or  tM)th  vocal 
cords  in  such  a  manner  that  thry  present  an  ecchyinotic  and  paretic 
app«'arance.  U»'st  and  .la  enioHient  spray  an-  indicated.  Sharj)- 
cornen'd  foreign  l)odies  occasionally  lacerate  the  interior  of  the  larynx, 
cs|)ecially  during  forcible  extraction;  such  wounds  usually  heal  n-iulily 
under  antis<'[)tic  and  einollieni  sj)rays,  hut  it  is  jwissihle  for  an  abscess, 
|)erichondritis,  and  (rdenia  to  Ih-  excit«'d  in  this  way.  Bokay'  re|)ort8 
that  out  of  12(X)  cases  of  intubation  of  the  larynx  obs<'rved  by  him 
there  were  four  cases  of  false  pa.-wage,  all  in  the  ventricle  and  all  fatal. 
The  false  pa.ssage  nmy  also  Ik;  forced  through  the  membrana  thyn)- 
hyoidea.  (Kdeina,  suppurati(m,  and  perichondritis  are  very  prone 
to  follow.  Tracheotomy  should  Ik»  immediately  substitute<l  for  mtu- 
bation.  The  ulceration  and  pressure  n«'crosis  which  occa-sionally 
results  from  the  j-rolongtnl  use  of  intubation  tulx's  merely  re(|uir(^s 
mention  in  this  connection,  h  is  rarely  serious,  but  very  exception- 
ally may  he  followed  by  cicatricial  stenosis.  The  same  is  true  of  high 
tracheotomy  when  the  tub'  is  so  placed  that  the  upper  curve  impinges 
u[K)n  the  inferior  surface  of  the  vocal  cords.  The  author  hivs  recently 
observed  a  case  in  which  a  web  extending  largely  across  the  glottis 
and  an  ankylosis  of  the  left  crico-arylenoid  joint  had  resulted  from  this 
cause. 

In  the  swallowing  of  corrosive  li{]uids  the  epiglottis  and  aryepiglottic 
folds  would  be  the  only  parts  of  the  larynx  directly  affected,  but  ol)- 
structive  cedema  is  likely  to  easue.  The  inhalation  of  steam  is  fraught 
with  the  same  danger. 

Gunshot,  punctured,  and  incised  wounds  from  without  vary  in 
gravity  according  to  their  situation  and  extent,  yet  most  of  them  do 
well  if  the  hemorrhage  is  check(>d  and  the  i)arts  are  cleansed  and  care- 
fully coaptated.  To  avoid  stenosis  by  the  formation  of  a  diaphragm, 
the  divided  cartilages  should  l)e  deef)ly  sutured  by  silkworm-gut. 
Emphy.sema  of  the  neighboring  connective  ti.ssue  is  sometimes  a 
troublesome  symptom. 

Fracture  of  the  larynx  may  be  caused  by  a  fall  upon  a  projecting 
object,  i;.y  a  blow,  and  by  hanging  and  'loking.  For  instance,  a  man 
while  riding  a  bicycle  carried  sus[x>iii  round  his  neck  the  diamond- 
shaped  frame  of  another  bicycle.  11.  iell  and  compressed  his  neck 
in  the  angle  of  the  frame,  which  fractured  the  larynx  in  such  a  way  a.s 
to  result  in  immediate  death  from  asphyxia.  Fractun'  is  rare,  owing 
to  the  natural  resiliency  of  the  cartilaginous  framework.  The  ino.st 
serious  symjjtom  is  dyspna\».  which  is  usually  due  to  odema  of  the 
glottis  from  laceration  of  the  soft  parts,  but  which  may  be  caused  by 
a  disMlaced  fragment  encnwching  upon  the  lumen  of  the  larynx.  It 
may  .set  in  at  once  or  at  any  time  within  a  week.  <)t!  er  manifes- 
tations are  cough,  bloody  exfx'ctoration.  impairment  of  the  voice, 
emphysema,  and  pain  both  on  talking  and  swallowing.      Hy  digital 

>  Bokay.    Trauoatl'im  during  latubatiou.     Juurual  uf  .\mericaii  M«(iicul  AisociaUoii.  Jauiury  'J6, 
IWl. 


MEDIVISAL  ASD  SUROIVAL  TUE.XTMEST  OF  THE  LARY.SX.     921 

cxaiiiiiiatioii,  (Icfomiity.  in()l)ility,  and  crepitation  would  Ik'  iwrccivcd, 
ami  tli«  diagiioxis  thus  ccrtitii'd.  Laryiigoscopic  cxainination  will 
ilisclosc  .swelling  and  di  m  within  th«'  larynx.     Th«'  fracture  may 

lie  linear  or  coni'iiinutcii  ..u.  may  involve  one  or  more  cartilage!*.  The 
|iroj;iiosi.s  i.s  very  seriou.s,  tliree-fourth.><  of  the  recorded  ca.s<'s  having; 
terminateil  fatally,'  either  immediately  or  from  subsinjuent  pneu- 
monia, al).-<cess,  and  septic;  'mia. 

The  treatment  should  Ik'  directed  toward  the  promj)!  n'lief  of  dy.sp- 
iKi'a  hy  low  tracheotomy,  provided  then-  is  time  for  a  deliherate 
o|M'ration,  or,  if  necessary,  hy  a  hiusty  high  tracheotomy.  Intuba- 
tion as  a  substitute  for  tracheotomy  is  not  suitable  in  these  cases. 
Vavw  if  asphyxia  is  not  at  once  imminent  the  j)atient  should  be  kept 
under  close  surveillance,  for  it  is  liable  to  develop  .suddenly.  Prompt 
replacement  of  the  fragmentK,  cold  applications,  and  absolute  rest, 
including  f(>eding  by  the  n-ctum,  are  indiwited  to  ward  off  (I'dema. 
The  hyoid  hone  Ijeing  in  clos<>  proximity  to  the  larynx,  may  l)e  frac- 
tured conjointly  or  alone  from  the  same  causes.  The  superior  cornua 
if  the  thyroid  cartilage  are  loosely  articulated  to  the  gi-eater  cormia 
"f  the  hyoid  bone  through  the  medium  of  the  thyrohyoid  ligament. 
.\  di.xplacement  in  the  nature  of  a  dislocation  of  this  articulation  occa- 
sionally occurs  by  muscular  action  in  sudden  movements  of  the  neck. 
\  return  is  usually  effected  in  the  same  way  by  nuiscular  movements, 
but  digital  manipulation  will  hasten  it.  Seve;e  contusion  of  the 
larynx  would  suggest  in  part  the  same  ciire  as  actual  fracture. 


BcMworth.    DUeaseM  of  the  N(Me  « '  .' Throat,  vt>t.  il.  p.  712. 


i! 


CIIAPTKR    XXI. 
DISKASKS  i)V   rilK  ACCKSSOllV  SINTSKS. 

Hv  StCLAIU  THOMSON.  M.I)..  M. U.C.I'.  I-<>m>..  I'.K.C.S.  Kno. 

Introductory.  With  the  cxcoptiDii  of  that  part  of  the  niof  of  the 
nasal  chanilHT  foriiicd  hy  the  crihrifonn  plate,  the  up|H'r  and  out^r 
wall.-*  of  the  nasal  cavities  are  ncciipied  hy  the  accessory  pneunuitic 
.sinuses.  Contiguous  to  the  outer  wall  of  the  nose  are  lodjfed  the 
nia.xillary  and  ethmoidal  ca  ities.  while  |)ortions  of  the  ethmoidal, 
frontal,  and  sphenoidal  chamlx'rs  help  to  form  the  na.sai  roof. 

It  would  Im'  a  natural  presumption  that  these  cavities,  communi- 
catiiifi  as  they  do  with  the  na.sai  fos.sa',  exposed  to  a  variety  of  possible 
etiolojiical  factors,  and  in  clos<'  relationship  with  sucii  im|H)rtunt 
parts  as  thi"  lirain,  eye,  e.ar.  and  throat,  woulil  not  he  exempt  from 
disease.  Thi'y  ;ire  indeed  suhject  to  disease  just  as  the  nasal  fos.se 
are,  hut  it  would  he  a  mistake  to  think,  as  some  authors  state,  that 
since  atTections  of  the  |)itiiitary  memhrane  can  he  |)ropafiated  to  the 
accessory  cavities,  the  latter  manifest  just  the  siime  diseases.  A 
little  reflection  would  show  that  this  view  cannot  he  correct.  The 
provision  in  the  nose  for  (ilterinj^,  warminji,  and  moisteni-iir  the  in 
spired  air  necessitates  special  anatomical  arrangeiuents,  which,  i.hi'ii 
disordered,  are  suhje- 1  to  particular  pathological  changes.  At  the 
same  time  this  continually  renewed  air  stream  hrinjpi  with  it  i)atho- 
penic  j)ossihiiities  from  which  the  acces.sory  cavities  are  nmch  more 
exempt.  The  nuicous  lining  of  the  li'.tter  has  not  the  same  fui'ctions 
to  jK'rform,  and  is  therefore  difTerently  iirranged. 

On  the  other  hand.  .-dTections  of  the  simises  require  individual 
consideration  '  \vin<;  to  (a>  the  shaix'  of  each  cavity,  ih)  the  >ituation 
of  its  orifice,  i.'<l  (c)  its  relation  to  neighhorin};  organs.  It  will  he 
noted  that  all  'h.ese  three  factors  ]>ertiiin  to  anatomical  chanicteris- 
tics.  and  hence  the  great  importance  of  an  exact  practical  ac<iuaiutance 
with  the  surgical  anatouiy  of  this  region.  It  is  .seldom  t.augiit  ado- 
<iuate!y  in  the  dis^i-ctiiig-room,  ;ind  the  consideration  of  the  surgical 
point '.  in  the  anatomy  of  the  sinuses  hardly  a|)peals  to  students 
sufhciently  at  an  early  jM-riod  of  their  career  to  conmiand  nmch  atten- 
tion. 

A  rorrert  idfa  <>f  the  top>gniphir:\I  anatomy  of  the  arct--s.=on- 
sinuses  can  only  he  ohtained  hv  the  study  of  hoth  dry  and  moist 
sections.  I'A'ery  surgeon  who  aspires  to  a  profound  study  of  tln' 
diagnosis  and  treatment  of  nasal  suppuration  should  lose  no  oppor 


/'/.n7;.|n7-,.s  itF  rilK  .irrK'S'iliy  SIMSJ-SS. 


!ij;j 


I  unity  of  cxjiiiiiiiiiiK  :i  ^n-nvx  of  coroiml,  j<!i){itt:i!,  .'irul  horizontal 
xciioiis  of  the  lic;ii|,  wliicli  lie  should,  if  iK)s.«.il(lc,  prcparf  with  liid 
own  h.'iri'ls.  Those  who  have  not  tlirsc  op|)orttinitics  can  to  soin«? 
fxtcnt  siippicnicnt  thcin  hy  the  stinly  i  •  phistt-r  casts,'  while  much 
can  Ik'  ffaincd  from  the  iiuincri)Hs  atlascH  mid  s|x'ciai  tn'atis<'s  dc- 
voti'd  to  the  siilijfct 

Surgical  Anatomy  of  the  Accessory  Sinuses.  Matiy  of  the  itn- 
|)ortant  points  of  the  lopojiraphical  and  surjjical  anatomy  of  the 
accessory  sinuses  are  shown  in  the  illustrations,  an<l  othi-rs  will  he 
referred  to  in  treating  of  the  diseases  of  the  individual  cavities.  It 
will  therefore  lie  sudicient  here  to  briefly  refer  to  a  few  of  the  jioints 
which  deserve  s|M'cial  consideration. 

I'roin  lioth  anatomical  and  clinical  considerations  it  is  conveniriit 
to  dividi'  the  accc.sHory  sinuses  into  two  groups,  a'Tonling  as  to 
wliethi'r  their  ((.s7/rt  o{M-n  (ii)  aniiriorli/  into  the  middle  meatus,  Im'Iow 
the  attachment  of  the  middle  turhinal,  or  (/)|  ittisttriorltj  into  the 
■superior  meatus  and  ahove  the  middle  turhinal.  Thus: 
.Vnterior  group. 

Maxillary  sinus. 
I'rontal  sinus. 
.\nterior  ethmoidal  cells. 
I'osterior  group: 

Posterior  ethmoidal  cells. 
Sphenoi<laI  sinus. 


I  i'rt'|«rp<l  )>>-  nr.  Bull,  nt  ilvilbronn.  and  nld  by  Inilniraent  (lealen. 

-  John  Jmnw  Walt.  Anstumlcu-thlriirgi™!  Vlewn  of  the  Nine,  Mouth,  Larynx,  and  Fauoa. 
Lmiloii.  IHU. 

/Mtkirkaiiill't  .\n«tomlo  Nnrmale  et  l'«thol<>glque  dos  F  <iiies  Nasalis  et  de  leun  Aiiiu'xt-<  Pneu- 
iniiiic|iiin,    Tniilin'iioii  Kmtv  aise '||.  i,|..htw(tz.    l^irl«.  O,  ?.;  ixm  IH'jrv 

onmliii  Atlas  of  the  Safwl  Cavit)  ami  Sluuse-,  tr«i>«i  .twi  by  3i<'uir  Thum*)n.  London,  U.  K. 
i.f«is,  i<<n. 

l)r»  K.  (inuirenhclm  et  J.  Olover.    Atlas  de  I.aryn(tologfe  et  de  Rhln«l(i([ie.    Parin,  (i.  Ma»on,  ISW. 

Aritiur  Uiin  iiann.  Atlas  der  Anatomie  der  Silriihiihic,  dervotdereii  Siebelnielluii  und  den  Ductus 
Nasofrontal!,!.      Wieohaden.  J,  W.  Horxmann,  19()0. 

Or  I',  ri  (terrier.  Atlaader  Krankheiten  dcr  Na«e,  Ihrer  Nebenhiihlen  uud  desi  Naaenrachenrau- 
iimis.    IUtH  1,  S.  Kanter,  1901. 

Iir  Robert  Krie«.    Atlaa  der  Sasenkrankheiten.    Stuttgart.  Ferdinand  Enke.  1901. 

I.oKrtii  Tiiniir.    The  Aece»«ory  Cavities  of  the  .Nose.    Edinbunth.  fireen,  imil. 

J.  H  llr  an  A  further  Contribution  to  the  Study  of  Snppuratitre  Diseases  of  the  Accessory 
■Minuses,  with  lieport  of  Cases  Transactions  of  the  American  Ijiryngological  Association.  wj:>.  j>. 
7'..  and  New  York  Medical  .lournal. 

llnwar.1  A  Ijithmp.  The  Anatomy  and  Surgery  of  the  Frontal  Sinus  and  Anterior  Ethmoidal 
'Vlli.     HeprinttsI  from  Annals  of  Surgery. 

Hmdc'i  Kvie  The  Relation  of  the  .Vasal  Chamber  and  Accessory  Cavltien  and  Dental  I.eslons 
JonmHlofthe  American  MellcJil  As«,K'iation,  October",  1H99. 

Ki!it'liptwTi.     Ititernational  Dental  .lounnil.  1«<*7 

Kiiifc  'c  s.  T'llhit.    Jounuil  of  tile  American  M-'dlcal  Association.  Noveralier2l.  !*.►*. 

McHiuKn  Douglass.  The  Pneumatic  Sinuses  In  the  Sphenoidal  Wings.  Laryngoscor>c,  l<i«l,  vol  x 
No,  -'. 

.1.  Mouret.  Anatomie  des  Cellules  Ethmoldales.  Revue  hebd.  de  I.aryngi)logle,  is;i8  xlx  2  No 
•n. !,.  M:'.. 


A  Onndi  Des  Rapports  du  Sinus  Maxlllaire  avcc  le  Sinus  Sphenoidal  et  Ics  Cellules  Ethmoi- 
■  iftle*,  Anterieiires.     Kevue  hetn!   de  I.Hrvngologie.  F.'V.  Irt,  I'lOI.  sxli    I.  N'o.  7.  p,  177. 

M  II.  Crv.'r.  siuilies  of  s...ne  Facial  Bones  .lournal  of  the  American  Medical  Association. 
I'urtyeigh.h  meeting,  \'<:n.  and  Frftieih  meeting,  ITO:i. 


I 


124 


SosK  AM)  Til  1:0.11: 


The  maxillary  sinus,  or  aiitiuin  ni'  Iliiihnuirr,  li.is  (il'tcu  liccn  coin- 
part'tl  ill  shape  Id  a  tlifci'-siilcil  |)yrainii|.  Sniiic  autliois  ili'scrihc 
it  as  all  iiivt'ilcd  ])yramiil.  the  basr  lii'iiitj  t'lirmcil  iiy  the  floor  of 
the  orliil  and  the  apex  siliiatcil  over  the  loots  of  tiic  molar  tcctli. 
Others  place  the  base  of  the  pyrainiil  at  the  ou!i'r  wall  of  the  nasal 
(•!iaiiil)er  ainl  the  apex  towanl  the  malar  process.  In  that  case  the 
three  sidi's  of  the  pyramid  arc  formed  l)y  the  facial,  orbital,  and 
zyirom.'itic  walls  of  the  sinus.  The  temporal  or  posterior  wall  is  loriiied 
hy  tlie  holly  of  the  superior  maxilla:  it  is  concave  and  laces  toward 
the  zyfioniatic  fossa.     This    is    the    thickest  wall.     The  thin,  orbital 

Flc.   ISO. 


Corunal  section  in  the  anterior  thir<l  of  the  iiO!-e  \  u  .vt-l  trom  the  front.  Shows  the  inferior  anil 
tnidille  tnr)>inHlK :  |iol.vpi  Krowlli^;  Iroin  the  ethinoliliil  leKinii  in  eaeh  Mile;  ami  |><il,V|>iiiil  tleKelieni- 
tion  ot  the  liiiitii;  i>l  the  lelt  inuxillary  sititls.  A  prolie  is  |iasse<l  np  into  ihe  Iroiilai  Minis  on  the  lell 
siile.     (I'reparalujii  h>'  "^ri'i-xiu  Thomso.s.j 


wall  forms  the  roof  of  the  sinus.  The  anterior  wall  corresponds  t 
the  lacial  surface  of  the  superior  maxilla  and  is  always  very  mucl 
thinner  over  the  canine  fossa.  Here  it  may  only  measure  "_' mm.  ii 
thickiies.s.  The  ba.se  of  the  pyramid  corres|)onds  to  the  outer  wa! 
of  the  nasal  fossa,  which  is  markedly  convex  toward  the  sinus.  Th 
anterior  and  posterior  jiarts  of  the  base  are  formed  by  the  su|)criii 
maxilla,  and  a  referenr-e  io  a  dried  skull  will  sliow  how  relativel 
stout  they  are.  The  central  area  of  tlie  base— formi'd  chicliy  li; 
parts  of  tlieethinoid  -is  very  thin,  and  in  certain  points  is  closed  oiil; 
l)v  membrane,     'i'lie  natural  openiiii;  of  the  sinus  which  is  fount 


i>isi:asi:s  or  riii:  Mcrssajn'  si.\i:si:s. 


»2.5 


nil  tills  wall  is  iiiiicli  iii'arcr  In  tlic  ninl'  tliaii  tu  tlic  llnor  (if  tlio  caxity. 
Il  iipriis  iiitDtlit'  iiiiilillc  meatus  (if  the  ikisc  \)y  t\ic  nslinnt  tiiiixillnre, 
at  the  |i(ist('i'iin-  cxtrciiiily  nl'  the  hltilH.<  si'niihiiiiin.'i.  line  or  more 
aci'css()rv(ii>ciiiiijrs  arc  somctinics  met  witli,  also  in  tlic  iiiiildlc  iiicatiis, 
iri'iicrally  posti'rinr  to  the  nsliiim.  Above  the  level  ol'  the  o>^linni 
ni'ifilliin-  \hf'  inner  wall  of  th  •  •  ,•'!■,  "oines  into  relation  with  the 
eiliiiinidal  labyrinth.  The  .  .  ('iii.  ni  'iic  iMiterior  and  posterior 
walls  forms  what  is  fre((iientl;    refi.reii  ti  as  •(i(  floor  of  the  sinus.     It 


»'nr<i!ml  st'ciiou  aboiii  the  centre  of  the  nose,  viewe*!  'loni  the  biu-k.  The  seetiDii  shows  the  hi- 
liTior.  niliMle.  iiii'l  Mi|ieMiir  liuhiiials,  hikI  the  ii';i\illttry,  cttitnoiilul,  un-l  Iniiihil  >iiiu^'s.  The 
rrlalioti  of  the  elhmoiiirtl  cells  to  itic  fronlal  --.mi-.  mii-I  ot  Uitli  to  the  ortut  tin<l  (Tiiiiiiiin.  are  well 
'tMii  I'oh  pi  are  se*.li  tit  the  tlliiMIe  itivatll>*  on  eacll  ■•i'le.  ijrowltit:  man  the  elliinoHlat  region  ;  an  J 
'iKTe  i!t  |i.-ly|)iii.I -K'neiiei^tion  cM  the  iimeoii^  iiieiiihratie  ol  the  laaxillary  sitius  on  the  left  Hi<le.  A 
|ir<ilie  i>  iiu>M-'l  throtiiih  the  tell  o^tiniii  tiiHxlllare.     tl'reiMiiatitin  by  STt'l-Alti  Tit  iMvin.) 

i~  really  a  riuiiuletl  ansrle.  It  lies  above  the  alveolar  liorder  of  the 
-iiperior  '  \illa.  ami  the  roots  of  the  teeth— particularly  the  second 
iiiriis|)i,;  I  the  'irst  molar— are  only  separated  from  tlie  cavity  by 
a  thin  lamella  of  bone.  Th(>  nnico-|)eriosteuni  is  fret|uently  arranged 
ill  folils  or  ritlijes,  which  form  sd  many  pouches,  but  it  is  very  rare 
liir  the  sinus  to  be  divideil  into  two  cavities  |>y  a  comulet(>  septinii. 
.\  larjie  aduli   mavillarv  sinus  will  holil  one  ounce  of  fluid.'     The 


W  A.  N.  catlliii     Tran««itiotis  iHoiit.  Swlely,  Lomlnn  l«'o,  vol.  jrlx.  p.  31. 


\)2i) 


yosi-:  AM)  tiiudat. 


avcrafjo  capacity  is  14.4  c.  cm.;'  hut  of  cniirsc  iiuicli  variation  exists, 
owiii^  to  the  numerous  irrejiuiaritics  met  witii  in  tli:' configuration  of 
the  sinus.  Tlic  cavity  may  i)i'  ri'|)rc.scnti'(l  hy  a  narrow  ciiink:  more 
rarely  it  is  entirely  absent.- 

Development.  Tlie  maxillary  cavity  exists  at  birth,  hut  in  a  rudi- 
mentary form.  It  reaches  its  full  ilevel()|)inent  about  the  a^e  of 
twelve  years. 

The  frontal  sinus  lies  b(>tween  the  two  lamelhe  into  whicl'.  the 
frontal  bone  sepaiates  in  the  re<iion  of  the  superciliary  riiljie.  As  a 
rule  the  cavity  is  decidedly  smaller  in  young  ])e()ple  and  in  women 


FIO.  482, 


Citninal  st'rtiiin  nl  the  ptwterior  thirti  of  the  lutse,  viewed  from  the  front.  Ttio  section  shows  the 
inferior,  iniildle.  ami  iiui»erior  tiirbinals.  Tliere  i.**  ft  i>c»ly[«ml.  inullK'rry  hy|iertlMi>hy  of  the  po«;terior 
end  uf  the  riKtit  inferior  turtiinal.  A  very  hhihII  (Mirtion  of  ttie  nitixillnry  untriitn  i.<l  seen  on  each 
side  The  relations  of  tlie  fronuil  vimi-ies  and  etttmoidal  cells  lo  one  Hnotlier.  and  to  the  orbit  an<t 
erainnin.  are  well  seen.  The  si»eeiint.  i  stio.\s  the  roof  of  llie  (Mislenor  choana.  the  front  wall  of  the 
sphenoidal  sinus,  and  the  sphenoidal  oritiee  on  each  side.  (Si»eeimei»  pre|>aretl  by  StCi.aibThomw>s.i 


than  in  men,  but  there  is  t  >  nece.s.sary  relation  between  a  promineni 
su|)er('ili;iry  ridge  and  a  capacious  frontal  sinus,  or  the  rover.se  fZiick- 
erkanill).  Hut  from  an  <>xainination  of  12")  preparations  Lothrop 
formed  the  opinion  that  ''in  g(>ner.il  it  is  fair  to  concluile  that  tin- 

1  Hrainii    nnd  I'lasen.     Hie  Nebenliohlen  d  menschl.  Nasc,  etc.    Zeitsehrifi  f.  .\ii»l  u.  Entwlik 
lunitsitesch.  IS77.  Hand  ii. 
'  MfirKAKni.     lie  Sedibtisel  cansiii  niorhornni,  )77'.>, 


DIS^A-StS-S  OF  Till:  .WVESSOKY  SIS  USES. 


•dT, 


more  proiuiiu'iit  the  sijpni-orbital  arcu,  iiifliKliiig  tlic  sii|)crciliarv 
riiincs  and  nasal  cini  iitr,  tlu;  greater  tlie  probability  of  the  ju-eseneV 
(it  well-defined  .sinusi  s."' 

The  anteri()r  wall  is  the  tliickest.  It  is  about  5  to  6  nun.  in  thiek- 
ness,  but  varies  considerably  in  different  skulls.  It  contains  a  good 
deal  of  diploic  tissue,  and  this  exphuns  the  How  of  blood  which  may 
take  i>lac(>  while  ojjeiiing  it,  v  '  also  the  pos-jbility  of  se])tic  infection 
ulien  'he  diploe  are  exposu..  The  posterior  wall,  su])porting  the 
anterior  lobe  of  the  brain,  is  thin  and  brittle.  The  floor  of  the  cavity 
is  irregular  and  often  marked  by  the  elevations  of  the  fronto- 
etiiiiioidal  cells.     It  overlies  the  roof  of  the  nose  and  the  orbit. 

Tlie  cavity  of  the  simis  extends  upward  on  the  forehead  for  a 
variable  distance— sometimes  for  one  and  one-half  inches  or  more. 
Backward  it  may  reach  so  far  that  the  entire  roof  of  the  orbit  is  divided 
iiy  th  •  frontal  siiuis  into  two  plates.  Outward  it  extends  in  the  direc- 
tion of  the  eyebrow,  sometimes  as  far  as  the  external  angle  of  the 
orbit. 

It  is  separateil  from  its  fellow  on  the  other  .side  by  a  septum. 
This  is  very  irregular,  and  is  so  seldom  in  the  mesial  line  that  the  two 
sides  are  often  very  irregular.  Indeed,  an  opening  made  on  one  side 
of  the  middle  line  will  sometimes  expose  the  cavity  on  the  ojjposite 
side  of  the  body.  The  cavities  are  very  irr(>gular  .and  unsymmetrical. 
They  may  lx>  very  small,  or  even  entirely  absent.  Logan  Turner 
found  the  sinus  ab.sent  on  both  sides  in  SO  out  of  ,500  nmseum  skulls— 
'.('..in  Ki.l  per  cent.  ),M)ut  Sieur  and  .Jacob  examined  loO  s])ecimens 
without  once  failing  to  discover  both  cavities.-'  The  sinus  nuiy  be 
present  only  on  one  side.  The  sinus  becomes  fuimel-shaped  as  it  jnisses 
downward  between  the  ethmoidal  cells,  to  open  into  the  middle 
tiieatiis  of  the  nose  at  the  upper  end  of  the  hiatus  semilunaris.  It 
is  noteworthy  that  the  ostium  of  the  frontal  sinus  lies  at  the  most 
'lepeiident  f)art  of  the  cavity.  It  is  foimd  at  a  short  distance 
from  the  septum  and  further  from  the  anterior  wall  than  might  l)e 
imagined.  Tilley  found  that  ihe  infundibulum  may  lie  as  deep  as 
-'Slum,  from  the  anterior  surface.'  It  leads  into  the  frontona.«al 
duct  (l.J  cm.  long),  which  oiH>n.s  into  the  anterior  end  of  the  hiatus 
-semilunaris. 

The  surface  of  the  cavity  is  .seldom  smooth,  rece.sses  of  various 
-hapes  and  sizes  being  present.  One  long  narrow  pouch  is  apt  to 
i)e  met  with  running  toward  the  outer  extremity  of  the  eyebrow. 

The  nuicous  membrane  is  thin  and  closely  adherent  to  the  pcri- 
oslium.     It  is  scantily  s'!|)plied  with  glands. 

Development.  The  frontal  sinus  is  absent  at  birth  and  during 
infancy.     It  is  .seldom  evident  before  the  seventh  or  eighth  year. 

'  l.<ithr()p.    The  Anatomy  and  Siirsery  nf  ihe  Fronul  Sinus  and  .\nterl(ir  Ethmoidal  (Vila,  p.  IS. 
-  I'-riM'h  Vr^II.-rtl  Joiirim!.  0!-(fl«T  li    i-:n 
Iti-ciircht's  Hniitomiiines.  plinii|ues  el  oiwralolres  sur  leg  fosses  iiasales  et  leur  ulnus     I'urls  J 
Kiieir.  .itit    VMM. 
<  Lancet,  September  2fi.  ISOti. 


928 


yisi-:  AMI  runo.xr. 


\\'\\A  |iii!)crty  it  imrcuscs  raiiidly.  iind  icaclics  its  full  size  aliout  tlic 
twi  riiicili  yrar.' 

The  ethmoidal  cells  (Icsitvc  sju'cial  considcratidii  fruin  tlic  iiii- 
portaiipc  of  their  topofirapliical  relations,  the  fre<[iieiicv  with  whicli 
etiimoiiiitis  is  assoc-iated  witli  ptis-foniiatioii  in  otlier  accessory  cavi- 
ties, and  their  irreijiilar  and  coinphcated  anatomical  arraiifienients. 
The  system  of  cavities  in  tlie  etiimoid  hone  is  iod'ied  between  the 
nasal  cavity  and  the  orhit.  On  the  outer  side  it  is  closed  in  by  a  thin 
plate  of  hone  which  forms  the  fireater  porti.m  of  the  inner  \va''  ' 
the  orhit  {lamina  jKipi/raccn  or  as  j)la)inm).  ( I'ifl.  4Sl.)  As  : 
of  arrest  of  development  I  Zuckerkaiidl)  and  in  old  jicople,  th.  _  '  .-■ 
may  i)0  defective  in  parts,  and  the  se])arat ion  from  the  orbit  is  then 
only  maintained  by  memi)rane.  On  the  iimer  side  the  ethmoid 
cells  form  a  part  of  the  outer  wall  of  the  nasal  chamber,  from  which 
they  are  separated  by  a  frajiile  lamella  of  i)one.  The  su|)erior  and 
middle  turbinals  are  in  connection  with  this  surface.  A  study  of 
coronal  and  horizontal  sections  will  show  that  the  cells  increasi?  in 
size  from  before  backward,  and  from  above  dowinvard.  They  are 
divided  into  two  groups,  an  anterior  and  a  posterior.  The  anterinr 
open  into  the  upper  jiart  of  the  hiiit:'^:  ."cmihinan's  by  one  or  more 
openinijs,  and  therefore  |)our  their  sect  'tion  into  tlu^  middle  meatus. 
The  ostia  of  thi'  posterior  fjroup  are  situated  above  the  middle  tur- 
binal,  and  therefore  o])en  into  the  superior  meatus  of  the  no.so. 

Development.  .\s  a  rule,  the  ethmoidal  labyrinth  is  not  apparent 
in  infant  skulls,  although  Laurent  states  that  the  cells  are  visible  in 
an  eight  months'  fcetus.-  It  conmiences  about  the  age  of  four  or  five 
years,  and  is  not  fully  developed    until  about    the  twentieth  ye:  .'. 

The  sphenoidal  sinus  is  an  irregularly  (piadrilateral  cavity  situ- 
ated in  the  body  of  the  sphenciid  lione.  |)art  of  the  an1"rior  wall  being 
formed  by  the  ethmoid  bone.  The  orilice  of  the  ca\ity  is  situated 
ill  the  th'ii  anterior  wall,  a  few  millimetres  below  the  roof  of  the  n.asal 
cavity,  and  therefore  comimnneates  with  the  superior  meatus  of  the 
nose.  The  two  sinuses  frei|ueiitly  do  not  correspond  in  shape  and 
size.  One  or  both  may  be  entirely  absent.  They  are  separaleil 
by  a  septum,  which  is  seldom  (piite  vortical,  being  bent  to  one  or 
the  other  side.     They  are  not  often  symmetric.d. 

The  average  capacity  of  the  sinus  isti.tlT  c.cm.  (('.  R.  Holmes).^ 

Development.  'Fhe  sphenoidal  sinus  is  not  present  at  birth.  Its 
appearance  is  given  by  ditferent  authors  at  the  third  Steiner).  seventh 
(Laurent),  or  twentieth  vear  iTillaux). 


'  For  fiirlherdotaiN  oti  the  iinatnmy  cif  the  fnmtal  'iiiiu-o.'s,  rirtr  Lotbrop,  loo.  cit. 

Tilk-y.    Lancet,  Sopti'inlKTi'tp.  lv.«i. 

Li)>;an  Turner.     Ktlilibiir«h  .Me<litMl  Joiiriml.  .\|'ril  iiri.l  May.  IsiWi, 

KtMlmoivl  W,  Piiyiiu.  Atiinnalk»<  of  the  Fnmtal  Sinus.  Junrual  iiftlie  .Amcrlraii  Mcliral  Asjocia- 
tlim,  .luly  JT,  l:"il. 

.-..•;ir.  N'pit- rrliitivc  .1  r.initMTnie  (U-:^ '■■inns  frnntau.^.  itLv;:.:  ijcbd.  tie  l.Aryiigt.ltigie,  lUtil,  iiii.. 
M..  Nn.  ^s.  p  :l;s,  anil  literalurc  on  pau'''  I'--!- 

'  ,Annal.'«  .ti-  mal.  de  rurfilli'.  !<:«,  xxv   ii.  p.  IJ.l. 

•  Arrhivesof  nphthalmnlojy.  IVW.  xxv.  p.  4fiO. 


disi:asj-:s  of  riu:  accessory simses. 


92y 


The  Mucous  Lining  of  the  Accessory  Sinuses.  Tlic  acccssory 
cavitics  arc  lined  by  a  mucous  iiii'iiihraiic.  which  is  so  thin  and  so 
closely  adherent  to  the  periosteuin  that  wiieti  a  heahliy  cavity  is 
ii|icned  in  the  iivinji  subject  the  bony  walls  are  seen  shining  throuph 
with  ivory-like  whiteness  and  with  all  their  ou  "ines  and  ramifica- 
tions clearly  (l(>fined. 

The  nuicous  surface  is  coated  with  ciliated  epithelium,  which 
|iro\ides  for  the  removal  of  >ecretion,  and  the  importance  of  tliis 
function  is  realized,  when  we  recollect  the  disailvantap'ous  |)osition 
for  drainaf;e  of  most  of  the  ostia.     The  imicous  membrane  is  coii- 


rto.  483. 


Kn>zeM  section  of  anierior  half  of  hcHd.  cut  Initneflidtely  in  front  of  I'liiasma.  ViewtMl  from  be- 
liiiiil  P.  Orbital  roof  of  Irontal  pinna,  o.  Ostium  splienoiilaie.  Y  Y.  Right  anrt  litt  sphenoidal 
■  aviiles.  J  M.  InfiTlor  ami  miihlle  tiirliiiials  1  (iptie  nerve  with  ophthalmic  artery,  a.  Thini 
iKTve.  3.  fourth  ntrvj.  4  First  ilivision  of  tlfth  nerve.  :i.  Sixth  nerve.  6.  Second  division  of 
lillh  nerve.    7.  Ophthalmic  artery.    «.  Ophthalmic  vein.    (C  R.  Hoi..me».i 

^iilerably  thinner  than  the  nasal  mucosa:  the  mucoii«  glands  are 
much  scantier.  Sappey,'  indeeil,  only  found  them  on  the  fioor  of 
tlic  maxillary  sinus.  Zuckerkandl-  says  they  are  distributed  on  all 
I  lie  walls,  but  that  they  ar(>  neither  so  regular  nor  so  numerous  as  in 
the  mucous  membrane  of  the  nose. 

Physiology  of  the  Accessory  Cavities.    In  the  history  of  medicine 
v.irjiius  theories  have  had  their  d.'iy  .-is  to  the  function  and  ptirjiriso 


'  Trait,'-  d'anatomie,  tome    .  '.le  partie,  Je  fasc,  p.  741. 

'  Aiiatoinle  aormale et  pstl..loglque  de«  foaaea  naaales,  tmduit  en  Fmn^aia,  IWi.  tome  i.  p.  310. 

."lit 


s 


9;jo 


yosi-:  AM)  ruuo.iT. 


of  tlic  iiiicumalic  cluinil/crs  of  the  face.  ( )iic  ancient  tlvory  was  tliat 
llicy  served  for  tlie  drainafje  of  the  hrain,  eonveyinp  tlie  iniieus  and 
secretion  of  that  or};an  into  tlie  nose— the  "clo;-.ca  del  cerehro"  (San- 
sovino).  Anotiier  view  was  that  they  served  for  the  ins|)irati()n  of 
air  which  went  to  tlie  elaboration  of  tlie  " animal  spirits."  At  one 
time  they  were  regarded  as  resonating  spaces  for  the  voice,  while 
at  another  it  was  thoufjht  that  they  served  for  wariniii)i  the  ins()ired 
air.  .\t  times  they  have  hi'en  reKarde<l  as  serviii};  for  the  secretion 
of  mucus  to  lubricate  the  nose;  as  assisting  in  directing  tlii"  inspired 
air  toward  the  olfactory  region:  as  accessory  organs  of  smell;  or 
as  Iielping  to  diminish  the  weight  of  the  bony  cranium. 

That  they  can  hardly  contriluite  toward  the  secretion  of  mucus 
re(|uire(l  for  lubricating  the  nose  is  evident  from  the  poverty  of 
glands  and  vess(>is  in  their  mucous  nicmbrar.e  (i.uschka),  and  from 
the  position  of  their  ostia. 

That  the  hollowing  out  of  the  chambers  would  render  the  cranium 
less  weighty  appears  at  first  a  feasible  suggestion;  but  if  the  cavi- 
ties were  rei)laced  with  spongy  bone  the  difference  in  weight  would 
be  so  slight  as  to  be  insignificant.  .\  more  jilausibh'  suggestion  is 
that  the  hollowing  out  of  the  bones  gives  a  wider  attachment  for 
the  ))lay  of  jiowerful  muscles  like  the  temporals. 

Against  the  theory  that  they  are  connected  with  olfaction  we  may 
|)lace  the  facts  that  no  trace  of  the  olfactory  nerve  can  be  found  in 
them,  and  that  not  only  animals  with  the  jioorc'st  seii.se  of  smell 
have  the  best  developed  cavities,  but  certain  apes  and  children  ~ 
whom  one  has  no  reason  to  think  are  devoid  of  the  olfactory  sense — 
are  practically  wanting  in  sinases. 

The  view  that  the  sinu-ses  help  as  re.sonating  chanibers  for  the 
voice  has  again  come  into  favor  lately.' 

Etiology  of  Sinus  Suppuration.  The  causes  of  sinusitis  are 
not  well-determined.  They  may  be  jirimary  or  secondary.  By 
most  writ  •••<  the  majority  of  cases  are  regarded  as  secondary  to  some 
intranasal  alTection.  By  others,  such  as  Killian,  they  are  considered 
to  arise  (irimarily  in  the  majority  of  instances,  and  he  appeals  to 
E.  Fraenkel's  pathological  researches-  as  sup,|)orting  his  views. 

rndoubtcdly  many  of  th(>  acute  infectious  diseases  give  rise  to 
purulent  intlamiiiation  in  the  accessory  sinuses,  the  most  common 
being  iiiHuenza.  pneumonia,  enteritis,  measles,  scarlatina,  smallpox, 
and  cerebro-spinal  meningitis.  Dijihtheria  ami  erysijielas  may  also 
he  inentioned,  and  among  the  rare  causes  are  glanders,  mumps,  and 
gonorrhcea.  It  has  Ikhmi  attributed  to  acute  rheumatism,  acute 
peritonitis,  an<l  also  to  contracted  kidney.  .Mercui'al  ptyalism  and 
phosphorus  |)oisoning  may  cause  suppuration  in  the  maxillary  and 
ethmoidal  cavities.    I'lumbism  has  been  found  to  be  a  causative  agent. 

I  W  Xrtvlor  Siiclrtnth.    The  Aitmm  <it  lliKhnii>re  iii  «»  Keiaiiou  lo  Vo'al  ReaouuiHf.    Jmiriial  >• 
AmtTictiii  Medicrtl  Awm'iRtinn.  November  17.  1^W. 
"  Virrhnw's  Arcliiv.  I*"^"',  Banil  cxlill. 
'  WKgner.    .New  York  Mo<lic«l  Juiinml,  Aiigu.it  l'>.  1S9«. 


lH6t'ASi:s  OF  THE  AViESSOUY  SISrSES. 


931 


Aiiioti^  till'  secondary  cases  are  those  wliicli  are  coiise(|iieiit  on 
ciiryza,  altlioiigh  many  of  tliese  doubtless  orifiinate  primarily  ainl 
conleniporaneoiisly  with  the  infection  of  the Schneiderian  membrane. 
All  processes  in  the  nose  associated  with  pus  formation  may  induce 
empyema  in  the  accessory  cavities.  Tiie  relation  of  oza-na,  how- 
ever, is  still  a  vexed  i|uestioii. 

There  are  numerous  traumatic  ctuses  which  are  instrumental 
in  conveying  pyoRenic  matter  to  the  sinuses  or  in  diminishinjj  the 
natural  resistive  power.  As  examples  may  be  mentioned  the  use 
of  probes  and  canulas  which  may  carry  pyogenic  organisms  from 
a  diseased  to  a  healthy  sinus,  t'"  em|)loyment  of  the  galvanocautery, 
tiie  misu.se  of  the  nasal  dourhe,  the  adoption  of  nasal  plugs,  the 
pre.scMice  of  flies  and  larva-,  and  even  of  vomited  matter  (Harke). 
Diving  info  water  feet  foremost  is  mentioned  by  Luc  as  a  possible 
cause.  Accidental  intrusion  of  instruments  and  dressings  will  some- 
limes  be  responsible  for  the  continuance  of  supjiuration.  Occa- 
sionally the  mucous  lining  is  extremely  tolerant,  as  is  shown  by  the 
c.ise  of  (Jerard-Marchant,  in  which  a  piece  of  forgotten  drain.age- 
tul)e  remained  in  the  antrum  for  tw(>nty-fi\T  years.  I'ortions  of 
instruments,  canulas,  gauze,  etc.,  may  gain  access  to  the  cavity  in 
tlie  process  of  treatment,  and  (louly,  in  relating  a  case,'  recommends 
the  ;ido|)tion  of  forcible  douching  through  an  alveolar  opening  before 
having  recourse  to  a  larger  opening.  In  this  way  he  succeeded  in 
driving  the  broken  end  of  a  canula  into  the  nose  tin  igh  the  osliiim 
iiia:.-:ll(irt\  Baratoux"  extracted  through  an  oj)ening  in  the  canine 
fossa  one  and  one-half  inches  of  laminaria  tetit,  which  had  slipix  I 
into  the  antrum  six  years  previously  when  being  used  to  dilate  an 
opening  in  the  alveolar  border.  Fnin  another  i)atient  he  extracted 
a  mass  of  cotton-wool  as  large  as  a  small  orange.  It  ajiix'ars  that 
this  material  had  been  used  by  a  dentist  to  stuff  a  hollow  tooth: 
he  did  not  realize  that  the  carious  cavity  conuiumicated  with  the 
antrum,  and  the  disa])pearance  of  the  daily  i)lup  of  cotton-wool  was 
thought  to  be  due  to  the  patient  having  lost  or  swallowed  it. 

I'xternal  violence  will  sometimes  sot  up  a  sinusitis — c.  g.,  blows 
over  the  frontal  sinus — and  when  several  siiuLses  are  affected  with 
ch.ronic  suppuration,  operative  interference  on  one  cavity  may,  by 
obstructing  the  outflow  of  the  others,  produce  in  them  acut(>  symp- 
toms. 

The  presence  of  nasal  polyi)i  occluding  the  natural  ostia  is  often 
considered  a  cause  of  empyema:  but  the  marked  manner  in  which 
polypi  cease  to  form  when  the  dis(>a.se(l  cavities  are  drained  compels 
us  to  view  them  as  usually  the  result  rather  than  the  cause  of  sinusitis. 

\  malignant  growth,  :us  well  as  tviberculosis  and  syphilis,  will 
give  rise  to  purulent  processes  in  an  acce.ssori-  cavity. 

Most  of  the  chronic  suppuraiions  in  the  sinuses  result  from  .""ute 
attacks,  either  from  the  intensity  of  the  primary  infection,  or  from 


Arrhivex  luternat.  <le  Laryngol.,  inah.  No.  1. 


!  Le  ProgTbi  MM.,  Avril  «.  1»95. 


032 


yoSE  AM)  TilliO.iT. 


sccniidary  iiifcctioiis.  or  tnnii  luc-il  or  ficticml  coiKlitiniis  iiiit:iviifiil)Ic 

In  rcsdliitiDll. 

Bacteriology  of  Sinus  Suppuration,  i'liis  lias  Imtii  carcfullv 
stiidicil  In-  W.  T.  Hciwanl,  Jr.,  and  .1.  ^[.  Itificrsoll,  and  sumniari/cil 
as  follows:'  Acuii'  and  cliroiiic  inllatnnialion  of  the  accessory  sinuses 
ot  the  nose  are  not  caused  by  a  sin{;le  inicro-orfianisin,  norCven  by 
a  single  jiroiip  of  niicro-orj;anisiiis.  It  is,  however,  demonstrated 
that  with  a  few  exceptions  (asjierjcilli  and  verin.si.  inllaniinations 
of  the  cavities  are  caused  hy  hacteria.  The  bacteria  found  are 
those  tli;it  .ire  coinnioMJy  present  in  the  buccal  .'ind  nasal  cavities: 
in  the  fornier  in  health,  and  in  the  latter  occasionally  in  healtlj, 
and  usually  in  disease,  such  as  acute  and  chronic  rhinitis  i  lioth  atrophic 
and  hypertrophic),  nasal  tumors,  and  the  like.  It  is  interesting  to 
recoirnize  that  the  common  aRcnts  in  the  causation  of  infl.immations 
of  other  jKirts  of  the  air  pass;ij;es  (the  diplococcus  lanceolatus,  the 
pyojrciiic  staphylococci  and  streptococci,  1  r  b.acilli  of  the  firou])  of 
Friedlaender's  bacillus  |H.  mucosus  capsulatusj,  the  H.  diphtheria", 
and  the  H.  influenza')  are  the  most  important  and  the  usual  micro- 
orfianisms  found  in  iiiHammatory  processes  of  these  .-idjuncts  to  the 
respiratory  system. 

The  relation  of  the  infectious  diseases,  both  local  and  general,  to 
these  intlanuTiations  is  of  j;reat  importance. 

There  are  two  jrroups  of  these  cases:  the  first  in  which  the  acces- 
sory sinuses  are  invaded  by  a  direct  extension  of  the  inflammatory 
|)rocess,  as  in  acute  and  chronic  rhinitis,  corvza,  influenza,  dii)litlieria. 
pharyngitis,  tonsillitis,  tuberculosis,  sypliilis,  na.sal  tumors,  erysiiielas, 
and  injuries:  .and  .second,  those  ca.ses  in  which  pa.rts  of  the  body 
remote  from  the  simises  are  primarily  afTected,  ;is  in  ery.sipelas, 
articular  rheum.iiism,  |)neumonia.  phthisis,  meningitis,  and  suppu- 
rations in  general,  or  diseases  in  which  the  whole  system  is  involved, 
as  measles  and  .scarlatina:  in  all  of  these  the  normal  resistance  of 
the  simises  is  .so  lowered  that  bacteria  which  read,  them  from  distant 
parts  by  means  of  the  blood,  or  from  neifrhborinK  parts  by  the 
spreadinjr  of  inflammatory  i)roce.sses.  set  up  inflammation. 

Fr.aenkel  is  the  first  to  sufiRcst  that  inflamm.atorv  proces.sos  of 
distant  parts  of  the  body  may  be  the  sources  from'  which  micro- 
organisms may  reach  the  acc(>.s.sor\-  siiiu.ses  by  means  of  the  blood. 
Somi    .f  his  cases  .strongly  support  this  view. 

Luc  records  the  ca.se  of  a  medical  student  who  was  attacked  with 
acute  fronto-maxillary  sinusitis  after  making  a  post-mortem  (m  a 
case  of  pneumococcal  meningitis.  He  had  no  dental  caries.  \  cul- 
tivation of  pus  from  his  empyema  showed  a  pure  culture  of  the 
pneumococcus.^  In  the  serosanguiiiolent  na.sal  discharge  of  an  acute 
sinusitis  which  did  not  go  on  to  a  chronic  .supjjuration  the  pneu- 
inococcu.'s  has  been  found  in  abundance.^     In  tiie  post-mortems  of 

I  America  i  Jo\irnal  of  the  .Medical  Sciences,  May,  1«98. 
•  Liic.    Revue  heW.  dc  Ijirynnol..  July  !,■),  1899. 
»  R.  Beniani.    Ibid.,  IXiW.  xviii..  i.  .Vo.  aj. 


i>ist:Asi:s  or  tiik  avvehsohy  sisvseh. 


D.-W 


many  aciiti'  iiitVclioiis  Wciclisclljnuiii  dclcctiMl  ilic  (liplix'occiis  |ni('ii- 
iiMiiiia'  ill  the  (liscasi'd  accessory  cavitii's.' 

I'].  I'raciikcl.  [)iiiu('hi)\vski,  ainl  ntlicrs  have  foiiinl  various  or;;aiiisms 
in  cniiiycniala  •  luit  tiicir  siniplc  cniiincration  ilocs  iioi  assist  the 
iiui'stion  in;it('vial!y.  More  intcrcstiiisr  arc  tlic  researches  of  Staiicu- 
Icanii  and  Maun,  who  found  that  th<' organisms  of  sinus  supjjuration 
i,iij;ht  l>e  ihviiled  into  two  ^roujjs:  (1)  Those  of  nasal  origin,  such 
usual  organisms  as  pneuniococci,  streptococci,  and  stapliylocorci, 
were  chietly  a('rol)ic,  and  the  pus  was  not  fetid:  (2)  those  of  dental 
origin,  such  as  hacilUis  raniosus,  perfringens.  thetoides.  an<i  stapliy- 
lipcoccus  parvulus.  were  r.udnlv  ariaeroliic.  were  found  to  i)e  (hie  to 
dental  caries,  and  produced  a  fetid  pus.  In  two  cas<'s  tlie  fetor 
was  attril)iital)lo  in  part  to  tiie  hacteriuni  coli.- 

Morbid  Anatomy.  The  changes  in  the  mucous  membrane  arc 
of  a  similar  tyjH'  in  the  various  cavities,  though  in  certain  sinuses 
one  |)articular  form  may  he  more  marked  and  more  fre(|uently  met 
with  than  in  another.  They  are  es.sentially  of  a  chronic  inflammatory 
(■har.icter.  and  the  changes  in  the  tissues  leading  to  a  round-celled 
and  serous  iiitiltration  are  descrilied  el.sewhere.  Following  on  this 
tlure  is  polypoid  and  cystic  degeneration,  ))eriostitis,  rarefying 
osteitis,  and  caries. 

In  the  maxillary  sinus  the  mucous  nioml)rane  is  genentlly  swollen, 
-oft.  and  gelatinous.  (Vsts  ;md  hemorrhages  are  met  with.  In 
rlironic  ca.ses  cheesy  pus  is  found  ui  the  villous  and  fungus-like 
pnices.ses  of  the  degenerated  mucous  menihiane.  Carious  spots 
iiiMV  he  met  with,  especially  on  the  nasal  wall,  where  X\wy  may  lead 
to  communications  heing  estahlishcd  witii  the  etlmioidal  cells,  and 
through  them  with  th(>  frontal  sinus.  Zuckerkandl,  however,  iuis 
never  ohserved  caries  ;is  a  result  of  empyema. 

In  the  ethmoidal  lahyrinth,  on  the  other  hand,  osteophytes  are 
very  rre(|uently  encountered,  and  their  jiathology  has  given  ri.se  to 
much  discussion  since  W'n.ikes  drew  particular  attention  to  them.-' 
(inmulatiiig  osteitis,  cari'  ~  ilestruction  of  hone,  and  jiolypus  for- 
iii.ition  are  all  met  with  \'iy  fre(|uently  in  purulent  ethmoiditis. 

In  the  frontal  sinus  suppuration  ap[)ears  to  have  a  special  tendency 
lo  produce  grave  secondary  changes  on  its  posterior  wall. 

In  the  sphenoidal  sinus  erosions  and  necrosis  of  its  anterior  wall 
m.iy  ( iccur.     Polyi)i  are  rare. 

Acute  Inflammation  and  Suppuration.  Etiology.  Acute  in- 
llammation  of  the  cavities  forms  a  part  of  many  acute  catarrhs  of 
ilie  nose,  from  which  it  may  spread  l)y  direct  extension.  Or  it  may 
•  irise  through  the  sw(>lling  of  the  na.sal  mucosa  hlocking  the  cf)m- 
inuiiicition  of  the  sinus  with  the  nasal  chamher.  The  confined 
.lir  hecomes  absorbed,  and  a  hijdroiis  ex  vticuo  takes  place.     This, 


'  wiener  meil.  Wix-l.i'iiBohrift.  1H90.  p.  -."-i:! ;  IN93.  pp.  :v.>.  3S. 
-  Ari'htvos  Intenmt  de  Lrtryni£i)!'Hcit».  I'.HH),  xiii.,  Xu  3.  p.  177. 
»  BriU.-li  Meill(Ml  J:iiirnal.  nt-crniUT  IT.  1S',I.>. 


'J.i4 


SOSL  AM)  TllUo.lT. 


If 

il 


with  a  coiincstcd  linini;  iiii'inlinirii',  is  .i  very  suif;il)l('  niiliis  anciit 
the  arrival  of  any  iiilVclivc  uriianism.  Kiit  acute  ititVctions  riiav 
arise  pririiarily  in  the  sinuses,  and  (iri<;inate  fmni  any  of  the  caiisi's 
alreaily  enunieraleil.  Acute  exacerhaliDUs  are  not  luicoinnum  in 
the  eiiurseipfchrnnicenipyeniala. 

Symptoms.  The  symptoms  complaineil  of  are  so  fre(|uently  asso- 
ciated wilii  acute  nasal  coryza  tlial  reference  sliould  l>e  made  to  the 
cli.apter  dealinj;  with  the  suiiject.  The  occurrence  of  a  rijior  or  rise  of 
temperatui;  would  indicale  more  than  a  simple  c.itarrh.  The  symp- 
toms which  chietly  i>oint  to  the  implication  of  a  siruis  dmin);  an  acute 
"cold  in  the  head"  are  d;)  pain  in  the  region  of  the  cavity,  f;enerallv 
descriix'd  as  neuralgia,  and  i/()  tenderness  oii  pressure,  f.acrymation 
and  photophobia  may  occur  with  acute  inflammation  in  atiy  sinus, 
althou;ih  more  conmion  with  affections  of  the  frontal  ami  ethmoidal. 
Facial  neural^'ia,  ie(|ema,  sliirht  conj;estion,  and  tenderness  are  most 
often  met  with  in  the  maxillary  and  frontal  simis.  A  ileep-seated. 
•  lull,  heavy  headache,  with  a  sense  of  oppression  ix'tweei!  the  eyes, 
is  more  often  encountered  when  th(>  siihenoidal  sinus  is  involved. 
.More  th.in  one  cavity  may  of  course  he  aifected  at  the  same  time. 

Relief  is  obtained  hy  the  discharge  of  mucus  which  forms  part  of 
the  usual  evolution  of  a  cold.  .Vs  it  is  impeded  it  fre(|uently  Ih-- 
comes  jiurulent. 

The  di-char;;,.  ,v  l)e  bloodstained,  and  an  acutely  purulent 
inflammation  i^  ,;  relieved  by  ;i  fn-e  ^\A\  of  pus,  fro(iuently  very 
otTensive  both  to  shiell  and  taste. 

Oil  examiniiiji  the  nose  tiie  usual  evidence  of  acute  rhinitis  will 
be  visible.  If  the  anterior  ^roup  of  sinuses  is  affected,  the  middle 
turl)inal  will  be  p.articul.irly  conj;ested,  infiltrated,  ;ui.l  pusheil  against 
the  septum,  while  the  meatus  below  it  will  be  cloj^fred  with  stringy 
mucus,  ami  later  on  with  muco-pus  or  jms.  This  discharge  may 
terminate  the  acute  stage:  but  occasionally  the  How  lessens.  an<l  the 
.symptoms  recur  until  relieved  by  a  fresh  gush  of  matter. 

When  the  posterior  group  is  affected  the  rhinoscopie  mirror  will 
show  a  deeply  congested  .and  velvety  appe.anmce  of  the  fornix  and 
;mterior  s|)henoidai  wall,  and  muco-pus  will  ultimately  be  vi.sible 
above  the  superior  turbirial. 

Transillumination,  to  be  describe<l  lati'r,  is  often  of  much  service. 

Treatment.  The  chief  indications  are  to  facilitate  the  e.scaiM>  of  the 
l)ent-up  mucus  or  pus  ;uid  to  soothe  the  pain.  The  principles  of 
treatment  are  ( 1)  rest  in  beil,  I'l)  very  w.arm,  moist  compresses  on  the 
forehead  or  affectecl  cheek,  (.'{i  fre(|ueiit  inhalations  of  steam,  medi- 
cated by  the  addition  of  a  few  drops  of  a  10  per  cent,  .solution  of 
menthol  in  alcohol,  (  I)  antiseptic  gargles,  (it)  anodynes,  and  (6)  the 
(•areful  u.se  of  warm  no.se  lotions. 

.\  sjiray  of  adrenalin  may  reduce  the  congested  turbinals,  and  the 
same  effect  can  be  obtainecl  by  a  spray  of  2  per  cent  cocaine.  If 
the  maxillary  sinus  is  affected  any  carious  or  suspicious  teeth  should 
at  once  be  dealt  with. 


i>/ii.  ISA'S  '>/••  Tin:  .\<(:essory  sisvsi:s.  !(;t:» 

Ft    llMS    Im'CII    rcCUllltllCllllfll  toUtlClllpI    tllCI'\|llll-i'l|Mit'    till'  <'(lllt('nt.S 

ul   llu'  ravily  hy  the  iuliMinistratiDii  of  a   rolil/d-  iiillali< f  air. 

Slid'  a  |irtn'i'('.rm«  is  of  dimtitful  ctlicary,  ami  '-vcii  if  it  1ic1|mm1  t«i 
,iii|>lv  one  ravity  it  would  risk  scattering  the  cxiii'llcd  cuiilriits  in 
llif  iniildlc  rar  <"ir  clsfwlirrc.  A  Ix-Mcr  plan  would  he  tliat  siip- 
(icstccl  liy  adopting  llic  Toynhcc  in-  lod  for  cniptyiiif;  tlir  inidillc 
rar  of  air— swallowini;  wati-r  while  tlie  nose  is  tirniiy  held  -so  as  to 
Mick  liciuid  secreted  in  the  siinises  into  the  throat. 

.\s  Mion  as  free  secretion  takes  place  from  the  no.<e  it  can  lie  en- 
conraned  liy  the  usual  nie'liods.  The  neural};if  pain  is  l>est  relieved 
hy  keepin-i  the  patient  warm  in  bed.  with  tiie  head  well  wrapixyl  \\\^ 
in  tlannel.  A  fi-w  doses  of  antipyrine,  or  other  coal-tar  anaifresic  or 
a  hvpoderinic  of  morphine,  will  hest  secure  relief.  The  treatment 
otherwise  is  that  of  the  accompanying  coryza.  and  in  the  majority 
i.t  cases  is  sullicient.  If  very  urgent  symj-toms  are  present  the  an- 
terior end  of  the  iriiddle  turliinal  should  be  removed  and  an  attempt 
may  l)e  made  to  catheterize  the  atTected  cavity.  An  exteriial  opening 
>iiould  be  reserved  for  extreme  cases. 

Chronic  Suppuration  in  the  Accessory  Sinuses.  This  form  is 
(ret|uenlly  referred  to  as  an  empyema,  .ind  has  been  described  as 
•  latent. ■' in  order  to  distinguish  it  from  the  acute  type-,  which  makes 
its  presence  known  by  the  foudrovant  symptoii.s,  which  indicated 
to  surgeons  of  a  former  age  the  only  form  of  empyema  they  recog- 
nized." The  study  and  g<Mieral  recognition  of  the  latent  form  dates 
from  the  year  ISSt;.  wiieii  attention  was  |)arti(nlarly  directed  to 
it  bv  Ziem.  although  an  e.urly  appreciation  of  sinus  disease  was  mam- 
toleil  i>v  Spencer  Watson  in  bs7.").' 

.\  chronic  empyema  occurs  inudi  more  fieiiuently  than  was  for- 
rnerh  thought  to  be  the  case,  and  its  diagnosis  ami  treatment  call 
for  much  study  and  care,  and  tliis  for  tlie  following  reasons: 
ili  There  is  often  some  as,sociated  atfection  (if  the  nose;  (2)  several 
simises  mav  be  affected  at  t!ie  same  time:  Ci)  the  symptoms  are 
fre<|uenllv  not  characteri.stic;  (4)  direct  evidence  of  the  atTect-on 
or  of  its  localization  can  sometimes  only  be  arrived  at  by  indirect 
methods:  (."))  the  etiology  is  not  well  established,  and  most  of  tiie 
cases  take  a  common  origin  from  the  nasal  cavity:  fd)  the  prognosis 
has  to  be  verv  carefully  con.sidered :  (7)  the  indications  of  treat- 
ment varv  considerably  in  different  cases:  lience  (S)  the  impor- 
tance of  a  comjilete  diagnosis  of  all  the  sources  of  nasal  suppuration: 
il»)  the  aHVction  tends  in  certain  cases,  as  yet  not  well-determmed, 
lo  fatal  seiiueke:  tinally  (10)  the  treatment  retiuires  considerable 
si  udv  and  skill,  and  is  mit  devoid  of  danger. 

Frequency  of  Suppuration  in  the  Accessory  Cavities.  It  is  difii- 
cult  to  determine  what  proportion  of  patients  are  atTected  by  em- 
pyema.    Fein   leporl.-  that   among  22S()  private  [lalients  of  Chuiri 


1  W.  Spencer  Walaou.     iJiKjancs  of  ihu  Nose  and  lt»  .\cctiSMor)'  Cavities. 


LoudiMl,  H.  K.   Ij^wia. 


\)M  yttsi:  .iM>  ruiin.ir 

llitTf  well'    I")  ciiMs  uf  acccs.-".'v  sinus  siip|(iii;itiiMi.     Liclitwilz'  i-ii 
ciMiriiiTcl  -.'l.l  caws  aiiKiiin  l_',(KK)  patii-iil-.. '     Kuih  ilicsc  sialistio 
tuiiiciilf  ill  ^iviiijt  ail  avciaKi'  of  alHiiil  2  |mt  rent    of  tlic  iiaticnl- 
prcsciitiii);  tliciiisclvcs  at  a  tliroat  i-liiiii'. 

I'Viiiii  posl-iiinrlciii  uliscrvatioiis  we  liavr  several  sets  uf  statistics 
in  rejjard  tu  empyema: 

lUrki' r.iiiMil  111  cuMiifalniultli  .       ...  in  tKi  csiUvvm.' 

E,  KrHviik.l  loun.l                •«     ••               •• In  Urtc«.laviT.'' 

I.H|ii'llfi>n<l  Manlh  t'linnil    71)     ••               " In 'Jiiii  rulitvi'n.i 

'<''"■'■  f"'""l                         *"     ■■                       inl;i,-.c«.lHv.T!i.' 

Tliesc  fijiures  give  an  average  nf  over  :«>  [x-r  cent,  uf  sinus  ili.sease 
in  all  sui>jects  cominji  t"  the  deail-liuuse.  The  hrst  idea  suggested 
hy  them  is  that  we  must,  in  the  living  suliject,  overlook  an  immense 
numlKT  of  cases:  but  a  critical  study  of  the  ahove  reports  shows  that 
many  slight  changes  are  recorded  as  sinus  disease,  and  hesides  we 
have  no  means  of  judging  how  many  cas«'s  originated  only  in  the 
last  lalal  illness— often  some  infective  alTection.  The  conclusion  is. 
however,  ilouhtless  justihed  that  a  fair  number  of  cases  do  escape 
detection  during  life. 

Tliese  post -mortem  observations  agree  with  the  majority  of  clinical 
observations  in  showing  tli;it  the  m.axillary  sinus  is  the  iiiost  com- 
monly di.se;i>rd.  Killiaii  is  of  the  opini<Mi  "that  the  alTectioiis  of  this 
smus  only  unilateril  or  bil;it<'rai -form  one-half  of  all  the  ca.s<- 
we  have  to  treat.'  The  distribution  of  l.ichtwitz's  24;{  ca.ses  -aUo 
showed  that  the  ;iiitruin  of  Ilighmore  headed  the  list.  His  figures 
give 

A  Mniflo  inaxlliary  suiiL"* 1'*  tltii  "i 

Hcilh  ■•  ■■ .        .  '^     ..'    ' 

A  ultiKli'  splu'lKiidul  "  .        .         .        .  .        .  '      17      " 

B<i(ll  ■■  ■■ .        .         !  11      •• 

A  single  frmlal  "  r,     ■■ 

"""'  "  "  ....!.]'.,'.. 

Slt-.;le  fliiuioid '.      .. 

Ikjlli  ■•  ......',.. 

In  the  remaining  22  cases  the  sinuses  were  mon  mi.xed,  but  the 
following  Were  .atTected: 

Maxtllttr.v  !iimi« iQ,i„ 

Sphemiiilal    •                  n     •■ 

r'rr)ntal         "  .        .        .        .  iii     ■> 

Ethmohl                          ■.....!]'  7     .. 

l'ansinti>iiU!4  '  I      .. 

It  will  Ih>  noticed  in  these  figures  of  Lichfwitz's  that  the  sphenipidal 
sinus  IS,  next  to  the  maxillary,  the  nio.st  frei.uentlv  disea.sed.  This 
.sc-iiuence  is  supported  by  Criinwald.  wl-  .  has  ojjeiied  .ll  sphenoidal 
sinuses  and  has  only  found  it  necessary  to  do  the  external  operation 
on  14  troiitals.'' 

I  Wi'jner  k!in.  Wi>ehi.-n.ii'hrif(    MM   V.-.  '^  ,.  7^.1 

'  (Jnntol  by  F  Martin.     De  la  Kr.-iiufnce  ile  lEmpy^rae.    Bonleaux,  1911O 

"  (inoie.1  In  Thiso  of  F.  Martin.  <  The  Unnuiw-oie.  '\im.  vi..  No,  2  p  81 

'  Heymanns  llanilhuch  iler  Ijirynnoliigic.  Wien.  liHHJ,  Band  iil. 

•  Urilnwttld.    Nasal  i^iippuratiou. 


insE.ishs  Oh'  rut:  AcvEssouy  simsks. 


lt.)7 


To  show  liovv  (lifTcrcht  schools  aiid  oltsi  rvcrs  vary  on  this  |M)irit 
It  is  siillicit'iit  to  i|Uotc  Hoswot'tli,  who  is  of  the  opinioii  that  true 
[iriiiiaiv  ihscascof  thcsiihfiioiilal  sinus  is  vi-ry  ran-.  Hi-  hail  (in  ISil'ii 
only  seen  two  uni|oiil)tci|  cases  of  it,  to  one  hnndriMl  and  fifty  of 
cthnioid  troiil>lc,'  which  he  regards  as  "iiy  far  the  most  frt<|Mt'nt  of 
all  diseases  of  thi'  accessory  cavities."-  In  this  he  is  >ii|i|iort('il  hy 
-nine  recent  statistics  of  John  Muckie,  who  found  "lOof  his  cas<'s  dis- 
triliuted  as  follows:' 

l-.llimiilil 41  ilmw 

Maxillary  -       .  11      ■• 

Kmtital    ......  II      ■' 

S|ihciii)idHl  *      ■• 

I'vidently.  from  the  divergence  i>l  the.se  opinions,  certain  ("avities 
wlieii  diseased  arc  more  apt  to  he  lliagn"^■'d  liy  .some  oliservers  than 
\>y  others,  ami  therefoO'  we  may  conclude  that  a  fair  numlx-r  of  cases 
-till  esca|K'  detection  in  everyone's  practice. 

Symptoms.  .\n  em|>yema  in  one  of  the  acces.sory  cavities  of  the 
nose  is  often  only  referred  Ui  hy  patients  as  a  "chronic  cold  in  the 
iicad.  "  if  ins|M'ctioii  lc  I's  to  the  discoxcry  of  pus  in  the  nose, 
e--pecially  if  it  is  one-sido  <he  prohahility  of  an  em.  "m;i  is  at  once 
manifest,  r,  \  the  aj)plieation  of  certain  tests  will  r  i  i'  '  s  presence 
iriiaiM  Hut  in  a  large  numlwr  of  cases  the  .sympto.  .  v  Im-  more 
reiiiiiii  .  .iiid  attention  may  only  Ih'  direcli'il  incident.aily,  if  at  all, 
lo  nasal  tronhle.  It  is  imdoulited  that  a  Large  numhcr  of  cas«'s 
are  ovcrlooktij  in  practice  in  conse(|ueni'e  of  ;i  want  of  knowledge  of 
llie  niim<i'ous  results  which  may  follow  on  chronic  suppuration  in 
'ine  of  the  pneumatic  chamliers,  Ahhough  tliese  se(|uela'  should, 
-trictiy  speaking,  l)e  considered  as  complications  of  the  atTe<-tion, 
it  ,i|ipears  more  |)raetical  to  consider  tliem  as  sym|)toms,  and  in  the 
liist  place  to  p'view  such  of  them  as  may  occur  with  pus  in  any  cavity. 

Symptoms  Common  to  Empyema  in  any  Accessory  Cavity. 
Presimiptive  Evidence  of  an  Empyema,  The  one  constant  cause 
lit  the  symptoms  is  the  presence  of  pus  in  one  of  the  accessory  cavities 
of  the  no.se  .•uid  its  slow  outflow  into  the  n.asal  chamhers.  The  syinp- 
iniiis  this  condition  will  produce  may  \>v  grouped  in  three  cla.s8«'s, 
■IS  suggested  by  Lichtwitz:' 

I.  Symptoms  in  iieighl)oring  regions — the  nasal  chamhers,  pharynx. 
eyes,  ears,  lie.ad,  and  face. 

II.  .Symptoms  in  more  distaiii  organs — lower  respiratory  tract, 
digestive  tube,  etc. 

I!!.  Sym[)toins  of  interference  with  general  healt!!  — prostration, 
loss  of  Weight,  fever,  ete. 

I.  Symptoms  in  Neighboring  Regions,  1.  N'.ks.\i.  Symptoms.  The 
two  most  usually  complained  of  are  f«)  ohstruction,  and  (7))  discharge. 

'  Transa^-lions  nf  ttu'  Americnn  ljtr>'nfrnlogical  Assuciattoii,  .Stvfntuuntb  Congrew,  lfl9.'>. 

-  IWil,.  si.xteemh  Congress.  1M94,  p.  HH. 

'  British  Molical  Journal.  September  js.  I9(i!.  and  Journal  of  Ijtryngology,  1901. 

'  Aniiiil|.m1es  niiil.  .Ii>  I'oreille.  etc.,  IXidi,  Uimc  ixii   p.  113 


h' ; 


P 


'j;i<s 


.YO.SA'  AM)  TllliO.W. 


Tlif  iilislrKcliKii  may  be  uiiil:it( 


nil  or  hilatcnil.     It  varies  according 


til  the  MiiMPiiiit  of  cxcrctiini.  tin-  position 


if  till'  hcail,  tiic  time  of  dav, 


tl 


ic  genera 


ral  licaitli.  tiie  weal 


lier,  tlie  cavities  afi'ected,  and  any  recent 


increase  o: 


owin 


f  "cataiTli."     It  is  usually  worse  m  ( 


tlinioidal  affections 


<;  to  the  develoiunent  of  polypi.     The  discharge  is  more  marked 

to  accumulation  having  taken  place  in 


in  the  mnrnnig  hours,  owni 


the  nigiit :  and  also  w 


hen  the  heail  is  In-nt  forward,  and  during  cold 


dam| 


)  weather. 


The  ili.-<rli(irtir  may  tlow  forward  when  the  front  group  of  cavities 


are  a 


ffected,  or  backward  when  the  po.-terior  arc 


concerned,     lint 


there  are  exceptions  to  this,  and  the  outHow  may  take  place  hi  both 
ts  maiiv  varieties  of  luuco-pus  and  pus,  Ix'ing 


directions.      It   preseii 


vellow  or  green 


fluid  or  (Irving  into  crusts,  and  it  also  varies  in  amount 


the 


aine  wav  as  ( 


Iocs  the  obstruction. 


Mriijihii  of  the  nasal  mucosa  occurs  in  so  many  instances  that 
everv  case  of  atrojihic  rliinitis  should  Im'  reganlecl  as  ])o.s.sibly  Ik'j 


due  to  accessory  sinus  sup] 


iiiration.     Ciriiiiwalil  is  even  of  opinion 


that  it  has  not  lieen  established  that  oza'iia  rejiresents  a  pathological 
entitv.  and.  although  many  are  not  prejiared  to  accejit  this  view,  it  i 


ited  that  in  jiroportion  to  the  greater  fre<|uen 


iindouhteii  Iliai  in  |iro[)oriioji  lo  me  nuan-r  in-,ni,ii.  y  with  wliich 
.sinus  disease  is  now  recognized  in  our  clinics,  cases  of  true  fetid 
atrophic  rhinitis  have  become  proportionately  (liminished. 

H;ipvrtn>i>lnc  rhinilix  i.s  1ps.s  often  met  with,  but  is  found  in  early 
stagi's.     Sometimes  the  two  conditions  are  present  togethei 

fihituhs  cisrosii  is  so  frciuentlya  symptom  of  shii'^'i-.  chiefly  of 
the  antrum  of  llighinore,  iliat  Luc  is  of  opinion  tu..i  it  does  not 
exist  as  a  separate  |)atliological  entity.' 

Xasdl  jutliipi  are  so  suggestive  of  disease  in  the  accessory  cavities 
lliat  Criinwald  has  stated  hat  "polypi  in  a  majority  of  all  ca.ses  are 
almost  as  good  as  |)athogiioiiioiiic  of  einpyeniata  of  the  acces.sory 
cavities,  or  focal  suppuration  in  the  nasal  jiassages."- 

Disiinlrrs  iif  siiirll  and  UiMv  are  often  indicative  of  the  disease. 
There  may  be  parosmia  or  eoinpiete  aiiosniia.  More  fre(|uentty  the 
complaint  is  ni  an  intolerable  cltliough  intermittent  cacosmia,  always 
worse,  as  the  patient  puts  it,  "  \\hen  the  discharge  comes  away."  Thi- 
sinell  is  seldom  |M'rceptible  to  the  patient's  entourage,  and  this  helps 
to  distinguish  it  fn.m  the  smell  of  true  oza'iia  which  can  Im"  p'l- 
eeived  at  s<inie  distance,  lilthongh  undetected  by  the  patient  herself 

2.  is  Nasopiiakvnx  and  Pmai{V.\x.  Postnasal  catarrh  is  .sonn - 
times  the  only  symptom  a  jiatieiit  will  coin|)laiii  of. 

Tornwaldt's  disease,  or  bursitis  pliaryngea,  is  considered  by  Ziem 
to  be  merely  a  symptom  of  suppuration  in  the  accessory  chamber- 

nyiMilH'  e(  (It'R  CBvitu^s  s('rcsw>Irej*  'les  fn-^ - 


I  l.uc.    Ix'viins  Hir  le»  niipinimtioiisile"  I'lireilli.' 
tia.'iuli'S.     Paris.  I.lhrairii' .1   H.  H«illiin>ol  Ills.  lilOil.  |i.  ■-'-'T. 

-  (iriituv.i!;!.     NttyH!  stippnr**'"*"      Tf'in^lHltHl  l,y  I.iiiilb.     Londnli.  I'.KXI.  It.  M7. 

'  >;iein.    IVNt    ri'tnmasHl     Kiilarrli    imd     wnft'iiimnli'  Tcirii\v«MI«cli 
Menials..  l«!m.  N"  4 

/iem.     NcK'liiniiN  die  wiircnimnli'  Tiirinvnldt''«'lii 
No.  !■.. 


Krankhelt.     rhemin 
Kraiilihilt.    Wiener  klin.  W<icheniichrtfl ,  I- 


DISEASES  OF  THE  AVVESSOHY  SISLSES. 


939 


IaH.u,uation.   suppuration,   an.l   J^^^^  ^ ^ .S^^J'S' u^k 
„,,atiuo  tonsils,  tlj.  P»f=-y:-;4^; ,    f-.n    S^^u  t1u>^inusos. 
,„av  1..'  symptotnutic  of  tl.e  '';^^"; '''  th.MUsolvos    in    the  first 

,ZX\^%^ZCi.  ^""^^ '"  •"'  »^«  --"" 

,vtro-..cular   phlcfinion.  etc        ' '^,,  ;  ,/'.  "^.."^  (ti/,Un.inuti..n  of  the 
;;,";t  „,„«•  n-n-,.  l,,.  l.,..,  .....n;  'X'"S^^     .....■.'   ■»»'  -«- 

:i»^7^'' fit  lEEfe;^^^^^^^ 

.vinptomsofan  cmiiyoina.  Thk   Larynx.     Unox- 

H.  symptoms  m  More    f;»°**  J"!f 't/ i^^vn-ritis  and  hronchiti., 

;:;:::;;!;  ™";;;;;i;s,  :;r.«n:ii;^"'r»:;: ««... .. ...  ...ryn. 

i<  nii't  with.  »u..,„t;,.    ntt'ipks     ami    rocurrpnt  out- 

Cliroiiif    l)roiu-horrii(va,    asthmatic    attaoKs,    an.  f 

It. .,.  .,„,,,,..,..,.».■...,,,.„»  ■|;;'i-|;„'>"»;;i  ■■',*,  tmST .» 

puliiionarv  tulxToulosis  havo  m   Nariou. 

.vini.ton.atic  of  al .sorption  of  nasal  pv^^  stomach 

ul.stinatc  voiniliiiK  and  (harrhita. 

,  .,„.,.s„en.    ...e,.U„„„n...K.„..,S,nu.wU.ca«..   .ua.e.y  Me.c„U„ur„..  O.U..r. 

-T';r^r ";;:;'i;:::r  ..rt^v  ':^:.:u.  u.«..,  or .« «..  .o„n.. .  .^ 

AiiKTlcan  MwllCHl  AMOclatl.iii,  Sovcmber  11,  1ks». 


^■nr  I'^K^w; 


MJit  1 


^'j^'^^w^i':  ^^  ^'W^  ?s*."^» . 


940 


XOSE  AXh  THROAT. 


I 


\'ti!<i'ulfir  Sjislcni.  I'lilchitis  and  l)ra(lycanlia  liavt'  l)oon  foiiinl 
associated  with  the  affection  uniler  consideration. 

HI.  General  Affections,  .\nioiij;  the  conditions  which  have  in  some 
instances  JK'en  traced  to  a  sinus  enijivenia  are  tliose  of  jjeneral  ill 
iiealth,  loss  of  weight,  and  feverish  attacks  simulating  typhoid  or 
malaria,  with  or  without  septicemic  metastases.  Insonmia  or,  on 
the  other  liand,  marked  .somnolence  durinft  the  day  have  been  traced  to 
this  cause.  Various  cerebral  conditions  are  not  infre(|uently  traee- 
.'ihle  to  it,  sucii  as  irri'-d)ility,  loss  of  memory,  lanfjuor,  weariness, 
stupor,  aprosexia,  neurasthenia,  melancholia,  and  weakened  resist- 
ance to  the  action  of  alcohol  and  tobacco.'  .\t  the  meetinj;  of  the 
.\inerican  Larvn<;oloj;ical  .Vs.sociati()n  in  1S94,  Mosworth  relat<'d  tiie 
C!is(>  of  a  patient  who  was  restored  to  health  by  treatment  for  eth- 
moiditis  after  ten  years  of  suffering  from  ajjrosexia  and  m(>lancholia 
so  profound  that  he  had  meditated  suicide.  The  case  is  interestinjc 
from  the  long  li.st  of  medical  and  surj^ical  measures  which  had  pre- 
viously l)een  resorted  to  without  effect.^ 

Intracranial  Complications.  .Most  of  the  complications  wliicii 
may  follow  on  su|)purati()n  in  the  sinu.ses  have  already  Iwen  referred 
to  in  coiisideriufi  them  as  symi)toms  of  tjie  unreco}!;nized  condition. 
It  i.s  sufficient  here  to  direct  attention  to  the  most  serious  of  all  the 
possible  se(|ueUe  of  na.sal  su])puration,  viz.:  intracranial  complica- 
tions. These  may  arise  secondarily  to  suppuration  in  an_\  cavity, 
althoujjli  with  a  simple  case  <•'  't-axillary  sinusitis  it  is  a  comparatively 
rare  continjieiu'V.' 

Extension  to  the  base  of  the  skull  has  been  demonstrated  in  many 
instances,  and  |)().ssii)ly  takes  place  more  freipiently  than  is  sus])<'cteil. 
These  serious  complications  occur  in  both  acute  and  chronic  atTe<'- 
tions.  They  may  arise  (1)  by  infection  of  the  diploi';  (2^  by  in- 
fection throujih  the  venous  or  (.'J)  lymph  channels  of  the  bone,  with- 
out any  palpable  trace  of  the  route  of  infection:  (4)  by  caries  and 
destruction  of  the  sinus  wall,  so  as  to  allow  of  the  pus  coming  into 
ilirect  connnimication  with  the  meninges:  and  (.">)  by  mischief-spread- 
ing along  the  oplith;ilmic  vein  to  the  cavernous  sinus. 

When  the  bone  becomes  infected  it  may  give  rise  to  a  slow  and 
apparently  irresistible  septic  osteomyelitis  of  the  cranium.  If  tln' 
infection  traverses  the  l)one,  leaving  the  Latter  int.-ict,  the  result  ni:i\' 
l)e  a  cerebral  abscess,  or  thrombosis  of  the  superior  longitudinal, 
cavernous,  or  petrosal  simis.  When  the  duni  mater  is  exposcnl  the 
result  is  an  extradural  or  cerebral  ab.scess.  or  a  jiurulent  basal  >>y 
general  meningitis.  .\ny  combination  of  these  complications  ina\ 
be  met  with. 

I'ntil  the  acce.s.sory  sinuses  are  examined  .systematically  in  po.-'- 


'  Wnlter  A,  \\\'Vs.    Si)iue  Nervous  and  .MuiitHl  Manirit<tati>inH  0<-currln(f  iu  Connection  »i:li  N"-j' 
[*ip4?MMr.     AliKuIcMii  .ItMUlitil  ,ir  [Iio  McIiCul  ;-M  ieliotK,  Dvcmabvr,  1S9S. 

»  New  V'Tk  Me<tlral  JournHl,  October  M,  IsiC. 

I  K.  Dreyfus     Die  Krankheiten  dea  ilehirnii  iiml  3einer  .^dneia  im  Folge  von  .Nasenelliniun' 
<i.  Fixher.  Jena,  1H96. 


,UU41.f" 


DISEASES  OF  THE  ACCESSORY  SIX i'SES. 


941 


nu.rt.MiK  (111  all  fcrchral  (■:is<-s.  the  true  source  of  nmny  inf«'Ctioiis 
must  .■si-ii|)<'  (Ictcctiou.  Those  which  have  been  revealed  have  gen- 
n-illv  had  attention  directed  to  them  by  some  antecedent  nasal 
,,,'„.rition  It  is  not  fair  to  at  once  attribute  the  fatal  result  to 
Mir.'icai  int<Tference,  for  cases  have  been  recorded  m  which  some 
Mlhcr  coincident  latent  affection  has  been  the  true  cause.  Still  the 
tHtil  issue  in  some  cases  has  U-en  apparently  precipitated  by  surgical 
inatinent  which  has  interfered  with  drainajte  from  other  sinus(>s 
whose  diseased  condition  had  jM.ssibly  not  Ix'en  susiM'cted.  These 
(ciisi.lcrations  explain  the  importance  which  lias  already  bwi  laul 
mi  makiiijt  a  complete  diafjiiosis,  if  possible.  l)efore  initiating  any 
ndical  measures,  and  of  following  a  certain  seiiuence  in  treatuiR 
mVix.mI  cases.  It  is  liardiv  necessary,  in  addition,  to  emphasize  the 
uiipurtance  of  strict  asepsis  on  the  part  of  the  surgeon  so  as  to 
,v..id  the  imiiortatioii  of  anv  fresh  infective  material,  the  avoidance 
nf  n.i.sal  ')r  other  plugs  which  might  interfere  with  free  drainage,  and 
ilie  iiromjit   recognition  and  treatment  of  any  of  these   coniphca- 

Treatment.  It  is  onlv  possible  here  to  n'fer  to  the  importance  of 
■it  oiice  relieving  all  tension  in  any  suspected  case,  and,  where  neces- 
s.ry.  of  opening  the  cn-iial  cavity.  With  spreading  meningitis  little 
is  to  i)e  expected,  and  septic  osteomyelitis  apj)ears  to  be  a  jia  icu- 
laily  malignant  form,'  but  in  other  cases  it  may  still  be  possible  to 

'prognosis.  The  majority  of  primary  acute  cases  tend  to  complete 
res„luti()n,  although  the  progress  may  be  irregular  and  the  attack 
hist  for  a  few  davs  to,  with  relapses,  a  few  weeks. 

it  is  the  acute  attack  sujjervening  on  a  chronic  affection  which 
proves  most  intractable.  These  very  acute  cases  are  less  freciuently 
lui't  with  than  formerly.  Still,  if  unrelieved,  the  acute  suppuration 
nnv  lead  to  acute  distention  of  the  a.'fected  cavity,  which  may  ulti- 
un'telv  riiptun-.  Thus  an  acute  maxillary  sinus  abscess  may  burst 
thn.u'-'li  the  cheek  below  the  orbit,  the  canine  f<  sa,  an  empty  tooth 
socket,  or  even  through  the  hard  palate.     An  acute  collection  of  pus 


III 
til 


th( 


ital  sinus  may  point  anteriorly  beneath  the  inner  part  of 
"yelid:  or  it "niav  rujjture  into  the  cranial  cavity:  or  by 
,e  veins  of  the  diploi-  give  rise  to  spreading  septic  osteitis 
velitis.     The  roof  of  the  sjjhenoidal  sinus  is  not  likely  to 
'        .  recent  acute  attack.     Retention  of  an  acute  formation  of 
in  ethmoidal  cells  niav  also  burst  into  the  orbit  or  the  cranium, 
from  their  anatomical  connection  these  cavities  are  more  likely  to 
I'liiutv  into  the  nasal  fossa-. 

When  more  or  less  complete  obstruction  leads  to  threatening  symp- 
toms the  dominant  one  of  pain  generally  points  in  good  time  to  the 
iMcessity  of  intiTvention,  and  secures  its  acceptance  before  dangerous 
!!iii!p!jc:itioiis  arise. 

'  Luc,    J..urn»l  of  Ijurngolow.  September,  liiW.    Tilly.    Ibid. 


vu 
pus 

llllt 


1142 


A'OSK  AM)  rmtOAT. 


Ill  tlic  clirDiiic  fiiniis  tlicrc  is  littli-  tciuloncy  to  spontaiu'ou.s  rc- 
CDVcry.  Jonathan  Wriglit  lias  expressed  tlie  opinion  tiiat  many 
cases  must  tend  in  time  to  natural  recovery.  Tiiis  view  is  unsup- 
ported l)y  clinical  reconls,  and  most  observers  are  forced  to  the  con- 
clusion that  an  estal)lished  empyema  shows  no  disposition  to  dis- 
ap|)ear,  hut,  on  the  contrary,  tends  in  time  to  infect  other  accessory 
cavities.  Slow  and  insidious  changes  in  the  diseased  cavities  are 
often  only  revealetl  by  the  sudden  development  of  (jrave  intnicranial 
coin|)lications. 

Temporary  alleviation  is  very  common,  and  the  symptoms  in  some 
cases  will  almost  entirely  dis;i])])e;ir  durinj;  fine  weather  and  when 
the  patient  is  in  jjood  health.  Such  improvements  are  often  attrib\ited 
to  climate,  and  ;ire  apt  to  be  deceptive. 

The  dangers  to  health  vary  very  much  in  ditTerent  ca.ses;  in  .some 
a  lifelong;  "catarrh"'  causes  little  more  than  a  trifling  local  incon- 
venience. In  others  existence  is  rendered  almost  intolerable  by  a 
suppurating  focus. 

The  dangers  to  life  are  saiil  to  be  lare  wh(>n  we  remember  the 
small  proportion  of  fatal  cases  to  the  freciuency  of  the  disease.  The 
prognosis  will  depend  on  I'laiiv  general  considerations,  such  as  the 
patient's  age,  temperameii' ,  general  health,  and  occujiation,  as  well 
:i--  on  the  cavity  or  caviti(  s  atf'ected,  the  indications  of  secondary 
(iianges,  etc.  In  all  c.ises  a  guarded  prognosis  should  be  given  ;;s 
i.;;ards  .hiration  of  treatment  and  completene.ss  of  cure.  Final 
diagnosis  is  often  only  jMissibie  during  a  course  of  treatment,  as 
after  one  cavity  has  been  dealt  with  it  is  found  that  another  calls 
for  investigation.  In  many  cases,  while  decided  improvement  can 
be  promised,  the  necessity  for  continuous  treatment  should  not  be 
denied,  and  a  certain  amount  of  mucopurulent  discharge  may  have 
to  lie  tolerated. 

Chronic  Suppuration  of  the  Maxillary  Sinus.  Si/nditiims:  iMupyenia 
of  the  antrum  of  Higliiuore:  maxillary  sinusitis. 

Symptoms,  ''hronic  sujiiiuration  in  this  cavity  may  follow  on  an 
acute  attack,  or  may  develop  as  a  "latent"  affection.  When  any  of 
the  iiresumptive  symptoms  of  an  empyema  are  jiresent  th<'  discover' 
of  decayed  teeth  .  houlil  attract  attention  to  the  antrum.  Mveii  win;: 
the  teeth  api)ear  sound,  careful  examination  by  |)ercussion  ami 
transillumination  iiia>'  reveal  a  root  .ilTectioii.  ft  has  lately  been 
suggested  that  if  the  tuning-fork  is  applie(l  over  the  upper  teeth  ii 
will  -lot  be  heard  by  the  patient  as  distinctly  on  a  diseased  as  on  ,i 
healthy  side.' 

If  the  secretioti  of  |>iis  is  so  slight  that  it  only  occasionally  over 
flows  into  tiie  nasal  chamber  the  objective  syini)toms  are  projwir- 
tionately  slight,  ami  the  diagiiosis  the  more  difficult.       In  such  case- 
the  patient  may  coin|)lain  chii'fly,  or  only,  of  a  haunting    cacosniia. 
I''aeoachp  or  neuralgia  may  Im'   the  only  complaint.     The  j>ai!'  ■'■ 


1  D   A.  Kuyk.     l.:ir}llKi«ic)|ie.  IWU,  x..  N"   J.  l>   106. 


DISEASES  OF  THE  ACCESSOKV  SIM'SES. 


y4;i 


tciidcrncss  is  ftcncrallv  over  the  facial  siirfacf  of  tlic  sii|)<>rii)r  maxilla: 
l.iit  it  may  1m'  rcfem'tl  entirely  to  the  frontal  region.  It  fre(iiiently 
presents  a"  certain  periodicity,  increasing  for  son!"  hours  after  nsmg 
in  the  morning,  and  then  disappearing  as  the  day  g(H>s  on.  This  is 
explained  by  the  accumulation  of  the  night  escaping  from  the  cavity 
(luring  the  earlv  working  hours.  A  colleague  who  liad  lived  in  the 
tropics  had  diagnosed  his  own  ca.se  as  one  of  "hrow  ague,"  and 
was  unconvinced  of  tlie  correct  diagnosis  until  a  fearfully  foul  col- 
lection of  pus  was  exiM>lleil  from  iiis  maxillary  sinus. 

When  the  >,^ifl()w  of  pus  into  the  nose  is  more  decided  and  eon- 
liiiuous,  other  svmptoms  are  added  to  those  already  d(>.scribed. 
Sometimes  the  secretion  i)as.ses  so  rapidly  backward  that  it  may  be 
readily  overlooked,  or  mistaken  for  postnasal  catarrh,  or  an  affection 
of  the  po,sterior  group  of  sinuses.'  In  doubtful  cases  the  patient 
■ihould  always  be  examined  in  the  morning  hours,  as  after  midday 
the  s'luis  has  often  become  so  emptied  that  no  pus  overflows  into 
the  nose  during  the  rest  of  the  day. 

Fio.  4M. 


TransilluminiUng  lamp.    The  lower  fl(?ure  shows  the  removable  Rlai*  cap.    The  upper  figure  shows 
the  vulcnnlle  (u»p  as  U!*<1  with  ihe  fruiiial  sinus. 

lu^]wdion  of  the  nostril  on  the  affected  side  will  generally  reveal 
pus  in  the  mid.lle  meatu.s.  It  may  liave  accumulated  in  the  lower 
meatus,  or  bv  capillarv  attraction  may  have  travelled  up  between 
tiic  middle  turbinal  aiuf  the  .septum  into  the  olfactory  cleft.  It  is  seen 
ill  the  posterior  choana  lying  below  the  end  of  the  middle  turbinal. 
The  origin  of  the  pus  can  be  i)artially  determined  by  carefully  wiping 
away  every  trace  of  it  from  the  na.sal  cavity.  If  done  with  pledgets 
of  clitton,  moistened  with  a  lOjjercent.  soluti(m  of  cocaine,  the  in- 
spection is  more  complete.  The  detection  of  a  swelling  between  the 
concavitv  of  the  middle  turbinal  and  the  outer  na.sal  wall— so-called 

•cleavage  of  tiie  middle  turbinal,"  or  Kaufmann's  swelling— lias 
been  considered  as  in<licativ(>  of  an  empyema:  but  it  is  found  with 
pus  from  the  frontal  sinus,  and  has  i)(>en  seo..  when   no  (Miipyema 

\v;is  discovenible.     It  a})i.>ears  to  be  due  to  inflammatory  thickening 

I  Brady.    Journal  nf  Ijiryngoluiiy.     ovember.  ISW,  xlv.  p.  6M. 


i!i 


}t44 


yoUE  AM>  rilROAT. 


ovcrtlic  jiroccsnus  iiiirinaliin — the  lower  lip  of  the  iiiiitus  scniili.ii,  ris 
-  and  iiiifjlit  hr  iiiiliiccd  hy  any  irritation. 

After  waiting  a  few  minutes  the  nose  slioulil  again  Ih'  ,ii:  jvc'ed, 
and  if  pus  lias  reappeared  in  the  middle  meatus  it  would  :ai-e  »ne 
suspieion  that  its  origin  was  from  the  frontal  siiuis  or  aiiterio'-  eih- 
moidal  cells. 

I'osfiirc  Tcfl.  SupiMisinjt  the  pus  does  not  siKH'dily  make  its  re- 
appearance, the  patient  should  lay  the  head  well  'orward  iM-tween 
liis  knees,  with  the  atTecteil  side  uppermost.  This  test  (known  as 
Knienkel's)  brings  the  ostium  maxillare  into  the  most  dependent 
point  of  the  simis,  and  so  facilitates  tiie  outflow  of  any  liijuid  con- 
tents. When  the  hi-ad  is  niised  and  tlie  no.sc  again  ins])ecte(l,  a 
stream  of  pus  will  Ix'  found  in  tlie  middle  meatus.  Although,  in 
the  ;il)seiice  of  other  sym|>toms,  these  points  may  indicate  the  maxil- 
lary sinus  as  the  source  of  the  pus,  we  unist  proceed  with  our  ex- 
amination before  we  can  speak  positively.  I'olypi  and  granulations 
in  the  middle  meatus  are  often  st.ated  to  he  suggestive  of  antral 
disease:  hut  in  uncomplicated  ca.ses  they  are  rarely  met  with,  ami 
their  presence  generally  points  to  infection  of  the  neighboring  eth- 
moidal cells. 


KlG.  4S,'i. 


Fig.  4»6. 


Flu.  4S.'>  -TrHiisllliiniliiation  of  Iho  frontal  sinus.  Shows  how  the  niiius  on  the  right  side  i»  lit  "p. 
while  the  left  remains  ohncure.    (StCl\ir  Thomson.) 

Fiu.  4«(T.— TranBillunilnatlon  of  th'  maxillar)'  sinus.  Shows  on  the  right  side  how  the  cheek  ie  lit 
ii|i.  a  stmiliinar  t)and  of  llglil  apiit'ars  bilow  the  eye.  ami  the  pii|iil  is  ill\iminate<i.  On  the  left  slil.' 
these  results  are  absent.    (StClaik  Thomson,  i 


The  /c.v/  11/  tranyilluminnliiin.  chiefly  develoiMvi  by  Heryng,  will 
sometimes  afford  strong  confirmatory  eviclonce.  It  is  applied  in 
the  following  way:  It  retjuires  a  small  o-candle  electric  lO-volt 
globe,  of  about  1  amp("'re  current,  enciseil  in  a  glass  cover  which  can 
be  detached  and  disinfected.  (Figs.  4S.")  and  4S(>. )  'I'he  examination 
must  take  place  in  a  completely  darkened  ch.-uiiber,  or  else  the  head- 
of  both   patient  ami  |>hy.siciaii  .should  lie  envelojieil  in  a  thick  black 


DISEASES  OF  THE  ACCESSOHY  SIS  USES. 


1)45 


I'Idtli,  such  as  that  used  by  i)h()tORrai)h('rs.  Any  dpiitiirc  present 
liaviufi  been  removed,  tlie  lamp  is  intr<HUi(e<l  intc  the  eentre  of  tlie 
patient's  mouth,  an<l  the  current  switched  on.  In  normal  condi- 
tions tlie  rays  of  lij;lit  pass  upward  and  outward  unopposed  through 
tiie  iioliow  cavities  of  tlie  face,  produciiig  the  following  results: 

1.  A  ditTused  glow  of  light  over  the  lower  part  of  the  cheek  and 
iH'tween  the  separated  jaws. 

2.  A  semilunar  patch  of  light  immediately  below  the  lower  eyelid, 
caused  by  the  jjas.sage  of  the  light-rays  through  the  anterior  part  of 
the  orbital  wall  of  the  sinus. 

;{.  .\  subjective  seii.«ation  of  light  by  the  patient,  as  the  current 
is  switched  on,  sometimes  more  marked  when  the  eyes  are  kept 
dosed. 

4.  Illumination  of  the  pupil  by  the  rays  penetrating  the  sclerotic. 
so  that  the  centre  of  the  eye  is  lit  uj)  and  glows  like  an  animal's  in  the 
dark.  In  a  healthy  subject  all  of  these  may  be  present,  but  some 
are  of  more  freijuent  occurrence  and  of  greater  value  than  others. 
Thus  the  third  and  fourth  points  are  freciuently  wanting,  and  the 
second  is  the  most  valuable,  and  should  be  most  carefully  looked  for. 

When  jius  is  jiresent  in  the  antrum  of  Highmore  the  passage  of 
tl.(  rays  is  so  obstructed  that  all  these  phenomena  are  diminished 
or  abrogated.  Tliis  transillumination  test  renders  more  .service  if 
only  the  siims  on  one  side  is  suspected,  when  positive  results  are 
easily  contrasted  with  the  opposite  side,  and  would  lend  strong 
contirmatory  support.  On  the  otlier  hand  a  negative  result  would 
tend  to  indicate  that  the  pus  seen  in  the  middle  meatus  came,  not 
from  the  maxillary,  out  from  the  frontal  sinus.  Transilluinination 
may  give  positive  results  in  the  absence  of  an  empyema,  owing  to — 

1 .  Small  size  or  complete  absence  of  sinus. 

2.  Abnormal  thickness  of  bony  tissue. 

3.  Permanent  thickening  and  opacity  sometimes  remaining  in  the 
lining  of  the  cavity  after  complete  cure  of  suppuration. 

4.  Presence  of  a  malignant  or  other  neoi)lasm. 
Transillumination    may    give    negative    evidence,    although   the 

antral  cavity  is  diseased,  owing  to — 

1.  The  cavity  hapi)ening  to  be  more  or  less  empty  at  the  time  of 
examination. 

2.  The  bones  being  particularly  thin  and  translucent. 

The  test  must  not,  therefore,  be  too  much  relied  on.  If  positive, 
it  may  arouse  a  suspicion  or  confirm  other  symptoms.  If  negative, 
it  may  point  to  other  cavities  as  the  source  of  the  pus,  or  inayonly 
indicate  the  necessity  of  seeking  for  other  signs. 

Thi'  onlv  conclusive  evidence  of  a  maxillary  sinusitis  is  the  ex- 
pulsion of  pus  from  the  cavity.  This  is  done  by  exploring  the  cavity 
from  (1)  its  na.sal  wall;  (2)  the  alveolar  border;  or  (3)  from  the 
caiiihc  fi).s.sa. 

Kxploratary  Puncture  of  the  Antrum.  This  can  be  carried  out 
under  .adrenalin  and  cocaine.    A  good-sized  pledget  of  cotton  soaked 

60 


11 


I 


946 


XOSK  AXn  Til II OAT. 


wilh  a  10  |)or  cent,  solution  of  coraiiii'  is  tiiri<cil  well  uinlcr 
tli<>  inferior  tiirbinal,  so  as  ♦(>  aiuustlictizc  tin-  outer  wail  of  tlie 
inferior  meatus.  The  anterior  part  of  tlie  septum  sli..ii!il  also  he 
anu'sthetizcd.  as  the  hilt  of  the  nee<lle  may  press  jiainfully  against 
it.  .V  stout  hollow  neeille.  eithe'-  sir.iicht  (Liehtwitz)  or  curved  at 
the  extremity  (Sclurdt,  .Myles).  is  ftuideil  hijfh  ui  umler  the  con- 
cavity of  the  inferior  turbinal.     It  is  then  pressed  apiinst  the  antral 


Fill.  4K7 


■«#= 


k*»»*i.tktH 


Hollow  needle  for  explonttor)'  puiictun;  of  the  ra«xill»ry  ptliius. 

wall  at  a  point  which  is  judged  to  be  about  the  junction  of  the  middle 
and  posterior  thirds  a  point  much  further  back  than  is  penerally 
sup|M)sed.  The  patient's  head  being  steadied  with  the  left  hand, 
the  needle  is  pushed  gently  in  a  line  directed  toward  the  outer  angle 
of  the  orbit.  The  shaft  of  the  needle  is  gnusp'd  about  half  an  inch 
outside  the  nares,  in  order  to  prevent  it  plunging  too  far  into  tht; 

Fig.  4»s. 


MyleK'  trocar  ami  canula. 

sinus,  and  so  traversing  the  cavity  and  p(>rietrating  the  orbit.  The 
point  of  the  needle  being  felt  free  in  tli.^  sinus,  a  llustachian  catheter 
bag  is  now  attached  and  air  pumpc  ilirough  the  cavity.  If  the 
na.sal  cavity  is  kept  under  observatii  i.  jnis  and  air  bubbles  will  be 
seen  making  their  exit  from  the  Pinion  of  the  ostium  maxillare, 
while  frequently  the  foul  odor  of  the  .secretion  will  be   only  too  per- 


FlQ.  4»9. 


r^J;^^Jfc=a=^ 


-^ 


Curved  hollow  needle  for  explomtory  puncture  of  the  maxillary'  sinus. 

ceptil>le.  This  is  followed  by  syriiiging  a  tepid  solution  of  sterile 
normal  saline  fluid  or  of  boric  lotion  through  the  hollow  needle. 
This  should  be  |)ropell<'d  with  some  force,  as  the  secretion  maybe 
very  inspissated,  the  cavity  very  tortuous,  or  the  natural  opening 
obstructcil. 

The  pus  ex|K'lled  is  goierally  fetid   and  freiiuently  Hocculent.      \ 
small  amount,  or  even  a  decided  turbidity,  of  the  lotion  is  sufficient 


inshAsES  OF  Tilt:  AccKssoRY  sisrsjis. 


1)47 


,„  «.ttl.-  tl.r  aiapiosis  (.f  oininvnm.  Who.,  tho  l..t.on  c.m.'s  away 
,.|,.ir  thr  Kuslachiu..  l.:i>;shou!.l  iMjai.i  !«■  coi.iM-cto.l  w.th  tlu-  oxplor- 
,„.'  ...■.•,11c.  !i...l  air  fr.'.-lv  i..s..lIl:.t.Ml  t..  .'XIH'I  any  ro...a.i..i.K  luiu.'l. 

'"«;ho.il,l  thcs<>  ..ru.-.-(vii..(rs  fail  t..  nvcal  a  (M.ll.'ction  of  pus  a  small 
,,„'.,„titv  ..f  a  20  ixT  .•.M.I.  >ohiti..n  ..f  10  v..l.  hydrogen  iM'r..xulc  is 
,,„V,..l.ir.Ml  ...to  tho  simis.  wl..'..  tl..-  ..iTerv.'scM.c.'  with  a..y  pus  will 

|,iil>l)l.>  out  into  th(>  meatus.  ,    ,    ,       „        ^v,  ,„,i 

Hrnloration  oj  the  Antrum  from  n  Tooth  Socket.  If.  on  the  susix-cte.l 
.„|,.'  wo  fi...l  a  carious  bicu.spi.l  or  Hrst  m..lar,  or  if  tho  tooth  sockets 
.,,,.  "..niptv  w.>  can  not  oiilv  explore  the  cavity  from  the  alveolar 
|„,nler  hut  at  the  sa...o  time  initiate  the  troatn.ont  by  .Irainage. 
If  nocossarv  the  cario.is  tooth  can  In- remove. I  im.lor  tho  san.e  ana-s- 
thcV.-i  .,r.-ferahlv  that  of  nitrous  oxi.le  gas.  A  large-size,  han.l- 
.Irill  is  employed".     ( Fig.  490.)     Some  prefer  to  employ  a  .iontal  engine 

PIO.  49a 


AckUnd^B  h»nd-drtll  for  opening  the  n»xiUar>-  »lnu.  from  a  tooth  socket 


ora..ol.^ctromot<.r;  but  th.-y  are  "»f  f^«\2^  '^^V  £  Z  t  of 
„..l  1..SS  certain  tlian  an  instrument  guuled  by  the  han.l.    The  pou.t  o 
th..  drill  is  .lirocte.1  vertically  to  tho  alveolus  and  in  a  plan.'  with 
,1...  .•.-ntn-  of  th.>  patients  eye.     Firm  pn'ssuro,  with  a  f.>w  rotator> 

,v.    .-nts,  is  sufficient  to  quickly  p-rforate  the  fl..or  ..f  the  antrum^ 
'n...  drill  is  prevented  from  plunging  in  too  far  by  the  operators 
tlnin.b  tixe.1  about  half  an  inch  from  the  margin. 

[  pr,.liminary  ins,x>ction  v  !1  h.-lp  to  a...ure  the  success  of  t  ns 

„n...a  i..n.     Thus,  if  the  facia     urface  ..f  tho  superior  maxilla  is  ^er^ 

!   ."  the  hanl  palate  arch    1.  an.l  the  nasa  chamln-r  o..  the  sam.> 

.  wi.l.-r  than  usual,  greater  care  must  be  taken  in  scnng  that    le 

,  ,  11  d...-s  ..ot  .niss  tho  antrum  In-  passmg  (.)  outwanl  Ix.neatl. 

'k    (h)  inwanl  thro.igh  tho  Ho..r  of  the  nose,  or  even    <■)  int.,  th. 
,;;!.;  of  tl... .....uth.     it  i.  rare  for  this  simple  o,K-rat.on  to  be  attende.l 

with  a  serious  hemorrhage.' 

Fin.  491. 


Mailllary  sinus  drainage-tubes. 


.\s  th.>  .Irill  is  withdrawn  tho  escape  of  pus  will  often  confirm  the 
diagnosis.  When  th.-  patient  has  roovercl  fro.n  the  anirsthos.a  the 
iotio..  a.i.l  air  should  b.-  so...  through  the  cavity,  a.  already  .lescnbed. 

1  -ichcppcgrell     .lournal  of  ..Hrynsology,  im.  ii..  No.  9.  p.  m. 


(! 


It4« 


SO-St:  AM)  riHtn.lT. 


opciiinj; 


and  a  i)oriiianfnt  ilniitiaKf-liihc  slimild  Im-  inscrtcil.     If   tlic  result 
til'  the  I'xploratiuii  is  negative,  iii>  harm  is  iliiric,  and  if  the 
is  left  aliini-  it  will  clos*'  up  in  twfiity-foiir  hours. 

Exiiloratiim  Ihritnijh  tiw  Citnlitr  Fossit.  Thi^  route  is  unsatisfactory, 
as  it  is  more  painful  and  not  well  suited  for  estahlishiiiK  treatment. 
!t  need  on'y  Im-  adopted  when  no  tooth  socket  is  available,  when 
attempts  to  explore  the  antrum  from  the  iio.se  have  failed,  and 
when  the  diagnosis  eaiinot  otherwise  he  fully  estahlished.  It  ran 
he  carried  out  under  nitrous  oxide  >jas.  as  local  ana'sthesia  is  not  suffi- 
cient. A  .-;ma!l  incision  is  made  down  to  the  hone  just  ahove  the 
prominence  of  the  canine  fang;  with  a  nispatory  the  muco-j)eriosteum 
is  turned  up  and  down,  and  a  drill  is  employed  as  for  the  alveolar  (>ik'h- 
in>t,  but  directe(|  vertically  to  the  surface  of  the  canine  fossa.  The 
exi)loration  of  the  contents  is  carrieil  out  lus  already  directed. 

Diagnosis.  Cases  have  been  refM)rte(l  of  maxillary  sinusitis  in 
children.'  This  is  surprising  when  we  bear  in  mind  the  rudimentary 
condition  of  the  cavity  in  early  life,  and  it  may  Ik-  suggested  that  the 
above  cjises  were  in.stances  of  acute  osteomyelitis  of  the  superior 
maxilla— an  atTection  describe<l  byseveral  authors'— or  of  tuberculosis. 

Obstructed  cases  have  more  than  once  l)een  mistaken  for  malig- 
nant disease  of  the  antrum:  and  on  the  other  hand,  the  association 
of  suppuration  with  such  growths  has  le<l  to  the  nature  of  the  case 
l)eing  overlooked.  The  age  of  the  patient,  exploratory  punctuit>, 
and  careful  examination  lx)th  of  the  canine  and  nasal  walls  will 
generally  prevent  any  error  in  diagnosis. 

Acute  suppuration  in  the. sinas  might  Ix"  mistaken  for  dental  perios- 
titis. The  latter  is  an  external  affection,  whose  progress  can  be 
watched.    The  teats  given  will  .show  the  freedom  of  the  antral  cavity.' 

Treatment.  In  all  cases  attention  to  the  teeth  should  precede  all 
other  treatment.  Treatment  of  a  maxillary  sinusitis  can  l)e  carried 
out  (1)  through  the  natural  orifice,  or  (2)  through  the  nasal,  (.3) 
the  alveolar,  or  (4)  the  facial  surfaces  of  the  cavity. 

1.  ThroMjh  the  .Watural  Orifice.  Daily  irrigation  of  the  cavity 
by  this  route  has  been  recommended  by  a  few  rhinologists.*  Garel 
hiis  succeeded  in  irrigating  twenty-eight  out  of  forty-four  antra 
through  the  natural  orifice.'  (Fig.  492.)  It  is  not  usually  ea.syto 
catheterize  th(>  ostium  maxillare,  and  the  manipulation  is  generally 
facilitated  by  removing  part  of  the  middle  turbinal. 

2.  Cases  have  been  recorded  in  which  a  single  exjiloration  from 
the  inferior  meatus  has  been  followed  by  apparently  jx'rmaneiit 
ces.sation   of  suppuration.     It   is,  therefore,   wise   to  always  defer 


1  BAny  Power.  British  .M<,1i<«l  Journal,  September  ij,  1S97.  Alex.  DouglM.  Ibid.,  February 
.'>.  189K.    Emll  Mayer.    TranMPtions  of  the  Arnprioan  LaryiigoloRlcal  A-Bociatlon,  19UI. 

•  Schmlegelow.  Archly  f.  l*ryii(colo(fle,  1S96.  Rand  v.  p.  IJi.  Ropke.  MUnchener  med.  Wochen- 
schrin,  .lanuarj-  i'l,  1S9S.  Llohtwltz  SoclitA  de  Ijiryngol.  de  Parta,  1897.  A.  Caatex  Bulletin  d<' 
l*ryiig.,  !30I,  IV.  p.  171. 

•  G.  Avelllii.    Revue  hebd.  de  Laryng.,  1899,  So.  2,  p.  48. 

<  Oaiel.    Journal  ol  LaryngolnRV,  August,  1894,  vili.  p.  .MO. 
»  Nerval  B.  Pierce.    Laryngoscope,  September.  1901,  xl.  p.  197. 


DISEASES  OF  THE  ACCESSOKr  SISUSES. 


y4S) 


turllicr  trciitiu.-i.t  after  an  .'xploratDry  lavage,  until  |)Uh  is  a^ani 
.viilfiil  in  the  nasal  chanilxT.  Tlu>  siicc-ss  of  a  su.kI."  tn-atnu-nt 
K  iHThaps  du.'  to  tlu'  fact  that  the  cas.-  was  rrally  a  r.'<vnt  one  und.-r- 
.rciii^r  spontaneous  cure.  Such  fsises  in  fld.-rly  (x-oplr  should  Ix- 
viewed  with  suspicion,  as  thoy  are  sotnetitnes  found  to  Ik-  owuik  to 
Mippuration  in  connection  with  a  nialiKnant  growth. 

V  Throuqh  the  Snxul  Wall.  It  has  Ix'en  prop<)s«'d  by  Mikuin-a 
,„(!  Krauso  to  niak.'  a  larger  oiMMiing,  w.-ll  forward  (Waiter  Iree- 
„n,0  '  un.ler  cover  of  th.'  inf.Tior  turhinal  with  a  large  tr-ar  and 
.••inula  (Fig    492).  so  that  syringing  an.l  other  treatment  can  l>e 


d)== 


Method  of  calhilerlzlng  the  maxillary  !<imis. 


riie   method    inav 


I... 


carried  out  fmin  the  inferior  meatus 
|,l(.vcd  ill  patients  who  hav<'  an  intact  set  of  ui)|)er  teetliou  the  side 
Mtf.rted  and  wlio  decline  more  aniuous  treatment.  It  is  jideqiiate 
l,.r  Miiii>le  rec(Mit  cases,  i.iit  does  not  allow  of  the  removal  of  patho- 
lo.'ical  products  in  the  lining  inenihrane.  The  opf-ning  also  tends 
lo'close  and  is  sometimes  dillicult  totind  hi.ld<'n  und<'r  the  turhmal. 
Access  to  it,  however,  is  faci'=;  'e.l  l>y  removal  of  the  anterior  end 
(lithe  latter.  ,      . 

\  TImmih  the  Alrcolor  liordi-r.  The  method  ot  gaining  access 
t..  the  maxillarv  sinus  from  the  alveolar  border  dates  fmm  the  time 
of  Cowper,  in  1707.  The  .-laiiner  of  drilling  the  oiieiiing  has  already 
1,,,,,,,  .i,.,,,.ri!«.d  It  is  irenerallv  recommended  to  introduce  a  dram- 
age-tulje  HtU'd  with  a  siud  which  can  he  inserted  cluring  meals.     The 

1  Jrairiiftl  of  lUe  Aiufri.-an  Me,llcal  Association.  November  M.  1"S5. 


•j.y) 


\J.SK  .l.\7»   rilliOAT 


Flu    W. 


.iiiiniiiit  (if  (Iriiii.ie'-  tlin  UL'ii  -ucli  an  npfiiini;  is  -in  -ilijflif  that  it  i- 
1>.  tier  to  (IciM'inI  (ily  .n  -ynii);iiij;.  ainl  In  irisiin- as  far  as  [iKssiltlc 
the  soparatinii  ■  ciiiil  tiinatioii  fmiii  the  tinmth  by  intrd.luciiijj  a 
solid  stciii  ol)t  iialor.  i  ;,is  laii  1h'  fitted  on  a  denture.  In  liiK4|>ital 
practice  [Mirfinns  of  i;ilis'  sjiinil  wire  are  cut  in  suitaiile  lengths. 

I'lie  iihturaiiir  ordraiii  is  reii'o,-ed  and  the  cavity  washed  out  with 
a  I Ii>r(;inson  syringe.  A  pint  of  epjd  sterile  fluid  Imuld  hceniployed 
«'a'h  line,  ni  I  the  medicament  used  with  !t  ijix's 
iifi  I  I  .  ar  n  most  cases  to  Im-  of  jrreat  im|x)r- 
ta'if  Siir  lal  saline  solution  is  generally  -'tis- 
facli'i  .  aiiii  'II  cases  of  fetor  we  may  add  jier- 
II  :iii.;Mati  oi  lotasli.  listi-rine,  sanilas,  piiennsalvi, 
eui'uaii'l,  or  in*'  of  the  nnirriti'Mnj;  compoMnd 
!iiit  •' plies.  At  (  rst  the  wasliing-out  sjiouh'  .ke 
pl;.i'(  ;.  ,  I  :ii!(!  e-.  linjr.  the  obturator  l-euij; 
th)-' anhl_\  '  insed  .nd  replaced  im:iiedi  lely 
afl>  I  >  ard.  K  th^s  is  n.-irlected.  ;rranulations  laay 
sprin-r  up  win  .n  ..•:  hour  or  -n  !m|H'ilin)i  the  re- 

plareiiienl  \\  lu'.    the     :ii|Uid    escapes  froi:;    the 

nose  in  a  clear  stream  the  washings  are  diminished 
to  •■nee  a  day,  then  )■■  every  other  daN  iid  so  i;radiiaily  to  on,  <>  a 
week      When  thecaxily  on  several  oc(     inns  is  I  lund  to  '■ofrce  !roin 


Ellis'  «)n>  tnh<>'<  for 
ilraiiittiK  tlie  uiuxillitry 
jiiiilH  fnun  tbc  ahwtliir 


Meth'i'l  "f  wa«liinKi 


tltt'  liiux:!!arv 


Ills  {Torn  tht'  ■ilvi.-.jlar  Imnier, 


secretion    aftii    remainiii<,'  n-cleaiised   for  a  week    we   niav  considr! 
the  I'ase  cureil  and  allow  th-  alveoi  ir  .  (K'ninjr  to  cl-^'— which  it  doe- 

StlOntanCOU'^lv  "V.   disc^.'!!ti!!':il!;»  th'-   dr:tin  <:!•  :>}>t!:T-t,-'r 

If  the  secreti<in    persists  we  may  iry  the  use  oi    'ntnger  antisef)ti(- 
or  astrinj^ents   diiniodi  !!•  of    morcurv.  chinosol         -tarjiol,  sulphaii 

IK        res. 


of  zinc.  etc.    -before  re^ortiiiL'  to  m:>rc  radical  i 


i,isi:Ast:s  "F  Tin:  .uvEssnRi   ■lyunEii. 


9.>I 


Ursul:  .  Mv  "wn  .'x,Hri.Mu-r  is  that,  ..  lui-.  cum  wh.cl"  ;.n. 
..,.inir  t.^  V..-M  to  till  iM-th.«l  -tiuv*  .iki..  >i  .l.-mj.  s..  ..url.Vyu  mi. 
;  i..w  w.,.k  whil.'  tnu-..  whi.ii  .-I...W  1"  >en..l.nrat...M  w.thi.i  n  ive 
:  ,.„.th-  an       tHTuilv  m^  -tmit...     A  Iti-fory  uf  |M„«-stan.l.nK  sn,>,m- 

,lu,,  tion  1   ivr  iH^-n  ,«-n  uinentl>    '...al'v!  with  thn-  month.         n.R- 

'"whon  ih.T.'  is  n.  -uunWr  ...^.  aai  tooth  or  .•nn-ty  s<K-kH  i  th<> 
,  ,uT  jaw  o|-  111.-  an. .  i.,l  mu,  it  i.  n-t  juHnllahl.'  t.  Haonii.-.-  a  souiul 
„'„  th  t-  it.iiiat..  u  i.K.h.Kl  of  tr  atn..-nt  which  is  .  .<-ertain  ...  its  n- 
M.ils  Hon..  i..  all  .  .-.  of  ..,  .xill  rv  si.n.H.t.s  -  a  scni.,.  sot  .f 
li-cMi  .'I'l  ill  thos«>  whi.ti  luivc  TO'  1  MitrMcta 
treat.',  "lit  aln-.   Iv    lo^'         i.  tn  '.V  um 

!!!;  il      .  (iiiiii    '"ssa  KTfo'  '!mg  V  nal 

the  (a  .Iwi  !    I    »•  o|-ra      ii. 
-,    Tin- ("III,,'   h'o.'<sa  ():   -niim.        Uh--'ie»i 


;   lo  th    nu'i    <m1>     ' 

irricd  out  liy  ojh  u- 

uciitly  ix'fprretl  to 


ill  1! /-.not 

sii|i  rallli 


...  N,., 
..i.i  <l. 
ati'  111 


rcc   >! 
lion 
lo  ll 
the 
<lfah 
Iniu 


llO! 


"  cavil} 
lueiplfs 


!ih 


puoil. 

•ii:i\!ii.ir> 

■V  cai. 
'•■  !h. 

froi:     tic 
wi 
aci's  tills  . 
MiT  nicthi 


York/  i     It^'i 
rilx-d  u.   l.'^OT 
t(.  ihc  suhj  " 

■..(,■ 
lie 


Th. 

r'liii 
■an'fii 

III! 


anil 


,1^'inally  designed  by 

M  wa.**  imlo|K»n(lpntly 

nivcii  con- 

xNlicd  in  a 

the  cxpcu- 

-iich  access 

fossa  that 

thoroughly 


as  sM 
■<'i.i<.' 
olv 
ir  curi.i}. 

il    the    C!l. 

ts  conten 
.i   princiiMi'  is  the  cstablishiiicnt  of  free 
iito  the  nose,  on  a  level  with  the  flc-r  of 
■  seen  that  the  realizatio.i  of  these  two 
rat  ..'11  at  a  great  advantage  in  coi.i|)anso" 
of  treatment.     In  thos».  which  have 
•rp  is  either  inadoiiiiate    >r  takes  placf 
"■tioii  readily  takes  place!,  while  the  i 
il<     -;  to  the  exact   pathological  conditi. 
;„|  I       ffon-  in  ignorance  ;us  to  what  prosiw^ 
thods      i  reatment  may  s^x-ure. 
.igj!  the    ■ai.iiie  fos.sa  r<-.|iiires  a  general  ana^s- 
should  h.ve  tlie  usual  preparations  made,  and 
ve  the  teeth  put  into  good  order  and  the  mouth 
...p,       IS  jMissihle.     The  nsv-sal  chaml«^r  of  the  same  side 
louslv  IK>  cleared  of  any  polypi  which  ..!,ay  be  present, 
ent  having  Ikm^i  a..a'sth.>tize.l  the  hp  and  cheek  of  tne 
.  :.|  side    are  n    .-acted  -.  as  to  show  the  ,  .>;rne  fossa.    A  mouth- 
„i.  ij,t.        ....l     .-tween  the  molars  on  t.v.    side  affected  will  be 


iread\        -crilK'l 
•!,,    nio;         wlienr 
■ia.     is  ciilirel;     '' 
,f  •  ,(•  disea.sed 
it>ui  ics,shisn 
The  o|MTati' 
•hetii       i"he  p:.nf 
IS  di'-      Me  t'l  1 
ier  as<'i>t 


He   i, 


u,m«..!ihcCllnic«ls.K.ic.ty.    l^.ndon,  May  12,  !8«. 
„1  Novt.n.l*r4.  .s.«!.    The  making  of  a  .Ic.ble  ..penlt*  tbr'-'W' h"'" 
.alls  ol  the  anlnim  «««  designed  by  Seances  Spicer  in  1»M.    British 


■  -.tciiitr 'I  iu.u. 
N.-v  Yi)rli  Me. 
tit.   canine  and  tt.^ 
Mmiieal  Juiiiiitii.  U* .  cn:r:v-  r  •. 

I'liris.  l^KX). 


952 


A'O.VA'  ASD  THROAT. 


•■  I 


found  us(>ful  in  al)si)rl)iiijt  blood,  which  niiftht  otherwise  trickle  back- 
ward into  the  throat.  .\n  incision  is  tiien  made  at  a  distance  of  a 
few  niilhnietres  i>el(.w  tiie  «inKivodabiaI  furrow,  and  extending  from 
the  level  of  the  first  molar  tooth  forward  to  the  canine  prominence. 
(Fig.  495.)     This  incision  passes  at  once  straight  down  to  the  bone. 

Flo.  496. 


Oreiiini!  the  frontal  and  maxillary  sinuses,    shows  the  point  on  the  sltull  for  exposing  the  tVonUl 
sinus;  tlie.lolle.louilim- indicate  the  directions  in  wiloh  the  opening  may  have  to b-- extende.1 


,,  .,,  openinii  may  have  to  b"- extended 

over  the  ma.illarj-  sinus  the  dark  line  marks  the  situation  and  extent. ,f  the  in<i«ion  through  the 
Kingivu- labial  fold. 

which  is  rapidly  disjilayed  by  reflecting  tiie  muco-iH>riosteum  with 
a  raspatory  or  |.eriosteiim  detacher.  With  the  cliisel  an.l  mallet 
the  canme  fos.sa  is  broken  down,  and  the  entry  into  the  sinus  is  often 
.signihed  by  the  escajx'  of  pus  and  sometimes  of  a  foul,  penetrating 
odor.  Ill  many  cises  profuse  bleeding  takes  place  a.s  the  cavity  is 
entered,  but  generally  ceases  as  the  o|)eniiig  is  enlarged,  so  th:it  a 
small  sponge  or  plug  of  g.-uize  can  Ik-  inserted.  The  sjK.ngc  placed 
iM'tween  the  p.-ttient's  back  teeth  often  nvpiires  n'liewal  at  this  time, 
anil  the  h(;d  slioulil  Ik-  well  tm-ned  to  one  side.  The  opening  intti 
the  sinus  .should  Ik"  enlarged  wiili  the  chisel.  l>one  forceps,  or  burr 
driven  by  the  hand  or  eleciromoi..r  h  is  important  to  rememlH>r 
the  exact  direction  in  which  this  (>iil.irgeiiicnt  should  take  [ilace.  It 
should  be  both  .lowiiward,  so  thai  the  (.pnijng  is  on  :i  level  with  the 
alveolar  floor  of  the  sin.is,  and  forward.. so  that  it  approaches  closely 
to  the  n.asal  wall  of  the  cavity.  This  situation  is  preferable,  as  the 
n|>.-n!!ig  i«  (n\  distant  fr.-in  .l.-mgernus  regifms;  ,7,i  giu-s  (he  iiesl 
view  of  the  cavity:  (r)  is  in  the  most  favomble  situation  for  drain- 
ace,  and  (d)  is  most  suitable  for  |«'rf(>rming  the  s<>cond  part  of  the 


tm 


DISEASES  OF  THE  ACCESSORY  SIS  USES. 


903 


oiHTatioii,  viz.:  tlic  cTcation  of  the  ()j)oninR  into  the  iiiisal  chamber. 
Tlie  caiiinc  oiM-niiiK  is  ciiiargwl  sufficioiitly  to  admit  tlif>  oiK-rator  s 
little  tiiipcr.  Till'  marRiiis  of  tlio  o|X'ning  in  tlic  t)t)nc  arc  kept  as 
^mootli  us  possihie,  any  spicules  which  may  have  iH-en  .Invon  m 
with  the  chis«-l  ar(>  carefully  removed,  and  the  reflected  nuico-iK-nos- 
teum  is  carefully  pres<>rve(l.  Care  should  be  taken  to  avoid  injury 
to  the  infra-orbital  branch  of  the  trigeminus  nerve.  ( )ther\vise  tn.u- 
i)l(>s()rne  neuritis  may  be  set  up.' 

riie  lileeding  from  the  lining  of  the  antrum  is  carefully  stanched 
with  lengths  of  sterilized  p  ie,  and  the  walls  are  then  carefully  in- 
-pected  with  a  frontal  electric  searchlight.  The  diseased  mucous 
membrane  is  now  dealt  with,  and  all  redumlant  or  polypoid  tissue 


lirUuwald!,  forceps. 

is  comi)letelv  removed.  This  can  Ix"  done  by  Crimwald's  forceps 
iKig.  4iW')),  which  will  only  embrace  any  hypertrophie<l  tissue  which 
priijects  above  the  surface,  or  by  sharp  s|M)()ns  or  some  form  of  ring 
knife,  preferably  such  as  that  of  Myles.    (Fig.  497.)     It  is  often  adviseil 

Fia.  497. 


MjlM'  riiiB  knife,  used  for  cureltlng  the  sinuses. 

lo  curette  the  walls  vigorously  and  fn-ely,  but  it  is  difficult  to  imagine 
liow  a  good  ri'sult  can  be  exiM>cted  from  entirely  denu<ling  the  sinus 
of  its  mucous  lining  and  then  rubbing  a  strong  corrosive  on  to  the 
bare  walls.  On  the  contrary,  care  should  Ik-  taken  to  remove  only 
Mich  tissue  ;is  is  diseased.  In  some  cases  the  antrum  will  be  found 
ajnio.st  completely  filled  with  jKilypoid  masses  of  hypertrophy.  (Fig. 
\\)S.)  In  other  cases  the  mucosa  may  1m'  found  to  be  thickened  only 
ill   parts.     The   rejjions   which  slmuld 


l>e  most   carefullv  <'\aniii!e<l 


1  I)e  Ri)«l<le».    TreniiacUonii  of  the  American  Urynitoloflcal  Amoctatlon,  ISM 


*  i 


y54 


yont:  A.\D  TiiRo.ir. 


are  (a)  the  (loo|x»st  part  of  tlic  internal  or  nasal  wall — /'.  c,  near  the 
natural  opening  and  in  the  ncijihborhood  of  tlir  cthnioid  bone;  (b)  the 
irrcffularities  on  the  floor  of  the  sinus,  especially  between  any  |)ro- 
jeetions  of  the  dental  nH)ts,  and  (r)  the  outer  part  of  the  anterior  or 
facial  wall  and  the  tnalar  fossa. 


Fig.  498. 


Life.«izo  drawing  nf  polypoid  hypertrophies  removed  from  a  maxillary  sinus.    (StClaib  Thomson,  i 

Caries  of  the  walls  is  much  less  fretiuently  met  with  than  some 
l)atholof;ical  investifjations  would  lead  one  to  expect.  Once  the  toilet 
of  the  cavity  lias  been  conipl"ted  we  proceed  to  the  second  stej)  of 
theo|H'ration.' 

Cmiliiiii  of  a  Xtixal  OfHuimj.  During  this  part  of  the  ojx'ration 
blood  is  very  apt  to  find  its  way  into  the  })ostnasal  s|)ace,  and  it  is 
a  useful  precaution  to  insert  into  the  cuvuin  i)haryn<teum  a  small 
s|)onp;e  attached  to  a  tajx'.  The  na.sal  cavity  on  the  affected  side  is 
first  well  ijluininated.  and  the  anterior  third  of  the  inferior  turbinai 
is  amputated  in  the  following  w;p  :  With  a  stout  pair  of  Panzer 
scissors  (curved  at  an  angle  and  als<i  on  the  flat)  the  attachment  of 
the  anterior  third  to  the  outer  na.sal  wall  is  cut  through,  and  this 
portion  is  then  removed  with  a  cold  wire  snare.  This  proceedini; 
may,  with  advantage,  be  carried  out  undiT  cocaine  some  time  liefore 
the  major  oiK-ration.  It  gives  us  fre(>  access  to  the  partition  between 
tile  !io:  ,'md  antrmn  which  we  wish  to  break  down.  This  is  done 
with  the  chisel  and  hammer  through  the  canine  ojK'ning,  working 
i'lose  to  ilie  floor  of  the  sinus  and  as  anterio:  i-;  possible  under  cover 
of  the  severed  attachment  of  the  inferior  twrbinal.  .As  soon  as  the 
chisel  has  p  iietrated  the  wall  a  Krause  canula  with  pro'he-pointeil 
trocar  should  be  introduced,  to  define  and  increa.se  the  oj)ening.  b 
can  then  Ih-  enlarged  with  tl;e  cliisel  and  hammer,  or  suitable  burrs, 
until  at  least  the  anterior  third  of  the  outer  wall  of  the  inferior  meatu- 
has  been  resected.  There  is  little  fear  of  resecting  this  wall  too  freely, 
as  it  always  shows  a  remarkable  tendency  to  contract  afterward,  ami 
many  ca.s<>s  of  failure  are  due  to  the  inadecpiacy  of  the  njusal  ojx'nintr. 
While  tliis  upfiiiiig  ir^  being  (iiade  i-,ire  slumlii  be  taken,  either  b;. 

'  The  ortKiiml  canine  ojieni'ion  icnown  tis  DewiIt'H  or  Kuster's  terrnlnated  here,  and  subaeque'  ■ 
treatment  w«.s  carried  out  through  ihis  opening. 


l)ISEASt:S  OF  THE  ACCESSUJiY  SIM'SES. 


955 


u\u!iii\utl  the  iiMsc  on  that  ^i.lc  with  fiimz>'  or  by  introducing  the  litti.' 
tlnwT  into  it,  that   the  septum  is  not  injured.  ,,      ,      i-i 

The  n.iixiiiarv  cavitv  is  now  onee  more  .Ine.l  of  any  blood  which 
„nv  have  accmnulated.  It  is  fnH,uently  advised  to  pamt  the  wails 
with  -i  U)  or  20  IKT  cent,  solution  ..f  chloride  of  zmc:  the  cavity  is 
well  powdered  with  io.loform,  and  is  then  firmly  packe.l  with  one 
l„„tr  'trip  of  drv  i.Kloform  ribbon  gauze,  which  shou.d  l)e  about  one 
ui.l  a  half  inches  wide  and  with  selvage  on  both  sides.  The  end  of 
the  ttiuze  ribbon  should  be  led  through  the  na.sal  oix-ning  until  it 
.„)|M"irs  at  the  nostril.  The  inuco-[K'ri()steum  reflected  from  the 
;..,,' ine  opening  is  carefully  lifted  buck  into  position,  and  any  sponges 
in  the  postnasal  space  or  angle  of  the  jaw  are  removed. 

Fio.  4W. 


Panzer's  ticiMon. 

It  is  recommended  bv  Luc  and  others  to  carefully  suture  the  buccal 
xvuund  with  cat-It.  This  ste))  is  not  only  te.lious  and  (juite  un- 
necessary, but  the  insertion  of  stitches  apix'urs  rather  to  retard  rapu 
union  Tiir  sides  of  the  wound  fall  into  coini)lete  apposition,  and 
if  a  pad  of  cotton-wool  is  placed  externally,  .and  mastication  on  that 
<ide  avoided  for  a  few  days,  union  is  both  rapid  and  complete. 

»/,.  -f^ratmrnt.  There  is  seldom  any  marked  general  reaction 
•liter  ti  .  .  operation,  and  the  physician  need  not  be  alarmed  if  the 
.•lieek  on  the  same  side  iM-comes  so  swollen  as  to  partly  occlude  the 
eve  Tlu<  feeling  of  distention  is  relieved  by  a  firm  compress  ot  cotton- 
wool, or  by  hot  fomentations.  For  a  few  days  the  diet  sh.mld  be 
fluid  and  should  be  swallowed  through  the  opposite  side  of  the  mouth. 
The  mouth  slmuld  »)e  rins,-.!  out   fre.piently  with  some  cleansing 

alkaline  lotion.  .  ^,    ,  -p, 

Th(>  ribl)on  gauze  is  removed  on  the  Hfth  (Luc)  to  tenth  day.  Ihe 
extraction  is  easy  if  the  resection  of  the  anterior  end  of  the  inferior 
.urbinal  and  of  the  antrona.sal  well  has  lu-en  adequate.  Otherwise 
it  i.  apt  to  be  s:.  i)ainful  that  it  is  well  to  administer  some  nitrous 
oxide  ga-  The  gauze  is  g..n.>rally  fn>e  from  fetor,  and  m  its  removal 
it  ci....r  .  ■  .X  any  debris  left  from  the  operation.  The  large  opening 
into  th.  ^'M  )r  meatus  is  sutficient  for  natural  .Irainage,  but  it  isas 
well  to  .  !  (iie  antrum  out  through  it  for  a  few  weeks  imtil  after 
an  interva.  ,,f  a  f.-w  ,lavs  the  loti.m  used  return?  clear.  Th,.  cWns.mg 
is  easily  carried  out  with  a  short  length  but  full-bored  silver 
I'ustachian  cathcU-r,  and  some  sterile  salt  solution.    For  some  time  the 


1  i 


956 


XOUE  AM)  THROAT. 


iiuiciisof  t'i(-  iiusc  is  apt  to  (irv  into  crusts  along  thn  irrofiular  bonier 
of  the  ar*  ilcial  hiatus:  Init  this  ihsapjjoars  iis  tho  margins  heal  over, 
anil,  as  ulrca  i\  stated,  the  large  oix-ning  shows  a  remarkable  ten- 
ilenc.\  ;(>  n-i'l  i  ontraction.  The  cure  is  generally  coint)lete  in  from 
three  to  siv  wwks. 

Indications  for  Treatment.  Surgical  treatment  of  the  maxillary 
simis  is  not  a-ssociated  with  the  possibility  of  any  di.sfigurement  of  the 
face,  and  is  so  free  from  risks  that  our  ainbition  should  Ik>  to  obtain  a 
complete  and  lasting  cess'ition  of  the  discharge  in  all  uncomplicated 
cases.  Treatment  through  the  antronasal  wall  may  be  tried  in 
patients  who  have  intact  teeth  in  the  upp-r  jaw,  and  who  pn>fer  to 
essay  a  simpler  method  l«>fore  submitting  to  the  canine  operation. 
When  a  suitable  tooth  socket  is  available  the  method  of  washing 
out  through  the  alveolar  opening  may  be  given  a  trial  of  a  few 
months.  If  either  of  these  methods  do  no  more  than  reduce  the 
secretion  to  a  tolerable  inconvenience  many  p-itients  may  decline 
further  interference.  Whenever  the  teeth  are  inlact  and  when  the 
patient  is  anxious  to  have  a  radical  cure  effected,  the  canhie  operation 
should  be  carried  out. 

Chronic  Suppuration  in  the  Froatal  Sinus.  Symptoms  and  Diagnosis. 
In  a  large  imniber  of  ca.ses  of  frontal  sinusitis  there  are  no  subjec- 
tive >ymptoms  which  point  particularly  to  that  cavity. 

Whi-n  the  oiitHow  of  pus  into  tne  no.se  is  obstructed  we  may  get 
local  symptoms  of  \)a\n,  tenderness,  lacrymation,  etc.,  .siniiljir  to  those 
met  with  in  acute  cases.  Mut  in  the  chronic,  "latent"  cases  it  is 
seldom  that  any  of  the  sui)jective  sytiiptoms  an'  at  all  trustworthy. 
Thus  pain  and  even  tenderness  over  the  suiM-rciliary  region  or  frontal 
headache  niav  'm"  ilue  entirely  to  pus  in  the  maxillarv  sinus,  while 
the  frontal  cavity  in  jinother  ca.se  may  l)e  full  of  pus  "without  there 
Ix'ing  either  frontal  headache,  pain,  or  neuralgia.  In  .some  .such 
ca.s(>s  the  headache  m;iy  even  be  referred  to  the  occipital  region. 

Still,  in  .all  suspected  ca.ses  it  is  well  to  note  the  presence  of  frontal 
pain  or  lie;idache,  and  to  t(>st  carefully  the  s(>nsitive!iess  of  the  region, 
i'ressure  should  be  ap[)lied  first  to  tile  apparently  healthv  cavity,  so 
that  the  (lifTerence  by  contra.st  will  be  recognized.  The  siipra-orbital 
nerve  must  be  avoideil. 

.Vnother  extern;d  method  of  ex.amination  is  the  test  of  Iransilltimi- 
nalion.  The  same  preparations  are  re<iuired  as  for  applying  the  test 
to  the  maxillary  sinus,  bu  the  electric  globe  instead  of  being  enca.se.l 
in  a  movable  gla.ss  hood  (Fig.  484)  is  fitted  with  an  oi)ai|Ue  vulcanite 
cap  which  directs  the  rays  in  one  longitudinal  axis.  This  is  pres-ecl 
firmly  against  the  lower  wall  of  the  simis,  under  the  inner  third  of 
the  eyebrow.  If  there  is  nothing  to  interfere  with  the  pa.ssiige  i.t 
the  light  rays  the  dear  frontal  sinus  will  be  lit  up  with  its  extensions 
upward  and  outward,  and  in  some  cises  the  sei.ituni  an<l  partial 
dissepiments  will  be  defined.  If  one  sinus  only  is  ob.structed  tliesr 
}X)ints  become  nion-  evident  by  eontnisf. 

It  is  imjHJSsible  to  compare  the  two  .sides  simultaneou.sly,  ii.s  we  d' 


UlfiEASEa  OF  THE  ACVESSOBY  SISCSES. 


957 


in  applviriK  111.'  t-st  to  th.-  maxillary  sinus.  Hciur,  Lulu-t-Harbcn 
MiJe.sts  that  the  rul)l..>r  c-ap  coi.tainiiiR  tho  lamp  should  \w  pn-ss.Ml 
m  ,inst  the  mi.l-linc  of  the  for(>h.-a<l,  two  or  three  cent i mot n-s  above 
tl„'  root  of  th.'  nose.  On  switchinR  on  the  current  a  comparison 
,,,,„  l„.  ,na.l.-  of  the  way  in  which  th.'  lipht  rays  traversi-  each  sinus 
to  iiiiht  up  the  antero-suiK-rior  allele  ot  the  orbit.' 

\  form  of  transillumination  lam|)  Juis  also  lK«en  .lesigne.l  by  which 
both  cavities  can  be  transilluminate.l  at  once  from  the:-  orbital  wall, 
so  that  the  results  can  be  compared.'  „„.,,•  i    i    „ 

Objections  to  the  TransiUumination  Test.  This  test  is  much  less, 
sitisfactorv  for  the  frontal  than  it  is  for  the  maxillarv"  sinus.  The 
,.,nat..micai  arrangements  an.l  relati..ns  of  the  cavity  lend  them- 
.clv<>s  less  rea.lilv  to  transilhimination  than  do  those  of  the  max- 
illarv  sinus.  Pus  mav  bo  present  in  the  sinus  and  yet  the  test 
mav  fail  l)ecausc  it  mav  be  slight  in  amount,  lymR  only  on  the  floor. 
an.l  the  bone  may  b.-  particularly  translucent.  Pus  may  bo^absent 
uu.l  vet  the  test  mav  fail  to  light  up  the  cavities  owing  to  the  great 
thi„u..ss  of  the  walls,  or  even  owing  to  their  entire  absence,  or  to  the 
presence  of  a  solid  new-growth,  such  as  an  osteoma 

It  can  only  be  regarded  ivs  a  subsidiary  aid  and  as  confirmatory 
of  other  tests,  to  be  shortly  descrilied. 

Pio.  900. 


FronUl  ainus  canula. 

Nasal  Examination.     The  discovery  of  pus  in  the  mi.ldle  meatus  of 

tlH^e  should  prt^are  the  observer  for  finding  that  its  source  is  the 

ntnl  or  m..ixillar;  sinus,  or  both.     If  the  pus  ts  seen  high  up  an- 

.        ■     f  it  is  acVompanied  by  polypi,  if  it  recurs  rapidly  when 

i  H.    awav,  if  it  flows  more  freely  when  the  middle  turbmal  is  pres.sed 

;   d  the  Septum,  and  if  then-  is  no  marked  cacosm.a.  the  evidence 

points  to  the  probability  of  the  upper  cavity  tang  its  «ource^  Grun- 

w.ld  has  s-.ggested  that  by  cleaning  the  mid.l le  meatus,  and  then 

•  n  ullv  packing  the  region  of  the  hiatus  semilunaris  and  waiting 

r:.w  miimt,  we  can  I  whether  the  pus  -^--^.^^-.-^^fX 

tlu-  plug     The  method  has  not  met  with  general  auoption   and  th. 

evidence  obtained  is  still  pn.blematical.     More  certam  evidence  can 

l>e  ul)taiued  by  washing  out  the  cavity  itself. 

.  Bulletin  de  U  8ocl«t#  r«..9.l«  rt'Otologie.  »«»•  W"*  "T-P^^ 
=  Furet.    Archive.  laternat.  de  Uryng.,  .^an  et  Avrll,  1899,  p.  1». 


JioH 


XO.SE  .l.\0  TIJUOAT. 


Sounding  the  Frontal  Sinus.  I  lie  iil)S(iv:itioii.s  of  Lnthntp  on  the 
(•:ulav<'r  show  that  in  the  majority  of  instances  it  is  iniixissililc  to  pass 
a  probe  t'rnni  tlie  nose  up  into  the  frontal  sinus,  ami  it  must  he  still 
inoreilillicult  to  do  it  in  the  iivinj;  subject. 

The  care  with  which  this  attempt  shoul,|  be  carried  out  is  U'xt 
impresseil  upon  us  by  beariii};  in  mind  the  case  recorded  by  Merrnod.' 
This  ex|K'rienc('d  rhinolo>tist  diagnosed  an  escape  of  watery  fluid 
from  one  nostril  as  .rifjinating  in  the  frontal  sinus.  lie  tried  to 
catheterize  the  cavity,  but  wasarri'  ted  owiiif;  to  the  pain  the  (irocoed- 
inj;  induced.  The  patient  died  some  d;iys  afterward,  and  at  the  post- 
mortem it  was  found  that  he  had  no  trace  of  frontal  sinus.  The 
Huid  had  esca|M'd  through  a  .small  openinfr  in  the  anterior  f()s.sa  of  the 
skull  and  mu.st  have  In-ei.  cerebro-spinal  fluid.  This  hati  Iw- 
come  infected,  although  the  attempt  to  sound  the  postulated  frontal 
sinus  had  Imh-u  carrieil  out  with  ev(>ry  a.septic  i   ecaution. 


AmpuUlion  of  tlio  iinltrior  mil  of  the  mlddli'  turbinal,    lilvliling  the  Rttarhraent  to  the  outer 

tci^itl  vvnll. 

It  is  wiser  to  secure  free  access  to  the  Irotitonasal  duct  by  amjiu 
tilting  the  anterior  end  of   the   middle   turbinal.      This   proce.lun- 
will  in  any  cas(!  Im-  re(|uired  as  a  method  of  treatment  if  the  sinus  i~ 
found  affected.     The  sinus  can  then  in  many  ca.scs  Ik'  catheteriz>Ml 

Amputation  of  the  Anterior  End  of  the  Middle  Turbinal.  Tin 
region  is  rendered  ischi-'mic  with,  .•idrenaliii.  !!!i>l  cucnifiixed.  !?i  thi- 
way  tiio  p.art  to  be  removetl  is  generally  well  exposed  and  stainl 

'  Annul,  rtea  Mul.  de  I'Oreillc  ut  ilii  (.nrynx,  April.  1«<.«,  xjll  .  .No.  4. 


DISEASES  OF  Tin:  ACCES'<OIiY  SIXi-SES. 


959 


,,ut  from  th<-  ncijrliboriiift  imrt<.  Witli  a  stout  pair  (;f  Gninwahl 
li.rn-ps  or  I'aiizfr  scissors  the  anterior  attachiiu'iit  to  the  outer 
\\;ill  is  cut  tiirougli,  so  as  to  free  a  licad  arouiul  wliich  ti  colil  snare 
,:iii  lie  passed  and  the  extremity  removed.  In  cjises  where  it  is 
litlicult  to  introduce  tlie  forceps  alonjj  the  aftger  nasi  to  the  attach- 
ment of  tlie  middle  turl)inai  the  h'.a.les  may  1h'  applied  to  the  lower 
laarfiin,  ahout  half  an  inch  from  the  anteiior  extrenuty,  and  hy  theii 
liitinj;  out  a  portion  the  loop  of  the  wire  snare  can  Ik-  passed  around 
the  head  of  the  turl)iiial,  which  is  easily  removed. 

Diagnosis  by  Exclusion.  If  the  sounding  of  the  frontal  smus  iia.s 
fiiled  all  the  points  already  rrferred  to  are  uncertam,  and  we  are  still 
in  doubt  iis  to  whether  the  discovery  of  pus  in  the  middle  meatus 
.•riuinates  from  the  frontal  or  maxillary  sinus,  or  both.  This  point 
can  really  only  Iw  positively  .settled  by  a  process  of  exclusion,  which 
is  done  iis  follows: 


Auii.uiatlon  of  th..  anlcrl.T  end  of  the  middle  turbinal.    Kemovlng  the  «p.rat<!d  extremity  with 

a  wire  snare. 


The  maxillarv  sinus  must  be  exjilored  in  one  of  the  two  methods 
,,ln"adv  describVd -cither  through  an  empty  tooth  socket,  or  by 
imncturing  the  inferior  meatus.  The  antrum  is  then  thoroughly 
,leare.l  bv  svringing  through  it  air,  st(>rile  salt  solution,  a  teaspoonful 
,.r  two  of  hvdrog<-n  jH-roxide,  more  salt  solution,  and  then  air.  In 
this  wav  we  can  .lelermine  ili  if  ihr  cavity  ct.ntams  jm=,  and  <1) 
iliit  if"  present,  it  has  been  temporarily  thoroughly  ex|K'lled.  it 
r,ov.  we  let  the  patient  wait  f.)r  from  ten  to  thirty  minutes,  anil  again 


9«U 


h 


XOSi:  AM)  THROAT. 


<m  .".ViiMiniiiK  hill,  fin.l  pu.  i,,  the  liii.l.ll,.  „i,-alUH.  w,.  vau  \w  (rrt'iiii 
that  this  can  ..riKii.at.'  in  no  ,.ih.T  than  tiu-  fmatal  siniu  or  untcrior 
('thiiioiilal  cflls. 

In  carrying  out  tliis  test  it  is  im|«,rtanl  to  avoi.l  cnusiiiR  anv  hh-t-.l- 
iiig  111  tlic  nasal  chainlMT.  as  this  inihtatcs  against  th.-  r.wult  Th.- 
nasal  chaiiilHT  should  als.,  Ik>  scrupulouslv  d.-an-.l  ,,f  anv  purulent 
matter  first,  as  othcrwis..  we  cnil.l  not  say  that  anv  (liscov.-rod  then- 
later  had  eoine  from  an  am-ssory  sinus.  It  is  hanllv  n<'ee..,sarv  to  do 
i.H.re  than  refer  to  the  method  of  exploring  th.- sinus  l,v  pun.-turing 
Its  door  from  the  nu>^'.  This  nieth.xi  is  s..  dangerous  that  it  is  ,,uite 
unjustihahle.  It  will  he  referred  to  later  under  the  hea<l  of  Treat- 
ment. 

CompUcations.  Many  of  the.se  have  alreadv  been  touohp<l  on  The 
most  common  an«  suppuration  in  the  anterior  ethmoidal  oell.s  and 
the  corresponding  maxillary  sinus.  According  to  Luc  it  is  excep- 
tional to  find  the  frontal  atTected  without  participation  of  the  maxil- 
lary sinus,  although  uncomplicated  .suppuration  in  the  latter  cavitv 
IS  trequontly  met  with. 

Treatment.  Intkanasai.  Tkkatment:  Puncture  of  the  Floor  of  the 
•yniis.  The  method  recommended  hv  Schaeffer'  of  puncturing  tlic 
t^oor  of  the  frontal  sinus  from  the  nose  is  only  mentioned  to  l)e  con- 
demned. The  anatomical  irregularities  which  render  such  a  proceed- 
ing much  too  dangerous  have  already  been  referred  too  It  is  com- 
iimn  knowledge  that  a  rhinologist  in  Pari.s,  believing  that  he  was 
affected  with  an  acute  frontal  .sinus  suppuration,  attempted  to  thrust 
a  trocar  and  canula  from  his  nose  into  this  cavity.  He  died 
shortly  afterward,  and  the  instrument  wa«  found  to  have  penetrated 
the  anterior  fossa  of  the  skull. 

Catheterizimi  nnd  Wnshing-ont  the  Frontal  Sinus.  Observers  differ 
a^  to  the  frequency  with  which  the  fmntal  sinus  can  l)e  explored  from 
the  no.se.  Some  authorities  believe  that  thev  .succeed  in  catheteriz- 
irig  the  .sinus  in  .50  {)er  cent,  of  the  cases,  but  most  of  us  acknowledg.- 
that  we  are  not  so  frequently  fortunate.  In  any  case  the  operation 
IS  greatly  facilitated  by  amputation  of  the  anterior  end  of  th.-  middle 
turbinal.  (Fig.  502.)  In  those  cases  where  the  method  is  feasible  ;• 
IS  best  done  with  a  Hartmann  canula.  which  has  a  double  sigmoid 

""r  ?■'''■  •!;''■?■  •^'■^•'  ''''"'  '"  '"^'•"'luc'^'l  i"to  the  middle  of  the  centiv 
of  the  mid.lle  meatus  and  f  n  gently  .lirect  v|  upward  and  forward 
until  the  ,)omt  is  felt  to  enter  a  free  caviu',  and  is  found  to  h' 
h  to  7  cm.  distant  from  the  nasal  orifice.  It  is  often  impossible  to  .sa\- 
whether  the  canula  has  really  entered  the  frontal  sinus  or  wheth('- 
the  point  IS  nier»'ly  engaged  in  one  of  the  fronto-ethmoidal  cell- 
It  IS  in  this  method,  and  in  such  cases,  that  Spiess'  emplo^Tr.er 
of  the  Roentgen  rays  is  .so  valuable.  With  the  shadow  thrown  up,-, 
the  screen  it  is  extr<  mely  ea.sy  to  follow  the  pa.ssage  of  the  poir' 

'  Otutwb.  med.  WochenKhritt,  October »,  isao.  p.  906. 


DISEASES  OF  THE  ACCESSORY  SISUSES. 


y«l 


of  tho  instrument  through  the  n..s.'  until  it  enters  the  fr.mtal  sinus, 

,,f  whicii  the '.valis  are  well  detineil.'  ■.     i      i  i  i>.. 

When  the  ruvity  ean  Ik-  catheterized  fnMn  the  nose  .t  should  Ik- 

w.'le.    nit  .lailv  with  li.iaids  similar  t..  those  m.l.cate.l  for  suppu- 

Ui      he  maxillary  antrum.     Whether  a  cure  w.ll  he  effected  m 

•n  prohlnnatical.    tilley  pave  the  meth-nl  a  careful  tnal  m  fou 

•uses  without  any  pennanent  result  except  m  one  cas,..-     "';«'•;'••" 

,  ,.es  where  the  cavity  can  be  easily  reached  from  the  "".'^  »'>  '    « 

„;,,l,od  the  patient  is  to  a  great  extent  n-heved  of  any  r.sk  of  the 

dangerous  complications  which  might  otherwise  ensue. 

Fig    SOS. 


Method  of  catheterlan»  Ihe  frontal  slnui  after  removal  of  tbe  anterior  end  of  the  middle  turbin.1 
The  drA«.;n,-  >ho*.  the  lu.tus  semilunaris,  with  the  edge  of  thi-  pnH>«».m  uncii.atui.  below  it,  and 
tliffthiuoidal  bulla  above. 

The  ln<llr,-tin,u  for  the  einplovment  of  the  proceeding  are  thereforo 
Iff)  a«  a  tirst  .step  in  all  treatment,  and  (b)  as  a  precautionary  measure 
ill  Midi  patients,  especially  young  women,  who  decline  an  external 

"'m  Eternal  Operation.     This  metho.!  of  treating  the  frontal  sinus^ 
l,v  .M«  ration  through  the  forehead,  was  first  described  by  Ogston, 
Init  it  was  indeiH«n.lently  conceive.l  by  Luc^  who  has  given  consider- 
uhle  attention  to  the  method.   The  patient  is  prepare.l  for  operation  m 

:  r'"";  i'':"::';l^^"'""^^  """"  o:.ir-  The  Me..lcU  Cb«.nic,e,  December,  :m. 

!  ijiuTOt,  Jiiiy  H.  i««i  ~ 

«  Luc     SockHi  Frani;iil»e  d'OUilogle,  eti.    Paris,  MM,  189B. 

61 


t>()2 


yoUK  AXD  Til  HO  AT. 


the  usual  way.  and  in  addition  thooy«'hn)W  on  the  .sninr'  side  is  cntirclv 
slmvcddffjinil  fh.' skin  of  the  forehead  on  that  side  imriHeil  twelve  hours 
iH'fon-hand  ;ind  an  antiseptie  dn'ssing  applied.  A  general  ana-sthetie 
having  U-en  adininisten-d  the  skin  of  the  eyebrow  on  the  affeeted  side 
is  drawn  wel|  up  on  to  the  fon-head  so  that  tiie  part  lying  inunediately 
Im'Iow  is  I'liled  up  on  to  the  edge  of  the  forelieiul  (liryan).  A  eurved 
ineision  is  then  made  down  to  the  Iwrne  along  the  inner  third  of  this 
n'gion,  reaching  from  near  the  middle  of  the  eyebrow  to  op|M)site  the 
anterior  paljicbral  ligament.    (Fig.  504.)    The'imier  extremity  of  tlie 

ne.  6(M. 


Eilenial  operation  on  the  frontal  slniu,    Showing  the  eituatlon  for  making  the  skin  Incltlon  whllv 
rtrawing  the  eyebrow  up  ou  to  the  forehead. 

inci.-iion  will  terminate  ()|)|M)site  the  suture  of  the  nasal  bone  with  the 
nasal  process  of  the  frontal,  while  the  outer  end  will  Ik-  internal  to  the 
supra-orbital  foramen.  In  the  latter  direction  it  can  1m>  extended, 
if  recjuired.  At  the  end  of  the  oiMTation,  when  the  .soft  parts  are 
allowed  to  fall  back  into  place,  this  incision  will  Ih"  almost  entin'ly 
concealed.  With  a  raspatory  the  soft  jiarts  are  turned  Ufjwarll 
and  downward  so  as  to  expose  the  anterior  wall  of  the  frontal  sinus. 
A  half-inch  treiihiiie  applied  at  the  jxiint  indicated  in  Fig.  495  will 
never  fail  to  expose  the  sinus,  if  one  is  present.  Instead  of  a  trephine, 
however.  I  recommend  that  the  cavity  Ix'  ojM'ned  with  a  chi.*l  ami 
liammer.  It  may  present  considerable  thickness.  Throughout  the 
ojK'ration  great  care  mu.-t  lM>t:iken  not  to  pn'ss  on,  disiibce,  or  other- 
wise iiijiiiv  the  eyeball.  As  .soon  as  the  sinus  is  {)enetratod  careful  ex- 
j)ii  'atioii  should  1k>  made  with  a  blunt  \)To\yp  to  detorniine  not  only 
the  direction  ande.xtont  of  the  cavity,  but  to  positively  ascertain  that 


DISEASES  OF  THE  ACCESSOHY  SISUSES. 


!Mi.l 


iIk'  liniri)!  incinhraiic  of  the  cavitN   hii-  Ikh-ii  cxiM.fwd  aiid  not  the 
uiiKT  surfac-  of  th.>  tlura  maUT.     Tin-  pyojri'iiic  m<Miil.ran<"  filling 
till-  siims  soiiH'tiiiK's  pivrtonts   an   cxffnial  siiioolli,  dark,  piiiplish- 
cray  surface  which  at  first  diaiicc  ininht  !«•  mistalvcii  for  the  (hira 
mater.     In  sonic  casJ-s  a.s  soon  six  the  sinus  is  o|KMie(l  yellow  pus 
makes  its  escajH';  it  is  never  possessed  of  the  same  putrid  odor  as  that 
from  tlie  antrum  of  HiKhmore;  it  is  never  hirge  in  amount,  and  m 
«..me  cases  no  j)us  mav  Ix-  encountered,  although  the  cavity    may  1)0 
mor.'  or  less  complctelv  ftlled  with  funnoul.  papillary,  myxomatoits- 
like  hviHTtrophies.     In  order  to  n-move  thes«'  the  (.iH-mng  mto  the 
-^inus  inav  have  to  »>«•  enlarged  with  chisel  and  hammer  or  Imwic  f<.r- 
ceps.  upward  on  the  forehead  and  outward  toward  the  outer  margin 
of  the  eyebrow.     This  orbital  arm  of  the  sinus  is  much  more  concave 
than  the  asrendinp  frontal.     In  securing  this  access  to  the  cavity, 
it  is  not  by  any  means  neces.sary  to  remove  the  entire  anterior  wall, 
but  only  so  much  a.s  will  allow  "inspection  of  the  contents.     The  cn- 
larirement  of  the  f)|)ening   shouM    lie  chiefly  on    the  antero-mferior 
wall.  Ih'Iow  the  glaU'lla  and  above  the  suture  of  the  frontal  with  the 
maxillarv  and    lacrymal   bones.     This  gives  the  freest  access  to  the 
part  which  nnpiirt-s  most  careful  tn>atment  -the  frontonasal  c-iinal— 
and  it  is  here  that  the  scar  is  I)est  hidden  by  the  eyebrow.     W  hen  a 
sutficii^nt  oiK>ning  has  Ikk'Ii  secured  th.>  depenerated  mucous  mem- 
brane should  be  carefully  removed  by  plucking  it  off  with  Oninwald 


Kia.  806. 


Fuu'  probe  forexplorinK  the  ftonliMmsal  duct. 


forceps  or  a  Hartmann  conchotoii:  The  further  recesses  of  the 
villus  esiM-ciallv  the  outer  angle,  imi.^t  \ie  carefully  cleared  with  t  le 
curette  but  this  instrument  should  be  us«'d  with  great  can',  especially 
on  the  thin  posteri.ir  wall.  It  is  {M)ssible  tiiat  .some  of  the  fatal  ca.ses 
<,f  septic  osteomyelitis,  which  have  followed  tiiis operation,  have  been 
partlv  due  to  too  "iree  curettage."  The  part  of  the  sums  winch 
dcnuinds  the  most  careful  toilet  is  the  floor  and  the  frontouiv-sal  .luct. 
When  not  evident  this  latter  c.in  readily  be  found  with  Paiuus  curved- 
eved  prolie  (Fig.  505.)  For  rea.sons  already  given  no  attempt  should 
be  made  to  pass  this  upward  from  the  nose;  but  with  the  tip  of  it  in 
the  sinus  the  ostium  is  rea<lily  found,  and  by  imparting  to  the  prol)e 


&(>l 


XO.Si:  A.\l)  111  Kit. IT. 


a  <^<'iitlc  ciirxiiisr  iUMion  ilnwtiwm  I,  backuanl,  and  then  forwnnl  flic 
I'vcd  cxtii'inilv  will  a|>iM-ar  at  ;  !m'  aiitcrinr  naris,  Thf  <)|M>rati)r 
slioiilil  iiitn-  Im-f  hi-  little  tinpT  into  tlu-  tioilril  lo  niift  tin-  proJK'  h> 
it  ilt'sci-Mils,  mill  he  iiiiiy  I"  MUpriscd  in  his  carlitT  cases  tn  lind  that 
it  is  ciicuuntorfd  in  tlu'  nn  ;.l  i  avity  ii!U"!;  .'  irthcr  hack  than  ho  would 
have  iniafjiiK'd.  The  jirolx'  is  chrcaiifu  wi  li  .••  stout  silk  liiratiin*  and 
withdiawn.  To  thv  silk  end  mow  projecting  from  the  sinus  a  strand 
I  iodnforni  rihhon  Kauz<>,  one  to  one  and  a  liilf  inch  wide,  and  with 
a  M'lvMttc  is  attacht  d  and  drawn  down  into  the  nos<'  and  out  throu-zh 
the  nostiii.  The  surucon  s'  /les  the  up|XT  exth  niity  of  the  puize 
rihiion  prujcctinji  from  the  frontal  siruiswith  one  hand  and  the  Iowit 
end  with  the  other,  and  hy  s.'iwinj!;  it  upward  ami  downwanl  he  will 
not  only  dehne  the  frontonjLsal  duct,  but  l)reak  down  some  of  the 
friable  ethmoidal  cells  along  its  track.  These  c«'lls  should  Ix'  further 
cleared  away  t>y  the  use  of  a  ring  knife.  <ir  sharp  s|K)on.  from  above. 
Once  the  frontonasil  canal  h;i.s  Imh'h  iletined  there  is  practically  no 
danger  in  working  along  it  ilownward,  inward,  and  backward.  Kven 
if  directed  too  iniich  outward,  the  only  risk  would  l)e  that  of  damaging 
the  OS  planum  (Fig.  4S1),  and  entering  the  orbit  when?  the  capsule  of 
ihe  orbit  would  pievent  any  injury  to  the  eye.  It  is  with  the  up|)«<r 
|)osterior  wi.ii  111;;!  cxtreiue  caution  should  b<>  us!>l.  .\s  the  success 
of  the  operation  ii<  !i  large  oxtvn*  deix'iids  cm  the  complete  removal 
of  the  anterior  ethnmidal  cells  tli  -  part  of  the  oivration  should  Im- 
carried  out  with  care.  With  the  liitle  finger  introduced  from  aliove 
into  the  funnel  of  the  frontonasal  -luct  as  a  guide  th(>se  cells  may 
also  Ih-  cleareil  from  lielow  by  working  arrmtKl  the  tip  of  the  fingc'r 
with  a  pairof  (Jriinwald  force|,-. 

When  the  parts  have  Ik-cii  salisf.ictorily  cleared  it  is  recomm-ndeil 
to  swab  out  the  cavity  with  a  soluHou  of  chloride  of  zinc,  forty  graiii- 
to  ttie  ounce.  This  is  uimeeessary  if  the  toil(-t  of  the  sinus  lia.s  been 
well  carried  out.  The  remaining  steps  of  the  o|K'ratioii  arc;  varii-d 
by  ditferent  op<'rators. 

I.uc  formerly  (>in])loyed  .i  rubbenlrainage4ulx>  with  a  fuTinol-sha|M'.l 
extremity.  The  latter  was  hxiged  in  the  sinus,  while  the  tul)e  passed 
down  the  frontonasal  duet  to  ap|)ear  at  the  anterior  naris.  The  ex 
tiTnal  forehead  wound  was  closeii  at  one",  and  any  sub.sei|uent  treat- 
ment was  carried  out  through  the  ilrain,  which  wa.s  generallyVemoved 
at  the  end  of  eiiiht  or  nine  clays.' 

He  has  lalterly-  abandoned  the  niblxT  drainage-tube,  and  now. 
after  dusting  the  cavity  with  iodoform  gauze,  he  jiacks  it  with  a  rit)iMiii 
of  iodoform  gauze,  which  he  leads  dow!i  into  the  nose.  The  extern;!! 
wou.id  is  cio.seil  ;it  once  and  the  gauze  is  removed  on  the  second  n' 
third  day,  by  which  time  it  has  ensured  the  pateiicv  of  the  frontona.sa! 

du-t. 

Walker  Dowiue'  does  not  attempt  any  irrdnage  jnt^*  the  nose.     U 
packs  the  sinii.s  tirmly  with  a  strip  of  gaiizc  which  he  leads  out  througl 


Archives  Inlomat.  <le  [«r;iii;ol ,  lS9fi,  tome  Ix  ,  Nii.  ,1,  p   lfi3. 
1  i.lB-giiW  .M'.'dlcal  Journal,  M«y,  tVM. 


hoc.  cit. 


DisEAiEs  OF  rut:  AccKii^iont' sisuiks 


!)(».'> 


Miuv  ihf  ftriRiiml  svtiuml,  which  i-*  (•nrn|)K'Hy 


|,,s<m1     The  Rii  izf  ir"  I'-ft  in  pluci!  for  sovcri  i..  f'.iirtcfii  Aii\>*.  ami 
till    liruufili  tho  poiinNT-ojK'niiiR  the  wouiul  w  found  to 


whi'n  oxtr:i< 

Ih'  ri<'atii/,i'(l.  ......  ..• 

1  h.ivi"  ;ilrcailv  ri-ffr-<'«l  t<>  the  aurigcr  ol  inihsornmniiti-  curi'ttuiR. 
\ii,.ih.'r  risk  is'  that   attni-linc  iiiim.Mliat.-  clnsim'  of  ih.'  .'Menial 

'   Kr^'atly 


WIMIIII 


1.  ami  «1h-  ptcntinn  in  ai.  iiiiyiclilinii.  Imuiv  Ciivity  \vi 


Ictuiilnl  walls  of  s.-cri'tion  wliicli  couKl  Imnlly  havr  Im-cii  cMinplPtely 


-ii-ri 


lizf'il,  in  .•<pit<'<>f  cvi-ry  f 


arc 


I  have,  thcrcfon',  always  iiv 


■oidod  imincdialc  pomplcto  plosnrp  o 


S 


ihi-   lori'lu'ad   won 


nd.     MU'r  drying  tho  t-avity  we 


I   have  timily 


iki'd  it  with  a  .iry  strip 


.f  io  ;   form  rihlxin  >taiiz<',  of  wliich  the  t-x 


in-iiii 


IV  W!i.s  left  proji'Ctiug  fro...     c  internal  anR 


i.f  the 


WOUIli 


1.  thp 


ulcrixirtion  i 


f  which  inavlx'  dosed  with  a  few  silkworiii-KUt  stitches 


A  few  lavers  of  cvaiiide  jiaiiz« 


wruriK  out  of  iioracic  lotion,  and  covor<-d 


\y\ 


th  a  sui)i)rtiiiR  l)ad  of  aleniliroth  w<m) 


il  is  then    fixed    on  with  a 


liaiidap'  like  an  ey 


Ire.s.sini'.     No  ruliher  or  Rauze  drain  is  in.sc 


ited 


ihroURh  the  coinn 


iiunication  with  the  nose      Honc^"  there  is  no  ri: 


I  if  a  "dram 


pa 


actint:  its  an  o 


teiu'v  oi"  th-    .nlarfp'd  fmntona.-a 


V  ii,i.sses  off  in  a  week 
he  forehead  on  the 
.  •■':K  hi's  of  tlie  supra- 

.■■    .-nd  of  twentv-four 


ibturator,  instead  of  as  an  outlet.  The 
,1  duct  is  demonstrable  in  most 
,  IMS  afterward  ix'th  hv  the  eas«'  with  which  the  lower  part  of  the 
Minis  can  U.  washed  out  from  the  nose,  and  also  by  tlie  fact  that 
patients  can  force  ail  from  the  nose  up  into  the  sinus.  Not  only 
'lues  the  patient  feel  the  distention  of  the  cavity,  but  the  impact  of 
rhe  compressed  .ail  can,  in  some  cases,  be  l«)th  .sirn  and  felt  against  the 

I niiital  cicatrix.  ,  .       ,    ■•   ,     • 

Progress.     For  some    time  the  p;ttient  may  complain  of  diplopiti, 
particul.  K-  if  the  pulley  of  th.-  sup.ri..      bruiue  was  int«-rfered  with 
diirinp;  ti:      ijieration.     This  diplopia  (.   . 
or  two.     I'atients  may  also  iiulice  a  m.' 
atTi:  'ed  si-le.  due  to  division  of  some 
..ri)ii   1  division  of  the  Hfth  nerve. 

The  external  dn-ssinR  m.ay  in-  chaii;:  .      . 

h.airs.  s,,  .as  to  bathe  the  covered-u].  eye  wilh  Ix.racic  lotion.      I  H' 

packing  of  tlie  sinus  can  be  left  in  jilace  for  three,  five,  or  iiion-  days, 

according  to  the  absence  of  anv  supi.iiratioii  or  reaction.  .\n\- ten.siou 

can  Ih.  reli.-ved  bv  Reiitlv  puUiiiR  out   and  cuttinR  off  an  inch  or  two 

everv  secmd  or  thinl  .lav.     When  tii.'  whole  <•<  this  tirst   packiiiR 

is  nmiove.!  at  the  en.l  ..f  five  t..  ten  -lays  Ih.    'Mside  ot  the  sinus 

sh..ul.l  be  can-fullv  insiK'cte.!  and  syriiiKe.l  out      lih  sterile  salt  solu- 

tiun  or  iMiraci.-  aci.l,  which  should  p:i.ss  down  fively  iiito  the  nose  if 

the  l"ronto-<-11  iuoi.lal  cells  have  l>een  adniuately  dealt   with.     Any 

.Irbrisor  firan.ilation  obstructing  the  na.sofroutal  duct  can  Ik>  cleared 

awav  with    .  .airved,  silver,  luistachian  catheter.     Tl      >ackinR  may 

have  t(.  I>e  renewed  at  inter\-als  until  about  two  or  thi-»,    .veeks  from 

the  oiH-ratiou,  when  Hw  cavitv  will  .apin-ar  so  healthy,  ai;.-     -.e  tarfje 

,luct  into  the  middle  .   .'atus  so  permanently  patent,  th.at    '.ere  need 

IK'  n.i  hesitation  in  allowing  the  external  wouii.i  to  close.     A  hrm 


Hi 


9m 


.vo.va:  Ayi>  THROAT. 


compress  is  applied  over  flic  Inmy  defect  in  the  anterior  wail  of  the 
sinus,  so  as  to  partially  ol)lit"rate  the  cavity.  Any  sul)s<'(|uent 
ivashinj;  out  can  1m'  conducted  from  the  nos<'.  Unless  an  extensive 
amount  of  the  miterior  wall  has  Iwen  removed  then  is  very  little  (hs- 
figurenipnt,  and  the  scar  in  most  cases  is  trilling.  (Fijjs.  5(W)  and  507.) 

Km    •«•..  Flu.  .107. 


Ffo.  'lOrt.— Frontal  sinus  n|>erati(in.  riitoiiched  photocrdph,  showing  how  the  sciir  is  eonceali'd 
below  the  eyebniw.    i  A  in  horn  cast*,  i 

Flo.  .V»7.— Frontal  sitms  o{ienitton.  rritoti^hed  photoRraph  of  the  same  jaac  seen  In  Fig.  .V!t'>, 
showing  the  situation  i.f  the  ttcar  when  the  patient  raises  his  head  and  elevates  liis  i>ye*)rou-.  Va^it 
siipiMiratioii  was  completely  arrested  after  o|ieration  on  both  antra,  both  ethmoids,  and  the  right 
frontal  sinus.  Tlie  latter  cavity  was  o(>eiied  twice,  owing  to  a  pouch  t4>wanl  the  e?tternat  orbital 
angle  having  been  overlooked  at  the  flrst  operation.    I  Author's  case.) 

Ktihnt'x  Operation.  In  the  above  operation  a  considerahie  amount 
of  the  cavity  is  ol)literat<'<l  hy  the  coaptation  of  healthy  graimiatiriir 
surfaces,  hut  it  is  not  entirely  ohliterated.  Hut  siim.ses  arc  occa- 
sionally met  with  which  are  so  cafiacious.  extendinp  hack  to  the  optic 
foramen  and  out  to  the  frontosphenoid  suture,  that  tlie  extensive 
granulatim;  surface  fails  to  cicatrize  over  and  continues  to  secrete 
pus  into  the  nose.  It  is  in  such  ca.ses  that  a  radical  cure  can  hardly 
he  liopeil  for  except  hy  Kuhnt's  method,  which  consists  in  chiselliiii; 
away  the  entire  anterior  wall  of  the  simis  and  then  pressing  the  soft 
parts  covering  it  down  into  the  cavity  until  they  are  a|)plied  to  the 
posterior  wall.  There  can  he  little  douht  as  to  the  satisfactory  result 
in  regard  to  nasal  suppuration  s(>cured  by  this  plan,  but  the  resultin;: 
disfigurement  is  so  marked  that  few  |)atients  care  to  submit  to  it 
Possibly  it  migiit  find  its  application  in  |H'i'sons  wtio  are  pre^"pnteli 
froin  earning  their  living  by  the  sufferings  or  inconvenience  entailed 


DISEAUKS  or  THE  ACCESSORY  Siy USES. 


mi 


hy  the  |M>rsist('iu-(!  of  the  sinusiti^■.  aiul  to  whom  appcaninces  are  of 
little  inonu'iit.' 
Suppuration  in   the   E'Junoidal   Cells.     .S//m>/(//m.    hthiuoKlal 

^  Etiology  The  (lir(>ct  inaimor  in  which  the  ethinoi.l  is  exposed 
to  e\t<Tiial  iuHuena's.  ami  its  anatomical  arraiiRenient,  n-athly 
exi.Iiin  the  fmiueiicv  with  which  suppuration  is  eiicounteix-d  m  the 
ethinoi.l  hibvriuth.  "it  is  probablv  attacked  priniariiy  in  a  large  num- 
ber of  eases;  and,  owing  to  its  position  in  the  centre  of  the  accessory 
system  supDuration  readilv  extends  from  it  to  the  other  snmses 
'Pliat  it  may'become  s.'condariiy  infecte.l  with  discharge  from  any  of 
these  cavities  is  also  very  possible,  and  Luc  has  suggested  that  m  the 
treatment  of  maxillary  siimsitis  by  washing  out  through  the  alveoltir 
...MMimg  we  rim  the  risk  of  driving  infective  matter  into  the  ethmoid 
c'lls  However,  in  the  inajoritv  of  cases  it  is  probable  that  tlie 
ethmoiditis  is  prinurv.  for  we  ohm  get  pus  in  these  cells  without 
encountering  it  in  the  frontal  or  maxillary  cavities,  whereas  it  is  very 
seldom  we  find  the  two  latter  attacke<l  (and  esix-ciallv  the  frontal) 
without  implication  of  the  ethmoid  labyrinth. 

The  external  sources  alnnvlv  n-ferred  to  are  the  most  common 
causes  of  ethmoiditis,  but  owing  to  its  '.x,x)scd  position  it  is  doubt- 
less more  commonlv  infected  by  the  conveyance  ot  sentic  m.ection 
by  the  surgeim  from  other  cavities,  from  the  reckless  use  of  the 
galvanocauterv.  or  fnim  incomplete  oix-rative  interference.  .Sec- 
ondary suppuration  mav  also  reach  the  ethmoid  region  from  the 
orbit,"  aiul  suppuration  in  the  anterior  fossa  of  the  .skull  has  been 
known  to  make  its  wav  through  these  cells  into  the  nose. 

Symptoms.  It  is  well  to  recollect  that  the  posterior  group  ot 
ethn.oidal  cells  are  smaller  an.l  their  mouths  are  much  more  open. 
Ilcnc-  diseas«'  in  them  is  less  commonly  met  with,  less  trouble- 
some but  more  .lifficult  to  treat  than  that  of  the  anteror  group 
Tli<-  interior  group  of  cells  increase  in  size  from  above  do-. nward  ami 
from  before  backward  One  of  the  largest  is  called  Uxo  oulla  eth- 
moidalis  It  is  generallv  concealed  just  Ix-low  the  aii.erior  extre-mty 
uf  the  middle  turbinal,  an.l  somewhat  overiies  the  cleft  .;f  the  hiatus 
s,.inilunar:s.  of  which  it  forms  the  upper  .an.l  posterior  lip.  just  as  the 
prominence  of  the  processus  uncinatus  forms  the  lower  hi).  Ihe 
'.pening  .)f  the  bulla  is  on  its  upp-r  an.l  posterior  surface,  close 
un.ler  the  attachment  of  the  mi.l.lle  tuH.inal.  Other  cells  oiM>n 
above  the  hiatus,  int..  which  their  secretion  nat'.irally  trickles. 
.\in.)ng  the  most  important  is  the  frontal  bulla  an.l  the  fronto- 

etlimoiilal.  .        ,    ,        ,..11 

Vcconling  to  this  anatomical  division  of  the  ethmoid  cells  we  can 
first  of  all  divide  the  stu.lv  of  ethmoiditis  int.)  suppuration  in  (a)  the 
anteri.>r  ethmoidal  cells,  and  (h)  posterior  ethmoidal  cells. 

■  W  MllUga...    Etiology  and  Treatment  of  Supimratlve  Dlsewe  of  the  Fronttl  sinuMi      Un<»t, 
Febnary  19, 18«8.    K.  J.  Moure.    LeTraltiment  de.31.iiuit«t    Rev.  h«M.  de  Uryngol,  189H. 


^ 


968 


SOSE  AXl)  Tiniit.lT. 


The  Anterior  Ethmoidal  Cells.  Adopting  the  ("liissification  of  Oriin- 
wulil  we  iniiy  divido  siipptiration  in  those  ciivitics  into  (a)  closed  sup- 
piinition.  and  ih)  <>|)t'n  suppuration. 

(n)  Cliisnl  Siiitimmfion.  It  is  now  ostahli.sh.  d  that  the  orifices  of 
a  cell  may  iK'conie  ohstrueted  by  inflammation  and  its  cavity  dis- 
tended witii  suppuration.  In  such  a  case  tiie  distended  portion  of 
tlie  middle  turhiiial  will  caus(>  symptoms  of  pain  and  obstniction 
accordinj;  to  its  situation  and  the  ihrection  in  which  it  tends  to  expand, 
eitlier  toward  the  na.sal  cavity  or  toward  the  orbit.  In  tiie  former 
case  tlie  chief  complaint  will  be  of  increasing  nasal  obstruction,  with 
a  feeling  of  distention  referred  to  the  bridge  of  the  nose.  Weight 
and  opi)ression  toward  the  forehead,  with  a  feeling  of  tightness  and 
heat  in  the  nose,  leail  to  ins(X!ction  of  the  na.sal  chanilK>r,  when  the 
normal  situation  of  the  middle  turbinal  is  seen  to  be  n-placed  by  a 
8mooth,  rounded  body,  impinging  on  the  septum  and  more  or  less  com- 
pletely blocking  up  the  middle  and  infe-ior  meatus.  To  the  prol)e  it 
fi'els  firm  and  resisting,  som, 'times  decidedly  Imjuv,  and  sometimes 
like  eggshell,  but  frecjuently  its  true  character  is  only  discovered  on 
puncturing  it  with  the  prol)e,  or  cutting  it  across  with  a  wire  .snare. 
It  is  thru  found  to  1k>  a  hollow,  bony  cy.st,  with  a  smooth  lining  mem- 
brane, sometimes  containing  j>o!ypoid  mucous  membrane  and  'illed 
with  mucoid  contents,  or  with  \mx.  which  may  1m>  strikingly  fetid. 

The  ci.^es  in  which  the  contents  of  a  cystic  dilatation  of  the  ethmoid, 
w'th  or  without  suppuration,  make  their  way  toward  the  orbit  have 
long  lH>en  reco-nized  and  have  generally  come  under  the  notice  of  the 
ophthalmic  surgeon.  Fiefeded  by  some  darkening  of  the  lower  eyelid, 
or  by  some  congestion  and  inilltratior,  a  swelling  makes  its  api)earance 
at  the  inrirr  ::ngle  of  the  .rbit,  displacing  the  eyeball  outward  and 
downward.  This  may  lake  pl.ace  (piit,-  pa.iiilessly.  Son-etimes  this 
d-ise.|  cthmoiiial  si:;)puratioii  pointing  toward  the  orbit  may  develop 
suddenly,  with  intense  pain,  fever,  Hgoi-s,  swelling  and  (edema  of  the 
eyelids,  and  a  lliictuatlMg  swelling  to  the  inside  of  or  below  the  eyeball. 
If  such  a  case  is  umclicved  ii  m.iy  g,,  rui  to  suppunition  within  the 
cranial  civity  and  f.at.il  meningitis,  .\lthougli  .ippaiently  primary 
these  acute  cases  .ire  ijnubtlcss  in  tlie  majority  of  instances  exaceriw- 

tioiis  of  a  chronic  < liiion,  ai'd  if  ^s  wi-ll  to  remember  that  they  may 

siipeivne  on  a  chronic  manifestation  or  be  induced  in  uiisusijected 
ca.ses  by  surgical  ir.auiuatism. 

Treatment.  The  circnni-ciilHil  ithtnoid.al  empyema  found  in  the 
tind.ilc  'fi.'atHs  should  Im'  ivmoved  with  ;i  cold  snare,  forceps,  and 
eunite  llic  iv.,iaining  ethmoid  region  .shoulil  then  Ije  carefullv 
ill  |K'cted  and  treated  .h  con lingly. 

When  tlic  direction  is  that  of  the  uibii  ihe  swelling  may  have  to  1m' 
df.ilt  with  by  sternal  incision,  but  communication  with  the  nose 
.should  be  established  as  soon  as  possible,  so  as  to  .s(>cure  gooil  drain- 
age and  enable  further  treatment  t..  Im'  carried  o'l  from  the  inside. 

(h)  O/Mii.  L'ltcnf.  "I-  MnnifrsI  Kiniii/rma.  Tins  is  the  most  common 
form  of  affection  of  the  ethmoid.     It  is  frequently  ovi-rlooked.  and 


DISEASKS  OF  TUE  ACCESSORY  SISVSES. 


ytjii 


the  actual  patholopical  affection  is  apt  to  bo  mistaken  for  nasal 
pulvj.i  <.r  atrophic  rhinitis,  which  ire  but  two  of  the  con.se(|uences, 
ilthou^h  often  the  most  prominent  symptoms. 

Symptoms.     In  this  form  of    nasal  sui)puration  the  patient  may 
,.,„nplain  of  almost  any  of  the  symptoms  which  have  already  been 
, I, .scribed  as  a>sociate<l  with  affection  of  the  sinuses.     Still  there    is 
.rl.lom  the  faceache  or  neuralgia,  although  a  dull  heaviness  at  the 
n,ut  of  the  nose  is  often  noticed.     A  general  sense  of  mental  hel)e- 
t,„l,.    apro^exia,  and  disinclination  for  mental  work  is  more  oiten 
,„inplained  of.     Depression  and  melancholia  are  more  often  trace- 
.,1,1,.    to    this    form    than    to   suppuration    in    the    larger   sinuses 
\  foeling  of  distention  of  the  bridge  of  the  nose  may  l)e  comi)lained 
,,r   and  acluid  enlargement  may  even  l)e  noticed.     Tendernes.«  can 
,,,'mctimes  Im'  elicited,  esjx>cially  by  pressing  on  the  lacrymal    bone 
•,t  the  inner  angle  of  the  orbit.     The  discharge  from  the  nose  is  .sel- 
,l„ni  so  ■<  •)ious  as  with  other  sinuses.     The  patient  rarely  complains 
„f  liu-  <A\\w  cacosmia,  but  o'l  the  other  hand  he  is  much  more  apt  to 
l„.  a!!ect(>d  with  anosmia.     Although  he  may  use  fewer  handker- 
niirfs  he  often  has  greater  difficulty  in  clearing  the  nose,  owing  to  the 
..(•(•iction  <lrving  into  crusts.     In  consequence  of  the  tendency  to 
.Irvness  of  the  s(>cretion,  and  the  turbinal  atrophy,  the  secretion  tends 
to"  be  inspired  toward  the  back  of  the  nose,  and  so,  in  some  cases,  to 
un'seiit  it.self  in  the  form  of  atrophic  or  crusty  postnasal  catarrh. 
I  Aainination  will  n>veal  pus  in  the  middle  meatus.     In  many  cases 

it  is  ac( ipanied  bv  ixilvpi,  and  it  is  in  such  instances  that  the  pus  m 

lluid  and  vellow.  In  certain  cases  the  pus  tends  to  dry  int  adherent 
.rr....nish-vellow  crusts,  the  ei)itlieliu.  i  gets  eroded,  and  the  turbinals 
;,tn,phy.so  that  the  appearances  an-  much  like  those  describe<l  under 

the  ii(.;iding  of  <  )za'na.  . ,  ,      „  r 

\lthougli  pus  fi:>ni  the  anterior  ethmoidal  -ells  must  of  course 
,uak(>  its  es(.aiH'  in  the  first  instance  into  the  middle  meatus,  it  is  often 
tumid  Iving  <.n  the  Hoor  of  the  nose,  and  a.lhering  to  the  margin  of 
til.,  ini.ldl.-  turbinal.  whence  it  i.a.sses  ui)ward  mto  the  olfactory  clelt. 

Ill  delennining  the  origin  of  the  suppuration  it  is  a  go(.d  plan  not 
to  wa>h  out  the  nose  \v:  l\  a  cleiiiising  lotion,  but  to  careful  y  lift  .jr 
wiiH.  out  the  crusts  with  nasal  dressing  forceps,  cotton,  and  a  little 
,.,„.Mine.  .Mrefullv  avoiding  any  blading.  In  this  way  any  pei't-up 
pu^  iiiav  sometimes  be  (liscovere<l  and  traced  to  its  source.  1  lie  use 
„f  tl...  nasal  prob(>  is  essential,  and  \  len  carefully  used  it  will  m  many 
.-.Kes.  es|K.eiallv  those  a.ssociated  with  jMilypi.  detect  canoas  bone. 
\tler  ihe  middle  meauis  has  Ikmhi  cleansed,  a  me.lium-sized  blunt 
i.K.be  is  insinuated  between  the  outer  nasal  wall  .and  the  middle 
lurbiiml.  which  is  then  pre.ss.-a  inward.  This  will  sometimes  allow 
tiie  ,..s,.ape  of  llui.i  i-us.  Tiiis  pus  might  come  from  the  anterior  et  i- 
in..idal  cells  or  from  the  frontal  sinus.  If  carious  bone  is  felt  in  the 
nei<:hborhoo<l  of  the  ethmoid  it  {>oint.s  to  ethmoiditis.  although  this 
does  not  exclude  the  pn-seiup  of  a  frontal  .sinusitis  which  often  ac- 
companies it.     The  mere  .sensation  of " bare  bone"  is  not  sufficient  to 


970 


XOUE  AXD  TUROAT. 


found  a  diagnosis  of  caries.  The  iinico-ixTio.stcum  is  so  tliiii  and 
closely  adherent  over  the  parts  in  tiie  concavity  of  the  middle  turhinal, 
that  the  hone  can  Im'  felt  in  many  cases  where  there  is  neither  |)us  nor 
any  symptoms  sugfjestive  of  ethmoii litis.  It  is  otherwise  wlien  the 
l)rol)e  meets  with  rouphened  and  readily  hreakinp-down  spicules 
of  hone,  or  on  slight  firm  jMcssure  enters  small  cavities  in  the  ethmoid. 
The  diagnosis  of  ethmoiditis  can  also  lx>  arrive  I  at  by  the  method 
of  exclusion  already  descrilx'd.  In  all  cases  it  is  a  pood  routine 
plan  to  commence  by  excluilinp  the  maxillary  sinus.  When  the 
symptoms  already  descril)ed  jis  indicative  of  ethmoiditis  are  j)res»^iit 
it  is  sometimes  dilFicult  to  say  if  the  frontal  sinus  is  also  affected. 
The  methods  suggested  by  (Jriinwald  of  damming  up  the  various  ostia 
might  l)e  tried. 

If  it  is  p<)ssil)le  to  catheterize  the  frontal  sinus,  and  pus  can  be 
washed  out  of  it.  the  diagnosis  is  facilitated.  In  most  cases,  however, 
it  will  first  be  necessary  to  do  the  typical  amputation  of  the  anterior 
end  of  the  middle  turbiiial.  and  there  need  Im  no  hesitation  in  taking 
this  step,  as  it  is  the  first  one  necessary  in  initiating  treatment  of  the 
ethmoiditis.  (Figs, .")()!  and  .t()2.)  Once  this  is  done  the  frontal  sinus 
can  l)e  washed  out  in  a  majority  of  cases.  In  ,sf)me  the  involvement 
of  the  frontal  cavity  will  still  remain  uncertain.  In  .such  cases  we 
should  i)roceed  with  the  treatment  of  the  affected  ethmoidal  cells,  and 
the  persistence  of  pus  from  high  up  anteriorly  in  the  middle  meatus 
will  indicate  that  the  up|)iTmost  simis  must  be  dealt  with.  If  there 
.in"  no  other  means  of  determining  the  coutiiuied  escape  of  pus  the 
urgency  of  the  .symptoms  may  justify  an  ext<'rnal  exploratory  opera- 
tion through  the  incision  already  descril)ed.  If  the  frontal  cavity  is 
found  healthy,  !i.s  in  one  of  my  cases,  the  wound  can  l)e  clos«'d  at 
once,  and  no  perceptible  scar  is  left. 

Treatment.  In  many  of  the  slighter  forms  of  ethmoiilitis  only  pal- 
liative^ treatment  is  called  for.  These  are  the  cases  in  which  a  small 
((uantity  of  nmcopurulent  .secretion  takes  place,  sometimes  ilrieil 
into  " films,"  •'casts,"  cru.sts,  or  merely  into  ''pieces  like  goldbeatn's 
skin,"  as  I  have  heard  patients  describe  thein.  These  fre(|ueiitlv 
forin  in  the  night,  sometimes  in  one  no.stril  <iiily,  aiid  .'ill  that  the 
|)atient  reipiires  is  a  cleansing  alkaline  lotion  tou.se  in  the  morning 
In  these  slighter  forms  the  .secretion  is  .seldom  s.i  dry.  or  -accreted 
in  such  i|uantity,  as  to  form  obstructive  collections.  It  i-  a|)t  to  be 
the  only  thing  the  patient  complains  of.  and  it  is  therefore  wi.se  not 
to  <)|)en  up  the  <  thmoirhd  labyrinth  mon'  completely,  when  infectiem 
might  only  si)read  and  rr(|uire  more  or  less  co?n|ilete  removal  of  a!' 
the  cells.  Sometimes  in  such  cases  the  patient  is  subject  to  reijeatel 
violent  "colds  in  flie  head.  '  with  profu.se  nuicopurulent  secretion 
and  the  prolonged  iliscomfort  of  acute  coryza.  It  is  then  to  I" 
considered  whether  more  active  measures  should  not  be  nroceede^ 
with.  ' 

I'olypi  .should  be  removed  with  the  cold  wire  snare.     When  sufli 
cif'iitly  cleared  to  enable  a  complete  di;ignosis  to  be  maile  the  ethmoid 


DISEASES  OF  THE  ACCESSORY  SINUSES. 


971 


MU  must  Ix-  fnH'lv  oiK-ne.i  up,  :uul  this  will  entail  roinoval  of  luuch 
o....(.u.s  tissue.  Iii  iK'iirly  every  ease  the  typical  a!ui.utati()n_..f  the 
interior  eii.l  of  the  niidillo  turluiu'l  must  he  performed.  (Iigs.  Ml  and 
-,()  >  )  If  this  enables  a  diagnosis  of  puK  in  the  frontal  sinus  to  be 
nnde  rnd  it  is  decided  to  o|)<"n  the  latter  from  the  outside,  the  cells 
rm  Ik'  cleared  from  above  through  the  floor  of  the  frontal  sinus. 
If  thi-;  step  is  not  agree.l  on,  and  if  the  frontal  is  not  attected,  the 
.MMMiiiiR  of  the  dis«'as<>d  ethmoid  cells  can  be  i)roceeded  with. 

The  -interior  end  of  the  middle  turbinal  havinp  been  removed, 
thi<  i-xposes  the  bulla  <-thmoidalis,  the  hiatus  s<>milunaris    and  the 
interior  cells       The  diaRiiosis  can  l)e  now  confirme.l  by  the  caretul 
us,.  ..f  the  prolK',  which  should  always  precede  each  subse.iuent  step. 
\s  a  .liseased  cell,  or  an  escaix>  of  pus  is  definitely  locate.l  with  the 
i.n.be    the  punch    forceps  of  (Iriiiiwald  or   Hartmann  should  ein- 
bnce  the  diseased  spot  und(>r  the  control  of  the  physician  s  eye.  and 
in  tlu-  i)ortion  removed  at  each  bite  carious  bone,  -.ms,  and  myxoma- 
tous-like  tissue  will  Ik-  found,     liefore  introducing  the  f<.rcei)s  again 
the  parts  .should  Ix'  dried,  an.l  the  prol)e  shoul.l  define  clearly  what 
the  next  step  is  to  Ik'.     In  some  ca.ses  where  the  patient  has  »)een 
carefullv  prepared,  an.l  resp<.nds  nuarkedly  to  the  ischa-imc  action  of 
Mdivnafm,  the  chief  part  of  thedisf>ase  can  be  remove.l  at  one  sitting 
In  ..tli.-r  cases  the  fr.-e  bleeding  soon  limits  further  oiK-ration    ami 
treatment  can  onlv  be  c.rried  out  at  intervals  of  ten  to  fourteen  days. 
Next  to  careful  use  of  the  prol)e  the  most  important  ixtmt  is  to 
proceed  alwavs  in  a  direction  upward  and  outwanl.      A  reterence 
o  the  topographv  of  the  reg^.n  will  show  that  this  w.,.il.l  Ix- toward 
,he  orbit,  and  this  is  a  .lire-tion  of  stifety,  for  little  harm  is  do  e 
,.v..n  if  the  cavitv  of  the  orbit  l>e  ix>netrate,l.     The  capsule  ..the  e>e 
W..U1.I  limit  th..  progress  .f  the  sprea.l  of  any  mischief,  an.l  the  acci- 
d,.nt  might  lK>  revealcl  ..y  a  "black-eye  '  incident  on   the  effusio, 
of  l,loo,l  below  th..  lower  li.l.      It  is  otherwise  if  the  .lm>c  ion  Im 
upwar.1  an.l  inwar.l.    The  surgeon  must   av..i.    most    carefully  an> 
approach  to  the  ..Ifactory  cleft.  f.,r  it  is  here  that  th..  '  anfrl.es  .,f 
,v.;„„,ling  the  cribriform  plate.     Still.  I  canno    think  that  there  is 
„„icl,  .langer  if  the  above  a.lvice  is  carefully  followe.l.  viz  :     It 
niak..  r..p..at..<l  invliminary  expL.ration  with  a  prolx;;  (2)  rem..\( 
.mlv  what  falls  within  the  grasp  of  the  f..rceps  and  avoi.    twisting  or 
„„tli,ur  anv  portion  .iut.  an.l  Ci)  work  always  upwar.l  .and  outwanl. 

It  ha^  been  reconimen.led  to  place  the  F>atient  un.ler  a  general 
ana'sth.-tic  an.l  scrape  away  all   .lisea^-'-d  tissue  with   a  ""f  1^'1'^<;- 
\lthough  th..  little  finger  can   be   intr...luce.l   into   the    nostril  fn.m 
tin...   to  time  t..  -letect   carious  areas,   still    the   proc.H..ling   mus 
1„.  „i..n.    haphaz.ard  than  that  ab.we  .lescribe.  ,  since  hea It.iy  an.l 
....-ful  parts  arc  ai)t  to  Ik-  remove.l  with  the  .lisea.se.l,  nn.l  when  a 


.  W  K  '-.swlberry.    New  York  MerticaUournal.  November  24,  1S91     A.  B.  Thrasher.    Necrt-Uof 
the  Mi.ldie  Turbinal     Ibiil.,  December  7.  1X9V  ,      .^       „v„ 

J  U.  L.  Lack     TraiiMCUons  of  the  Laryigological  Society.    London,  1901. 


972 


yoUE  A  so  THRU  AT. 


portion  of  l)oii(>  is  ripped  out  wo  arc  not  assuml  that  thi"  fracture  of 
it  may  not  extnul  to  the  (•ril)riforin  |)lat('      In  an  unconscious  |)atit'nt 

in  tlic  jmir"  position,  ami  witli  1)1 1  often  flowinj:  freely,  it  is  more 

(lillicult  to  iM.'iintain  anatomical  laiulmarks,  and  I  have  known  of  a 
case  where  the  rinj;  knife  had  broken  through  the  floor  of  the  iiuterior 
I'oss.i  of  the  skull,  with,  of  course,  fatal  conse<|U''nces. 

Kxternal  operation  of  the  anterior  ethmoidal  cells  has  already 
been  descrilied  as  part  of  the  o|M'ration  when  the  frontal  simia  is 
o|M-ned  from  the  forehead.  It  has  iM-en  recoiTUnended  to  treat 
ethmoidal  suppuration  by  this  route  in  any  case.  Kntry  is  obtained 
by  makinj;  an  incision  similar  to  tiiat  already  describee f  for  reuchinj; 
the  fr  intal  sinus,  but  it  is  better  to  chisel  throujih  the  frontal  bone 
on  it.^  orbital  aspect,  .so  as  to  jjain  ready  access  to  the  ethmoidal 
cells.  In  ex|)osin<;  tliei/i,  care  nuist  Ix'  taken  not  to  displace  and 
injure  the  eyeball,  as  ca.ses  of  iwrmanent  blindness  have  occurred 
from  doinp  so. 

Prognosis.  In  many  cases  a  complete  cure  can.iot  be  looked  for, 
and  if.  with  the  removal  of  the  anterior  end  of  the  middle  turhinal 
and  the  openinfr  up  of  the  larjte  ethmoidal  cells,  the  patient's  chief 
symptfims  .iiv  relieved,  he  probably  will  be  well  advi.sed  to  put  up 
with  a  certain  amount  of  muco-pus  from  the  nose,  and  possibly  the 
use  of  a  daily  nasal  lotion.  .\  glance  at  some  coroiuil  sections  of  the 
skull  will  show  how  impossible  it  is  to  o|)en  up  the  very  hij;hest  cells 
without  perilously  approachinf;  the  floor  of  the  cranium.     tFifr.  4,s_>.) 

Combined  Cases  of  Suppuration  in  the  Anterior  Group  of  Sinuses. 
Siiniiniinis:  ...axillary,  ethmoidal,  frontal. 

Diagnosis.  In  many  cases  where  it  is  difHcult  to  determine  the 
"ri<iin  of  pus  seen  in  the  miildle  meatus  it  is  safest  to  begin  bv 
settlini;  the  condition  of  the  maxillary  siiuis.  Rajiid  recurrence  of 
pus  will  then  |)(iint  to  disease  of  the  frontal  cavity,  and  in.xpection 
and  the  probe  will  determine  the  amount  of  involvement  of  the  aii- 
teriiirethnioidal  cells. 

Treatment.  .\  maxillary  simisitis  eatmot  be  radically  cured  so 
lotid  as  it  is  M'Uu<i  as  a  reservoir  to  the  frontal  sinus.  Tri'atment  of 
the  frontal  simis  will  be  unsati.^actory  if  the  ethmoidal  cells  con- 
tinue to  secrete  pus.  Therefore  in  initiating  treatment  the  maxillary 
sinus  should,  if  |)o,ssible.  be  (irst  drained  through  ;i  tooth  socket. 
The  anterior  ethmoidal  cells  should  then  be  restored  to  as  healthy 
a  conditi.in  as  po,-isible,  an<l  a  radical  operation  on  the  antruiii 
shoul.l  not  be  undertaken  until  a  frontal  source  of  re-infection  i< 
eliminated. 

Indications  for  Treatment.  The  frontal  is  the  only  one  of  the  ac- 
cessory cavities  whose  ostium  is  situ.-ited  in  the  most"  favorable  point 
tor  natunil  dminage.  Hence  in  the  absence  of  obstruction  there  is 
not  the  same  tendency  to  accumuLatioii.  .-md  the  cavity  can  rarely 
Ixronie  tilled.  With  certain  easily  ajiplied  iTieasures  this  tendenc'v 
to  obstruction  can  Ik'  further  obviated.  Besides  tiie  necessity  of  any 
radical  operati(;n  being  i)erformed  through  the  skin  of  the  face  rai.'ses 


IHSEASES  OF  THE  AVCESSOHY  Sl.\UiiEii. 


973 


the  i.ussil)ilitv  of  s.)in.'  (lisfiK„rpiu.'nt.  while  llu-  proximity  of  tl.o 
„„st .'riur  tl.in"  wall  of  the  s'mus  to  the  anterior  fossa  of  the  eraniuin 
Ivinl.Ts  all  surnieal  procedures  much  mon-  .lann.'rous  than  those  ..n 
the  antrum  of  Hislmiore.  .  , 

While  thes<-  consi.h-rations  induce  a  eertam  difhdence  in  eml)ark- 
in.r  „n  ra.lical  treatment,  there  are  two  oth<'rs  which  raise  the  .|uestion 
./attempting  a  complete  cure.  The  first  an.l  most  imiK.rtant  is. 
that  nedect.Ml  su|.puration  in  this  cavity  has  midout.tedly  iK-eii 
l„ll(,w..l  1)V  s«.ri<.us  results.  The  .second  is  that  neglected  frontal 
Minis  supiiuration  is  verv  likelv  to  infe.-t  the  other  cavities  iK-longiiiK 
to  the  anterior  uroiip,  viz. :  the  anterior  ethmoidal  cells  and  the  maxil- 
lirv  sinus  In  such  cases  the  amount  of  pus  secreted  hy  tlie  frontal 
.'inus  mav  be  .small,  and  the  symi.toms  induced  by  it  may  be  m  them- 
selves trivial,  but  the  indications  for  attemptiiif;  a  cure  of  the  ac( i- 

pinviiiL'  .'thmoidal  and  maxillary  suppuration  may  b<-  promment, 
l,ut"iini)ossible  of  realizaticm.  so  lonp  as  the  u-i)er  cavity  remains  to 

iv-infect  them.  .  ..       .         » 

In  ill  cLses  it  is  well  first  to  trv  the  effect  of  intranasal  treatment. 
In  the  pn-st'iice  of  troublesome  headaclie,  fre(|uent  neuralgia,  recurring 
■„.ute  or  subacute  attacks  of  exacerbation,  profust^  dscharge,  or 
marked  secondary  results,  the  position  of  affairs  must  be  explained 
ta  the  patient  aiwl  the  external  oiK-ration  advised. 

Chronic  Suppuration  in  the  Sphenoidal  Smus.  Etiology.  The 
..ti.iloL'v  of  chronic  sui)puration  in  this  cavity  is  simil.ar  to  tliat 
ncciirnng  in  the  sinuses  already  considered.  The  position  of  the 
.ntiiral  ostium  is  verv  unfavorable  for  the  escape  of  secretion,  and 
possihlv  this  is  a  reason  whv  the  secretion  escapiiiR  from  the  cavity 
is  part'icularlv  pn.ne  to  dry  into  crusts.  In  many  cases  th,.  smus  is 
itTected  at  the  same  time  as  others  situated  more  anteriorly,  and  it 
is  said  to  occur  ran>lv  bv  it.self.  In  the  only  p. .st -mortem  I  have 
s<.en  of  a  case  of  sphenoidal  suppuration  it  was,  however,  the  only 
cavitv  found  affected.  .         *         i  ♦ 

Many  cases  formerly  regarded  as  simply  ozienic  have  been  traced  to 

a  suppuration  in  this  sinus.  .  .      ,     ,  ,       i      •,•    i    ,= 

Symptoms.  The  svmptoms  complaine.1  of  may  «>  classified  as 
thev  refer  to  ui)  the  head.  ('-)  the  discharge,  and  (c)  the  eyes. 

(a)  In  manv  cases  no  svmptoms  of  pain  are  complained  of,  whereius 
in  others  the' patient  mav  only  s.'ek  relief  becaus(>  of  some  form  ol 
|».M.lache  This  mav  be  o'nlv  a  general  diffuse  headachi-  or  heaviness, 
or  it  mav  be  referred  to  the  temples,  the  forehead,  the  occ.].  t,  or 
d-cplv  b'ehind  the  eves.  Whh  this  headache  whi(  1.  is  sometiines 
verv  "variable,  the  patient  is  apt  to  complain  of  many  of  the  mental 
sv.nptonis  alreadv  referred  to,  and  I  have  found  that  afternoon  som- 
Mnl.M.n-  appears  to  !«•  more  common  with  rhis  than  with  other  smn.ses. 

(M  In  manv  cases  the  patient  has  nuul.'  the  diagnosis  o  his  case 
as  one  of  -'postnasal  catarrh,"  and  there  can  !)<>  little  doubt  that  a 
numJM-r  of  cases  whicli  are  ordinarily  treated  as  originating  in  the 
pharvnx  should  correctly  be  locaied  in  the  sphenoidal  sinus.     Cacos- 


y74 


SOUE  AXD  Til  HO  AT. 


mia  is  often  r<)in|)laiiio<l  of,  ami  in  advaiin-d  cases  the  sense  of  smell 
is  more  or  less  completely  lost. 

(r)  The  eye  symptoiis,  wliicli  are  often  tabulated  as  associated 
with  suppuration  in  tliis  cavity,  are.  in  my  opinion,  only  met  with  in 
the  l.if(  r  stapes  of  the  disea.se,  hut  of  course  they  might  Ix'  the  first 
to  attract  attention  in  patients  who  had  not  sought  advice  or  whos<' 
symptoms  had  Imm-u  misconstrued.  These  ocular  troubles  may  1h' 
of  the  nature  of  lacrymatioii.  photophobia,  bli'pharospasm,  transi- 
tory scotoma.  The  optic  neuritis  with  complete-  blindness,  and  such 
developments  as  exophthalmos,  basal  meningitis,  hemorrhage  from 
envsion  of  the  cavernous  sinus,  etc.,  an-  due  to  extension  of  disease 
to  the  walls  of  the  sinus,  and  should  pro|)erly  Ix-  cla.ssified  as  com- 
plications of  a<lvanced  disease.' 

Examination.  Attention  in  the  first  i.istaii.-e  may  be  directed  by 
the  patient  to  the  larynx  and  when  dried  greeni.sh  (ir  yellowish  scabs 
are  found  in  this  region  (oza>na  of  the  larj-nx  or  iracliea),  the  |M)ssi- 
bility  of  supi>uration  in  some  of  the  acces.^ory  cavities,  and  most 
probably  the  sphenoidal,  should  be  kept  in  mind.  Dried  ^cab8 
producing  .atrophic  pharyngitis  may  be  found  coating  the  posterior 
wall  of  the  |)harynx  and  the  roof  of  the  nasopharynx.  They  may 
be  found  lying  on  the  back  of  the  soft  palate  ami  generally  in'a  les« 
dried-up  condition  hanging  about  the  choana-.  It  is  important  to 
carefully  insiwct  this  n^gioii,  as  the  escai)e  of  r.(|uid  pus  from  above 
the  middle  turbinal  into  the  postna.^al  space  could  hardly  indicate 
other  than  an  origin  in  the  sphenoid  sinus  or  posterior  ethmoidal  cells. 


=m^ 


Fio.  508. 


Canula  for  wuhing  out  the  apbenoidal  iilniu. 


In  the  majority  of  ca.ses  the  How  of  pus  is  chiefly  backward,  but  in 
many  ca.<es  it  will  also  U-  visible  to  anterior  rhino.xcopy.  It  is  gen- 
erally fomiil  in  the  olfactory  cleft,  but  it  niav  even  pa.ss  around  the 
lower  margin  of  the  middle  turbinal  and  ap|K'ar  in  the  middle  meatus, 
when  it  would  have  to  1m^  distinguished  from  pus  originating  in  tlir 
frontal,  ethmoidal,  or  maxillary  caviiies.  In  ca.ses  of  doubt  th(sc 
latter  cavitii's  must  Iw  eliminated  by  the  methods  of  exclusion  already 
<lescribed.  It  would  be  well  in  the  first  instance  to  carefuliv  cleanse 
the  entu-e  iio.^e  and  postna.s-d  space,  and  then  to  watch  carefuliv 
tor  the  re:.pp<.arance  of  pus.  If  this  is  first  visible  in  the  olf;./- 
tory  (left,  and  still  more  if  it  is  .seen  on  the  roof  of  the  choana  an  ' 
above,  the  diagnosis  of  suppuration  in  cither  the  sphenoid  cavitv  o' 
posterior  <'thmoidal  cells  is  almost  as.sured.     If,  as  often  occure  in 

'A  i..,mm-.ry  of  22  rcTor-M  eases  of  fatal  intra.ranlal  complication,  following  ,Ilsc«..e  of  il„ 
sphcmmlal  s,nu.  will  be  fuuod  -cconled  by  Zoubert  in  ibc  A.-chlvea  iic«.^n.ie8  de  MMecini- 


DISEASES  i)F  THE  ACOESSORY  SiyUSES. 


970 


ilculiiijt  witli  tills  cjivity,  thr  rcapiH-iiriuiPf  of  pus  is  ditfirult  to  dotpr- 
iiiiiii'  aii.l  there  is  any  srspicion  of  its  entry  beinj;  iniule  in  the 
iiiiiMle  meatus,  it  is  safest  to  make  an  exploratory  puncture  of  the 
antrum.  This  will  not  only  settle  any  doubt  as  to  the  presenec  or 
.iliscnce  of  i>us  in  that  eavity,  but  any  reappearance  shortly  alterwanl 
..f  pus  in  the  middle  meatus  would  |>oint  to  the  anterior  ethinoi(jal 
c.r  frontal  eavities.  Of  eours<',  the  detection  of  pus  in  thes«'  r:ivitirs 
would  not  invalidate  itsoeeurrenee  in  the  sphenoidal,  imt  it  would  l»e 
wiser  to  assure  tlieir  eompletc  drainage  More  proceeding  to  deal 
with  any  n'lnaining  pus  which  inuat  then  c.nie  fmiu  the  iK)8terior 

Mucous  i)olypi  nn'  rarely  met  with  ui  association  with  this  form  of 
sinusitis.  I,' It  various  forms  of  iiidammatory  hyiierplasia  are  often 
found,  jKirticularly  in  the  comp-iratively  recent  rases.  In  such 
cases,  often  with  atrophy  of  the  pharynr  from  the  drying  and  irrita- 

Fio.  S0». 


Melhoil  iif  ittlheterizing  the  sphenoidal  tlniM. 


liMii  of  the  s«>cretioii  pus'ing  backward,  a  chronic  hypertrophy  is 
-Miiietimes  oncounteicd,  particularly  in  the  middle  turbinal,  which 
iiiav  sfciii  larjier  than  it  really  is  in  comparison-  with  the  atrophy 
which  has  often  set  in  in  the  inferior  turbinal.  The  midille  turbinal 
iiiav  be  so  closely  pressed  against  the  septum  that  a  sound  is  mily 
passed  after  careful  application  of  cocaine  and  adrenalin.  If  inserted 
ill  a  sloping  direction  inward  and  upward  diagonally  acro.ss  the  plane 
ni  the  middle  turbinal  it  will  imjunge  on  the  nasal  surface  of  the 
lid  in  the  neighliorhood  of  the  ostium.  (Fig.  509.)     'Uiis  open- 


spiienoii 
lii^:  htis 


Ix'en  found  catheU'rizable  in  only  40  per  cent,  of  cases.    It  lies 


JL 


»7G 


yonK  Axo  ntiti)  \t 


'llll 


III  ut  12  mm.  abovr  tlu*  |">st<Titir  I'lul  if  the  niiidlc  turhitiul,  uml 
plofK'  uiiiUt  the  n!i.s;i!  I  .of.'  ill  tlir  inujority  of  ciiscs  tin  it\>i  iiiii^  lies 
a  little  PXtfTiuil  to  th<"  (lin<'ti()i»  <»f  the  olfactory  ch'ft  ialH)Ut  5  iimi. 
from  tlic  iiiiddlt'  liiH'),  ami.  it  is  then  iinjMi.v  ilili'  to  p  i-,s  a  sound  into 
llu'  sinus  witlioni  n-nioxai  of  the  niitldlc  turlnnal.  This  should  Iv 
dono  as  alrc.'idy  dcscrilM'd.  If  i he  anterior  end  ha.-*  liad  llie  typical 
amputation  ixrfonned  then  tlu'  remains  should  l)e  removed  with  a 
Cold  win-  snan\  the  punch  forceps  of  (IninwM  I.  or,  under  a  Ronenil 
ana'sthetic  such  as  nitrous  oxide  gas,  with  thesimkeshave. 

A<'cordinjt  to  Cholewa  a  view  of  the  anterior  wall  of  the  si)henoida! 
sinus  can  Ik-  obtained,  and  the  midi'le  turliin.tl  at  the  same  time  re- 
tained, liy  the  following  method:  a  sh-nder  <  !<  -  ator  is  intriKluced 
iN'tween  the  tniddle  turhinal  and  the  septum,  and  the  former  is  pried 
outward  and  fraeturt'd,  pmhahly  alotig  its  base  of  attachment.' 

Kven  when  free  access  has  \h'vi\  olitaine(l  to  the  anterior  sphenoidal 
wall  the  ostium  is  seldom  distinctly  visible,  Immi.';  generally  close<l  by 
the  folds  of  mucous  membrane,  much  like  the  meatus  urinarius.  But, 
on  carefully  wiping  and  watching,  the  pus  may  Ik'  .se«'n  exuding  from 
the  region  of  the  ostium.  A  catheter  can,  however,  be  pjussed  into 
it  by  gentle  niani|)ulation,  and  the  cavity  should  be  syringed  out. 
The  nose  having  previously  Ix-en  carefully  cleaned  the  exit  of  any 
pus  will  show  that  it  comes  from  this  cavity. 

The  distance  from  the  anterior  nares  to  the  sjjhenoidal  ostium  varies 
iM'tween  "JJ  and  :i\  inches.  The  following  an>  figures  of  difTerenl 
ob.servers:  (Jriinwald,  in  males  H.2  cm.  (3}  inches),  in  females  ".ft 
cm.  (li  inches).'  R.  C.  Myles,  2V  to  3}  inches:  to  i)o.sterior  wall  ot 
sinis,  with  i)rol)e  lx>nt  a  little,  4J  inches.  .Jonathan  Wright,  2J  to  21 
inches  (5.4  em.  to  <>.7  cm.):  in  a  living  specimen  he  found  the  di>- 
tance  to  the  anti-iior  wall  to  Ix-  ,i  incht  s,  and  to  the  [xisterior  wall 
:i\  inches.'  (iKiismann,  4  inches.'  ('.  R.  flolmes,  from  5  cm.  to  7..") 
'■111.  average,  fi.lS  cm."  Uosworlh  found  that  a  prolK'  impinging  on 
til  |x)sterior  wall  of  the  sjihenoidal  sinus  was  ti}  inches  from  the  tip 
of  tiie  nose.' 

My  own  exjM'rience  is  that  th(>  secn^tion  which  can  be  washed  mit 
in  a  chronic  case  is  comparatively  slight  m  amount  and  it  is  .-ieldom 
l)iirc  pus.  It  is  nuich  more  apt  to  Ije  iiiuco-pus,  or  even  thick  mucus 
with  thi-eads  of  pus  in  it,  and  I  hav  rciiiarked  that  it  floats  in  tli'' 
lotion  used  nuich  like  islets  of  frog's  sjiawn  in  a  pond. 

hut  the  catheterizing  of  the  sinus  ha.s  anothiT  value  even  in  tlio 
case  of  a  doubtful  result  from  its  lavage.  It  is  this,  that  it  determim's 
|)ositively  till'  ijrescnce  of  a  sinus  and  the  justifiability  of  opt>ning  it  ti]!. 

I  C.  K.  Holmes     Anblvea  of  OphthalmnlnKy,  1H9A,  vol.  zxv.  p.  461, 
»  IJuoletl  by  II.  I'ordes.    Mont's,  fur  Olirtnlieilk.,  May.  I8'J9. 
3  Nuwl  S'lppnratloD.     l.oli<luii,  l*J01. 

•  Twemifth  Century  I'raclice  of  Me<ticinc,  lsa6,  mjL.  vi  p.  82,  and  Aniwln  <if  Otology,  KibruB  ■. 

>  New  York  .\.'ftJemyof  .Mi'dic  ne.    Joiir-ialof  Laryngology,  l)t9<i.  xl.  p.  13". 

•  Archive*  of  Ophilnlinoloity,  1S96,  xiv.  p.  461. 

'  Trani«ctloiu  of  the  American  Laryngological  Anociatlon,  IXit'i,  p.  94. 


DtSKAStCS  OF  THE  ACCESSORY  SISVHBS. 


U77 


Tlic  -phrnouliil  simiws  are  so  im>Kuliir  in  rDtit.mr,  iiiul  their  vitv 
|,rr«riic»'  soni.'tinies  sn  pr..l>l»-matical,  that  it  w..iii.l  Ix-  rash  to  atu-ii>l)t 
!M  hirak  into  u  siiiiw  without  Hrnt  .Irt.TiniiiiiiK  that  ono  is  pn'soiit. 

Xtronhv  is  a  iiuirli  "lorc  fmiiwiit  n-sult  of  proloiiip-.l  spl„-noi.hil 
suppuration,  an.l  not  iiifn^iunitly  the  nasal  loKsa'ari'  so  wi.l.-.an-l  so 
tillfi  with  fcti.l  «Tusts.  that  thi-y  pn«»ont  ail  thoapiM-aranc-sof  „za;na. 
!t  is  in  such  cases  tliat  it  is  sonietimcs  ih..ssii.I.'  to  fxplorc  th«'  ostium 
without  pn'iiniinary  n>niovai  <»f  the  niidtlif  turiunal. 

Treatment.  In  n.anv  <as<>s  wh<'n-  tho  ostium  is  not  n-aihly  acwss- 
il)lo  and  in  whicli  thcVomplaints  of  thepati.-nts  an-  not  very  nmrit«Ml. 
1,(.  will  Ix'  well  a.ivisc'.l  to  n'st  content  with  alioviativc  tn-atnuMit. 
niiswiii  consist  of  svmptomatic  treatm.-nt  to  sccun-  Inv  'Irainap;, 
an.l  chu-Hv  "'f  regular  cleansing  of  the  nose  an.l  i.harynx.  Ihis  w 
iH-sf  carriiMl  out  with  the  ,>ostniml  syringe,  or  the  anterior  nasa 
svrinee.  using  simplv  cleansing,  tepi.l.  alkaline  lotions  When  all 
.nists  an-  ex|)elle(l  the  nmil  fossa-  may  1h>  luhri-ate.l  with  som.-  oi  y 
preparation  such  as  simple  li.iui.l  vas««line  or  l)enz.)ni.il.  Ihe  a.ldi- 
ti..n  of  any  antiseptics  is  apt  only  to  be  irritating.     The  dryness  of 

Flo.  .MO 


Hl^k'i  hook  for  opening  uphenoiilal  (.Iniu. 

the  pharjTix  mav  be  relieved  by  a  carbolic  or  other  lozenge.  In 
nwiiiv  ca.ses.  once  the  natural  defensive  power  of  the  iinicnus  nem- 
l.raiie  of  the  nose  an.l  cavum  has  Ik-cii  assisted  by  this  treat  fin-nt,  it  is 
.)ften  remarkable  how  the  continuation  of  a  sphenoidal  suppuration 
can  be  tolerat*'.!.  i       i      •     j 

Where  more  active  measures  are  indicated  access  must  Ik'  obtained 
t.)  tlie  ostimn  as  already  imlicate.1,  an.l  the  sinus  must  Ik-  regularly 
••leanse.1  with  alkaline  and  antiseptic  loti.ms.  If  a  freer  exit  i>ji  '"died 
tor  the  natural  oix>ning  mu.st  lie  enlarged  by  inserting  into  it  Ilajek  s 
sphenoidal  hook  and  so  tearing  awa    p:irt  of  the  front  wall.     .\s  soon 


MICROCOPY    RESOLUTION   TEST   CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0 


I.I 


!-!  ~  {lilt   O  O 

**•  I     - 

l_ 

•-  i._ 

!"  136 


132 


m 

2.2 

[2.0 

1.8 


1.25  WWWA 


1.6 


^     APPLIED  IK/MGE 


i,''6)    *82    -  0300   -  P^o^t* 


978 


SOUE  ASD  Tim  OAT. 


as  tho  margin  is  dpfinod  it  can  ho  furthor  onlarRpd  l)y  the  use  of  Griin- 
waldV  iniiicli  forc('i)s. 

Where  tiii'n  is  ditficulty  in  eiilarf;inp:  tlie  natural  ostium,  and  par- 
ticularly where  there  is  any  softening  or  caries  of  the  anterior  wall,  it 
ran  he  ]H'netrate(l  with  a  trocar  and  canula  helow  the  level  of  the 
situation  of  the  ostium,  the  opening  being  enlarged  by  curettes  and 
sharp  s|)oons. 

I  have  found  the  following  a  simple  and  easy  method  of  effecting 
an  opening  into  tli'>  simis.  The  patient  is  placed  under  a  general 
ana'sthetic  and  the  fiireHnger,  introduced  through  the  mouth,  is  in- 
serted into  the  choana  of  the  affected  side,  as  high  up  on  the  anterior 
sjjhenoidal  wail  as  possible.  A  pair  of  blunt-])ointed  sinus  forceps  of 
sjK'cial  form  (Fig.  .tIH  are  introduced  through  tli:'  nostril,  and  the 
point  located  just  above  the  tip  of  the  examining  forehnger.  With 
a  little  careful  palpation  a  point  can  generally  be  found  where  with 
firm  ])ressuro  the  forceps  will  penetrate  the  anterior  wall.  As  the  in- 
strument is  witlxlrawn  the  blades  of  the  forceps  are  expanded  so  as 
to  enlarge  the  o|)pning.  On  the  following  days  this  opening  can  be 
further  enlarged  under  a  local  aniesthetic. 

Kio.  5U. 


StClair  Thomson's  forceps. 

It  has  lioen  proposed  by.Iansen,  and  lately  recommended  by  Furet 
and  Luc,'  to  a]ii)roach  the  s|)lienoi(lal  sinus  by  traversing  the  maxil- 
lary cavity  first.  In  that  case  a  large  o|)ening  in  the  canine  fossa 
should  be  made  as  already  directed,  and  then  the  nasal  wall  of  the 
maxillary  cavity  should  Ix"  freely  removf'd  in  its  posterior  two-thirds. 
The  anterior  wall  of  th(>  sphenoidal  sinus  then  comes  into  the  field 
of  view  oi)ene(l  out  from  the  canine  oiM-ning,  and  it  is  claimed  that 
it  can  readily  b<'  dealt  with.  The  extensive  destruction  of  ti.'^sue 
entailed  in  this,  the  dangers  associated  with  the  proceeding,  the  more 
or  less  pennanent  disfigurement  and  discomfort  of  large  urmatunil 
permanent  openings,  and  the  still  uncertain  results  obtained  for  what 
has  not  yet  In-en  proved  to  be  such  a  fre(|uently  dangerous  condition, 
prevent  this  operation  from  coming  within  tiie  province  of  {)ractical 
treatment.  The  iiossibility  of  reaching  the  cavity  from  the  naso- 
j)harynx  is  neither  practical  nor  useful. 

When  the  sj)henoid  s  nus  is  artiHcially  opened,  profuse  hemorrhage 


•  SocUHO  FrantKise  ■1c  l.arynKnl..  1901. 


DISEASES  OF  THE  ACCESSORY  SINUSES. 


97!t 


l,Ms  somotimos  occurml.  In  a  case  of  {Jleitsinann's.  the  bleeding 
,li,l  not  take  i)lace  until  seven  day?  after  tiie  oiM«ration.' 

TiH'  opened  simia  must  l«"  dealt  with  aceording  to  the  conditions 
met  with  Xeerosed  portions  of  bone  may  re(|Uire  to  be  remove.  . 
|>,,lvi)oid  conditions  of  the  mucous  lining  should  be  removed  with 
loireps  or  curette,  care  being  taken  to  respect  the  posterior  wall. 
The  condition  of  the  mucous  lining  may  be  improved  by  j)lugging 
with  iodoform  gauze,  or  cleansing  with  iodoform  emulsion  In  many 
CHOI'S  tlie  cure  is  incomplete,  and  Griinwald  has  found  that  oziena, 
traceable  to  suppuration  in  the  sphenoidal  sinus,  is  one  of  t!ie  most 
inveterate  forms.  ,     ,        ..      i 

Indications  for  Treatment.  Profuse  i)ostnasal  purulent  catarrh. 
-.Mvistent  headache,  orbital  or  intracranial  syini)tonis,  call  at  once  tor 
ireitment  In  their  absence  treatment  must  not  only  deitend  on  the 
atiiount  of  suffering  of  the  patient,  but  also  on  the  skill  of  the  surgeon. 
( irunwald  differs  from  manv  of  le,«s  experience  in  thinkmg  that  the 
sphenoidal  is  one  of  the  most  satisfactory  of  the  accessory  cavities  to 

"Mucocele.  Synoiiyms:  Chronic  catarrhal  sinusitis;  serous  sinusitis: 
cysts  of  the  antnmi:  dropsy  of  the  antrum:  hydrops  antri:  hydrops 
inthimmatarius.  .  ,  u         r 

Symptoms.  It  is  difficult  to  prove  that  any  increased  flow  of  muciis 
,,r  aiiv  serous  discharge  from  the  nostril  originates  m  one  ol  the 
•ure-^orv  cavities.  The  source  of  such  nasal  hydrorrhoea  may  be 
MisiH.ct<"d  when,  as  in  the  case  of  a  distinguished  colleague  there  is 
•1  <u.lden  escai)e  of  abfmt  a  teaspoonful  -f  clear  watery  fluid  from 
',hc  higher  nostril  when  one  ear  is  lowei..!  over  the  single  wooden 
-i.tho-^cope.  When  the  opposite  ear  is  used  no  such  flow  occurs 
other  possible  svnnptoms  are  supra-orbital  neuralgia,  and  occasional 
,n<al  obstruction,  without  any  intranasal  condition  to  explain  it. 
lixploratorva.^pirationof  the  n.ixillary  sinus  will  sometimes  with- 
(h'lwaclear  waterv,  sometimes  amber-colored  fluid. 

In  hv.lroi)s  antri  and  in  disten.led  mucocele  of  the  fn.ntal  sinu.s 
ih.M-e  is  a  gradual.  painle;<s  distention  of  the  cavity  unti  the  walls  of 
tiic  >^inu<  are  so  thinned  that  under  the  finger  they  "  crackle  like  stronv 
parchment.-^'  The  swelling  may  reach  the  size  of  an  ..umge.  S>nie- 
tini.-  the  external  wall  is  absorbed  to  such  thinness  that  fluctuation 
i<  readilv  i.erceptible.  The  walls  may  yield  so  that  when  the  maxil- 
l.uv  .imis  is  affected  the  hard  palate  becomes  flattened  and  the  nostri 
hl.;..ked  bv  the  bulging  of  the  nasomaxillary  wall  W  hen  the  fmntal 
.-.vitv  is  mvoived  the  orbit  is  seriously  encroache<l  on.  When  tUe 
,.„ntents  of  the  sinus  are  removed  they  are  found  to  consist  ,.l 
•inspissated  mucus"  (Ferguson),  or  clear  or  yellowish  serous  fluid, 
lrc(iuentlv  containing  cholesterine. 


1  TransactioMOf  the  American  I^ryngologlcal  A««oclatlon.  ia95,  p.  91. 

i  N.-.'::i!  =upi>urati<;tL    I.-amh's  trandatitin.    London,  !««) 

»  Sir  William  Fergiuon.    System  of  Practical  Surgery.  1x70.  p.  597. 


III''! 


'J8U 


yOUE  ASD  THROAT. 


I 


Pathology.  The  old  view  of  tliis  condition  was  that  it  was  due  to 
"catarrh"  of  the  niucoiis  iTicnihrano,  and  tliat  wlicn  the  exit  of  tliis 
secretion  was  oi)stnict('d  it  accmnulatcd  and  distended  tlie  cavity. 
Altlioiijili  ficneraily  abandoned,  this  view  has  -n  recently  supported 
by  Xohenitis,  who  reports  37  cases  in  whicii  '  y  ex])l(iratory  asi)iration 
he  found  serous  exudation  in  the  antrum  v.here  lie  thinks  it  was  pro- 
duced by  •  hydrops  inHannnatarius."'  Tiie  mucous  membruie,  as 
has  l)een  i)ointe(l  out,  is  inihtTerently  sui)plied  witii  f^lands,  and  has 
no  vascular  secretinji  arrangements  like  the  nose.  The  mucus  secreted 
l)y  a  catarrhal  .simis  amounts  to  very  little.  These  "mucoceles"  are 
much  more  likely  to  i)e  caused  by  the  develoi)ment  of  cysts  in  the 
mucous  membraiir  either  by  the  cystic  dilatation  of  a  jiland  or  the 
cystic  defteneration  of  a  polyjjus.  These  cysts  may  grow  to  such  a 
size  that  they  occupy  the  sinus  and  are  mistaken  for  its  cavity.  The 
cyst  wall  may  rupture  and  the  Huid  iM'como  free.  The  walls  are  thin 
and  the  contents  vary.  .\s  a  rule  it  is  a  viscous  !i(|uid,  thick,  .strinjiy, 
transparent  an<l  sometimes  yellowish.  In  other  cases  it  is  opa(iue 
and  even  caseous.  It  freciuently  contains  cholesterine.  In  large 
cysts  i'  is  more  li(|uid,  yellowish-white,  sometimes  transparent  and 
syni,  in  consistence,  or  stringy  like  white  of  egg.  This  pathology 
is  supported  by  Christopher  Heath, ^  who  thinks  that  the  term  "  dropsy 
of  the  antmm"  should  be  abandoned,  and  (iiraldes,'  Virchowj' 
Uernher,-'  Alexander,"  Scheppegrell,'  and  other-  object  to  the  designa- 
tion of  hydrops  antri  as  giving  a  false  notion  of  tlie  real  pathological 
process,  viz.:  cystic  dilatation.  (Jriinwald  says  in  relation  to  the 
frontal  sinus,  that  the  cases  in  which  the  secretion  is  [)urely  mucou- 
are  ''extraordinarily  rare.""  Luc  describes  a  case  of  closed  nuicocele 
(passive)  of  the  frontal  sinus,  the  contents  of  which  were  typically 
cystic."  Cases  in  which  this  sinus  are  affected  generally  come  under 
the  oi)hthalmologist.  Cystic  dilatation  of  the  ethmoid  cells  is  dealt 
with  el.-;ewh(>re. 

Treatment.  This  consists  in  opening  and  evacuating  the  affected 
cavity  on  the  iiriiicii)les  already  described.  There  is  no  hesitation 
in  recommending  ojH'rative  measures,  for  gen-rally  the  disfigurement 
of  tile  disea>r  is  worse  than  that  left  by  the  operation.  There  is  not 
the  same  risk  attending  it,  as  pyogenic  organisms  are  not  present  or 
only  in  insignificant  ntmiber  and  virulence,  and  there  is  no  need  to 
make  a  counter-opening  into  the  nose. 

Tumors  of  the  Accessory  Sinuses,  (irowths  in  tlie  acces.'jorv  sinuse,- 
niay  be  either  siii.ple  or  malignant.  Among  the  former  are"  (edema- 
tous fibromata  (so-called  myxomatous  jiolypi),  cysts,  and  osteomata. 


'  M.iiials.  f.  Ohrenlicilk.,  April,  lsa.'i.  (i.  JI4. 

=  Injuries  and  Diwwcs  of  tne  J«\v.    Tliirti  eilition,  London,  1HR4. 

'  Ui<hirchi'>  snr  les  Kystcs  mn.iiieux  (In  SItuib  maxillaire.    Paris,  isfio. 


<  Herliii,  kliii.  \V(K'hen»chrin,  1W*7.  .Vn.  1:1, 
•■  .\rchiv  f.  Laryngol  ,  1S97.  Band  vi.,  Hefl  I,  8.  130. 
"  Nasal  Siii^ii'.iralid!!.  i .  'J^5. 

'*  Annalesdes  mal.  lU'  rorville,  etc..  1M!><.>.  xxv..  No.  l,p  .I9r>. 
actionsof  the  American  Laryngologlcal  AssoclHtinn,  19«1. 


'  Archiv  f  klin.  riiir ,  Band  lii. 
■  Medical  Reconl.  August  26,  Vm. 

See  also  W.  E  Casnelberry.    Traii* 


DISEASES  OF  THE  ACCESSORY  SIS CSKS. 


9£1 


Tlic  latter  coniijrisf  sarpoiiiiita  and  ciMthclioiiiata.  Neoplasms  are  not 
of  conniion  occiirrence:  they  are  more  frecjuently  met  with  in  the 
maxillary  than  in  the  other  accessory  cavities. 

Masilhmj  Sinus.  Simple  growths  like  polyi)i  (irdematous  tihro- 
inata)  have  already  been  referred  to.  Cysts  of  ^he  antrum  may 
lie  due  to  (1)  obstructicm  and  dilatation  of  the  glands  of  the  lining 
mcmhrane;  (2)  cystic  degeneration  of  i)olypi:  Ci)  dentigerous  cysts; 
1 4)  dental  cysts. '  Tlie  two  latter  are  not  true  antral  cysts,  hut  only 
invade  it  from  without.  Osteomata,  fibromata,  and  true  myxomata 
are  rare  (Jonathan  Wright).  Among  the  malignant  growths  may  be 
mentioned  epithelioma,  carcinoma,  and  .sarcoma." 

Frontal  Sinun  Neopla.sms  are  rarely  met  with  in  this  cavity. 
Cysts,  ostfomata,  and  fibromata  are  the  innocei't  growths  which  have 
been  recorded.     Carcinoma  and  sarcoiuii  are  very  rare. 

Ethmoid.  The  occurrence  of  i)olypi  and  cysts  has  already  been 
dealt  with.  Osteomata  are  occasionally  met  with  presenting  at  the 
inner  angle  of  the  orbit.  Carcinoma  and  epithelioma  are  not  uncom- 
mon in  elderly  subjects,  and  it  is  important  to  remember  that  sarcoma 
may  occur  as  early  as  the  ninth  or  oven  the  fourth  year  (A.  A.  Bliss^). 
Sphenoidal  Sinun.  Polyi)i  are  not  conunon.  Nasopharyngeal 
til)ron!ata,  sarcomata,  and  carcinonmta  are  not  infrequently  met  with, 
but  generally  invade  the  cavity  from  the  outside. 

Diagnosis.'  The  age  of  the  patient,  the  progressive  character  and 
constant  pain,  the  occurrence  of  hemorrhage,  the  external  manifesta- 
tions, the  secondare  involvement  of  glands  and  neighboring  tissue?*, 
;is  well  as  the  api)lication  of  the  tests  described,  will  help  in  de- 
termining the  presence  of  a  malignant  growth.  The  simple  ont>s, 
with  the  exception  of  the  polyjji  and  cysts  already  descrilml.  declare 
themselves  bv  their  .slow  growth  and  evolution. 

Treatment  "  This  has  already  been  considered  except  in  the  case 
of  the  malignant  growths.  Ivirly  diagnosis  of  ethmoidal  cancer  will 
oiiiietimes  suciced  in  ensuring  success  by  intrana.>*al  treatment  only. 
Sarcomata  are  t.ften  slow-growing,  and  remain  limited  to  the  bony 
tramework  of  the  nose  for  some  time  after  declaring  themselves. 

W  hen  originating  in  the  maxillary  cavity  partial  or  complete  re- 
--e.tion  of  the  ui)per  jaw  is  generally  re<iuire(i.  In  the  other  cavities 
operative  treatment  is  almost  hopeless. 

Foreign  Bodies.  These  have  been  incidentally  referred  to  in  the 
pivc(>(ling  pages.  They  are  most  freciuently  met  with  in  th"  maxil- 
larv  sinus. 

Considerable  help  is  given  in  the  diagnosis  and  treatment  of  such 
toivign  bodicr:  as  metal  drainage-tubes,  broken  ends  of  instruments. 
.iimI  bullets,  l)y  the  employment  of  the  Roentgen  rays. 


<  liniitliaii  Wriglit.    New  York  ModicalJoumal,  November  4, 18«!.    ehrii!to;.her  Heath.    Injuries 
1.1  niseasos  of  the  Jaws.  London.    Hcymann.    Virehow's  Archlv,  1892,  vol.  c»xlx.    Bry«n.    Con- 
I  s«  iif  l-hysioiHiis  and  Surgeons,  18U1. 
-  TrttusutlionB  of  llic  American  Laryngologirai  AsrotiaUuii,  l'^*:  |..  4«. 


982  SOS  E  AND  Til  HO  AT. 


A  P  P  K  X  D  I  X . 


TiiK  fiillnwing  scheiiiii,  as  suggested  by  UiindaM  (trant,  is  founded  on  the  method 
employed  by  Lermoyez  of  dividini;  the  aymptorns  of  sinus  snp|Miration  into  preMiiin|i- 
tive,  probable,  anil  certain.'  It  must  not  be  employed  as  if  mathematically  exact,  but  is 
useful  as  indicating  the  steps  of  a  diagnosis. 

T.\B1.K  I. 
SuiNS  OF  A  C'liKoNir  Empyema  is  Onk  ..k  thk  .\cce.s»oby  Cavities  of  the  Nosk. 
PKESl  MPTIVE: 

(a)  Unilateral  discharge. 

(6)   Headache  or  neuralgia,  relieved  by  discharge. 

(«)  Subjective  caconmia. 

(d)  Polypi,  especiblly  ifbathe<i  in  pus. 

PROBABLE : 

(ii)  Presence  of  pus  in  middle  meatus  or  olfactory  cleft. 
(6)  Opacity  on  transillumination. 

CERTAIX: 

(a)  Catheterization  of  sinus  through  natural  orifice,  and  expulsion  of  pus  on 

irrigation. 
(h)  Exploratory  puncture  of  sinus,  and  aspiration  of  pus. 
(<■)  "  "  "  'xpulsion  of  pus  by  air. 

(<*)  "  "  ,  "  V I  pulsion  of  pus  by  irrigation. 


TABLE  II. 
Differential  Diagnosis  Accordino  to  the  Sitk  of  the  Pukulent  I)is<'ii\kue. 
PUS  IX  MIDDLE  MEATUK: 

!  Maxillary  antrum. 
Frontal  sinus. 
.\nterior  ethmoidal  cells. 

PUS  IN  OLFACTOKY  CLEFT: 

Posterior  cavities.   \  «ph«-noldal  sinus 

l  Posterior  ethmoidal  cells. 


TABLE  III 
Skins  of  Suppuration  in  Maxillary  .Vsthum. 
PRESUMPTIVE: 

(a)   Unilateral  discharge. 

(6)   Intermittence  in  discharge. 

(r)   Pain— infra-orbital,  supra-orbital,  dental,  or  more  distant. 

(«')  Subjective  cacosuia,  intermi'tent 

(c)  Carious  teeth. 

(/)  Pus  in  middle  meatus. 

(g)  Polypi  in  middle  meatus. 

'*)  Hyt)ertrophy  in  middle  meatus. 

'  Lermoyez.    Ther»|ieutlqae  des  maladies  des  rones  naaales.    P«rl«,  Octave  Doin,  1896. 


iJl.SEASJiii  OF  THE  ACCESSOR  Y  SINUSES. 


983 


PKOBAHI.K:  ,  ^     ^.       ^     ,  . 

(.1)   Reappearance  of  pus  on  cleansing  middle  meatiw,  and  bending  head  for- 
ward (Fracnkel). 
It)  Transillumination  showing  opacity  (lieryngi. 
Ig\  "  "  obscurity  of  pupil  (Davidsolin  1. 

Ijx  "  "  absence  of  subjective  sensation  (if  light. 

CKRTAIN; 

I'uncture  and  aspiration,  tranaulflation,  or  irrigation,  by— 
(a)  Ostium  maxillare. 
lb)  Inferior  meatus. 
(p)  Alveolus. 


TABLK  IV. 

Signs  ok  .Si-ppuration  in  thk  Frontai,  Sinus  •    ' 

I'KKSl'MPTIVE: 

((i)  C'ontinaou-.  discharge. 
(i)  Pain. 

(c)  Teiidemeiw  on  pressure. 

I'KDBABLE:  ,  ^     ^.       ,      , 

(a)  No  reappearance  of  pus  on  cleansing  middle  meatus  and  bending  head 

forward. 
(6)  Reappearance  of  pus  after  irrigating  maiiUarj;  sinus. 
(f)  Appearances  on  plugging  the  hiatus  semilunaris. 

(d)  Small  qiiantitv  of  pus,  which  does  not  crust. 

(e)  Transillumination  of  maxillary  sinus  negative,  and  of  frontal  sinus  positive. 


CERTAIN:  . 

Direct  proof  is  impossible  except  by  external  operation. 


TABLE  V. 
Siosa  OK  SiPPfRATioN  OK  Antkrior  Ethmoidal  Cells 

(DISEiSE  or  MAXILLARY   ANTBHM   HAVl.VO  BEKN  EXCLUDED). 

PRESUMPTIVE: 

(n)  Continuous  discharge. 
(6)   Pain. 

(c)  Tenderness  ov«  1    icrymal  bone. 

(d)  Menial  depref  ;io.i. 

(e)  Asthenopia. 

PROBABLE: 

(ii)  Pus,  with  granulations  or  polypi,  in  middle  meatus. 
( h )  The  use  of  a  probe  exposing  pus  or  bare  bone. 

CERTAIN : 

Exploration.  . 


TABLE  VI. 
Signs  of  Suppuration  of  Sphenoidal  Sinus. 


pr::sumptive: 


(a)  Pain. 

(6)  Ocular  disturbance. 

(e)  Somnolence. 


984 


XOSE  ASI>  Tim 


rUOBABI.K: 

l'ri*ence  of  \m»  (or  crusts)  — 

AiiU'riiirly,  in  olfactory  cleft. 

I'oBteriorly,  on  Huperior  and  miilillelurliinals,  on  roof  of  cliimiui',  anil  vault 
of  naxopharynx. 
I.rsions  in  olfactorv  i^left— 

Bulging  of  wail  of  sinux  in  acute  caHw. 
Mucous  |iolv|ii 
CKRTAIX: 

la)  Pus  seen  flowing  fnnn  ostium. 
(b)  Catheterization  of  sinus, 
(r)  Kzploratory  puncture. 


TABLE  Vll. 

SlONM   OK   Sl-PPIKATIOX    OP    t'oXTKRUlK    KtHMOIDAI 

PRESUMPTIVE: 

As  for  sphenoidal  sinus. 

PROBABLE: 

Poly|Hiiil  middle  liirbinal. 

(ERTAIX: 

Return  of  pus  after  irrigation  of  sphenoidal  sinus. 


Bare  bone  felt  at  poHterior  extremity  of  middle  turbinal. 


CHAPTER    XXII. 

DISEASES  OF  THE  OROPHARYNX  AND  NASOPHARYNX. 

By  H.  S.  BIRKETT,  M.D. 

SOFT  PALATE  AND  UVULA. 

Congenital  Malformations  of  the  Soft  Palate  and  Uvula.  Con- 
fliMiital  ahsPMco  of  the  soft  palate  and  uvula  is  of  rare  oecurrenee. 
^ceoinpanying  is  a  photograph  of  sueh  a  condition.  A  second  speci- 
men of  Ihis  malformation  was   lately  founa  in  the  dissecting-room 

of  McGill  University. 

Flo.  ijia. 


Congenital  nbnence  of  «oft  patate  Bnd  uvuUi.    (From  Professor  Shepherd's  Anatomical  Museum, 

McGtll  L'nlrenity.) 

(  98.5  ) 


nvui 


aso 


yosK  A.\n  THROAT. 


Aiii.tlicr  coiiKctiita!  coiKlilinii  of  tin-  soft  palate  and  uvula  is  a 
want  of  fusion  of  the  cniiiryonic  tnaxillarv  processes.  niviuK  rise  to 
!i  condition  known  iis  cirft  ix/lote  (complete).  Tliis  want  of  iniion 
may  vary  in  extent,  and  .sum,  ijme.s  both  hard  and  soft  palate  are 
involved  in  their  entirety,  as  seen  in  Fi^.  'A.i.     \\  other  times  it. 


Km,  .'iLi. 


Flu.  i\*. 


Cleft  palate  and  uvula,    (CnHF-N,) 


Defects  In  the  iinlirlor  pillar  of  the  fauct 


may  only  involve  the  soft  jjalate  and  uvula,  and  again  oiilv  tin  uvuhi 
Itself  may  be  affected,  ami  in  this  latter  ca.se  it  gives  rise  to  what 
IS  known  us  a  hiftd  uvula.  This  division  of  the  uvula  niav  be  partial 
Dr  complete. 

Another  congenital  defect  is  occa.sionally  met  with  in  the  |)illar> 
of  the  fauces.  Thi.s  defect  consi.sts  of  a  fXTforation  of  either  one  oi 
both  anterior  pillars.  They  -  ay  be  congenital,  due  tf)  an  incom- 
plete cKwuri'  of  the  branch'"  clefts,  or  as  the  result  f.f  ulccrati<.i. 
occurring  in  the  course  of  an  infectious  fever  (scarlet  fever),  as  in 
one  of  the  writer's  cases,  or  as  the  result  of  breaking  down  of  :: 
gummatous  infiltration. 


uinEAiiica  OF  Tin:  oropuaey\x  asd  XAsoPUAiiryx     i)«7 


DISEASES  or  THE  UVXTLA. 

UvuUtis,  Etiology.  Tlif  usual  oaus(>  of  an  acutr  iuHainmatidii  t)f 
the  uvula  is  ••cold."  It  luav  also  l)c  llic  rcsuli  of  an  .'Xtciisioii  ot 
an  acute  iutlaiuniatorv  process  from  th.'  a<ljac<'iit  strur.ur.>  ipiiarynx 
ami  tonsils).  It  may  also  occur  trau  .latically  tliroupli  torcipii  bodies 
or  from  the  aclioti  of  any  corrosive. 

Symptoms.  The  first  svmptoni  usually  iio''ce<!  is  a  sii>;lilly  pamlu 
sensation  of  liie  throat  upon  every  movement  of  the  soft  palat.,  aiul 
especiallv  marked  when  swalL.winn.  Later  on  this  is  followed  I >%•  a 
feelinU  o'f  a  foreign  hodv  in  the  throat,  and  every  eHort  to  dislodge 
it  is  apt  to  he  followe.l  l.v  an  iiitensitv  of  the  syin|itoms.  Tickling 
and  a  eoupli  are  also  apt  to  he  present.  The  symi)t(nns  may  l>ecome 
so  aggravated  as  to  actually  pnriintate  attacks  of  stiflocatiun  du.- 
to  the  ei'laifted  and  elongated  condition  of  the  uvula  irnt-vtuip  the 
upiier  part  of  the  iaivnx.  I'poii  examination  in  the  early  stage  of 
the  disease,  the  uviia  is  s<-<-n  to  he  uniformly  injected  from  its 
tii;    to  its    Ivise.  and    from    here   exteudinn   slightly  into   the    soit 

' '\vhen  exudation  has  taken  i)lace  into  the  loose  tissue  of  the  uvula 
it  then  a.ssiimes  a  swollen,  (edematous,  and  semitransparent  look: 
its  original  outliii.'  and  shai-e  are  c()m|)letely  altered.  The  general 
disturiiaiice  is  usually  very  slight. 

Treatment.  In  the  (>arly  stage,  before  traiifudatiou  has  taken  place, 
thea|ii)licationof  a  5  per  cent,  solution  of  adrenalin  chloride  (1  :  10()0), 
piiiited  everv  hour,  will  frequently  cut  the  inflammation  short.  It 
transudation  has  taken  place,  then  the  tension  is  best  relieved  by 
nuiltiple  punctures.  This  is  best  done  by  having  the  patient  hold 
his  tongue  down  himself  bv  means  of  a  <lepressnr.  then  grasping  the 
uvula  at  its  tip  to  steadv  it,  and  with  a  long  (Jraete  knife  make  several 
deep  punctures  into  the  most  dependent  portion  of  the  uvula.  The 
subse<iuent  treatment  is  the  use  of  an  alkaline  and  antiseptic  spray 
-^uch  as  Dobell's  solution. 

In  this  coniM>ction  mav  be  mentioned  adema  oj  the  uvula  occurring, 
ilthough  rarelv.  in  the'course  of  chronic  Blight's  tl'«ea.s(>.  and  that 
due  to  the  result  of  patients  suffering  from  jxistna.  al  catarrh  who 
attempt  to  draw  the  secretion  from  the  na.sopharynx  with  such  vio- 
lence as  to  produce  a  traumatic  (I'denia.  Relief  to  local  .symiitonis 
will  be  followed  bv  puncturing  the  uvula  a.s  described. 

Elongation  of  the  Uvula.  Causes.  Recurring  attacks  of  :  ute 
inflammation  of  this  organ,  chronic  pharyngitis,  nasopharyngitis,  and 

wan'  of  general  tone. 

Symptoms.  Fre(iuent  cl«>aring  f  the  throat,  tickling  followed  l.y 
cough,  especially  aggravated  whe..  lying  down,  and  in  some  cases 
the  uvula  ha«  been  so  long  as  to  reach  the  entrance  to  the  Larynx  and 
produce  a  spasm  of  the  glottis,  the  patient  awakening  with  feelings 
of  impending  suffocation. 


'J8H 


.\(»SF  AXh  THRU. IT. 


H 


Treatment.  Let  one  livar  in  mind  that  attention  to  tlic  pnticntV 
Kt'n(i;il  state  of  h  'altli  is  of  |iriiMaiy  iinixirtancf,  anil  eonihineil  witli 
the  u.se  of  astringent  apphcalions  siicli  !i.«  ftl.vcerin  ami  tannic  acid 
(H.  I*.  I,  or .")  per  cent,  solution  of  |)rotar>;ol  will  serve  in  the  majority 
of  cases  to  relieve  the  symptoms.  In  the  ca.se  of  coukIi  beiriff  "a 
trouhlesoriie  symptom,  h't  one  here  he  warned  not  to  he  deluded 
that  the  uvula  may  he  the  cause  without  first  carefully  investixatinfc 
the  patient's  jjeneral  condition  as  to  the  po.ssihie  existence  of  other 
causes.  The  writer  has  fre<|uently  seen  cases  where  a  portion  of  tiie 
uvula  has  heen  removed  with  the  exiM'ctation  of  relieviiiji  the  coukIi, 
when,  iipon  careful  examination,  the  patient  wa.s  found  to  1h"  sufTerinR 
from  incipient  (uherculosis. 

When  pfftiM-rly  indicated  a  portion  of  the  uvula  may  he  removed 
as  follows:  The  uvula,  es|M'cially  its  posterior  surface,  is  first  |)ainted 
with  a  U)  jier  cent,  solution  of  cocaine,  followed  l>y  an  application 
of  a  solution  of  aflrenalin  chloride  (1  I'MK)).  At  the  expiration  of 
ti'ii  mimites  the  uvula  is  sulficienlly  aiuesthetic  to  proceed.  The 
l)atient  lu.lds  his  own  tongue  down  to  the  floor  of  the  mouth  hy 
means  of  a  depre.s.sor,  and  the  uvula,  wiiich  hiis  been  grasped  at  it's 
extreme  tip  hy  means  of  a  pair  of  lonj:  anjrular  fon-eps,  then  with  a 
pair  of  long  scissors,  curvetl  on  the  flat,  the  excessive  len>;th  should 
he  cut  off  in  a  direction  from  Im-Iow  backward  and  upward,  thus 
leaving  the  greatest  jxirtion  of  the  cut  surface  posteriorly.  In  cutting 
the  uvula  one  must  he  careful  to  remove  (tnly  the  elongated  mucous 
membrane,  and  not  to  injure  the  azygos  uvula-  muscle.  Complete 
ablation  (»f  the  uvula  is  to  be  condetmied  as  wholly  unnecessary. 
The  slight  bleeding  which  usually  follows  a  uvulotomy  re.piires  no 
attention,  as  it  cea.ses  in  a  short  while:  but  it  has  occilrn  d  that  the 
hemorrhage  has  |,een  considerable,  and  when  of  such  a  degn'e,  then 
the  application  of  such  a  solution  as  ailrenalin  chloride  (1  :  l(XX)l, 
glycerin,  and  tannic  acid.  .,.  the  application  of  the  galvanocautery 
may  be  sufhcient.  If  none  of  these  measures  arrest  the  hemorrhage, 
then  the  application  of  a  ligature  around  the  uvula  and  above  the 
cut  surfaci'  will  suflice. 

The  subse(|uent  treatment  of  a  c;ise  of  uvulotomy  is  rest  of  the 
organ,  and  this  means  abstaining  from  speaking  and  Of  taking  nour- 
ishment in  such  ;t  form  as  to  re(|uire  the  least  amount  of  sw.r.iowing 
consistent  with  the  greatest  amount  of  nourishment:  therefore,  such 
foods  a.s  jellied  beef  '.s.sence,  calves'  foot  jelly,  and  oysters  are  the 
best  form  of  nourishment.  The  |)ai;i  fr.l'owiiig  a  uvulotomy  is  con- 
siderable, and  will  be  relieved  bv  the  !is>.  of  small  pieces  of  ice  being 
hehl  in  the  mouth  while  rec!ining. 

Hematoma  of  the  uvula  is  not  infre(|uently  .seen  as  the  result  of 
operative  interference  on  the  organ  itself  or  as  a  .se()uence  of  ton- 
sillotomy, '''he  writer  has  also  seen  it  as  the  result  of  violent  efforts 
of  nn.sal  screatus.  A  varicosity  of  the  superfici;i!  !>|n(»dvesse!s  of  th<- 
.soft  jmlate  and  uvula  may  occivsionally  be  se(>n  m  cases  of  arterio- 
sclerosi.s. 


DisK.isKs  OF  Tin:  onniif  ■  nrxx  asd  SAaovii.mY.sx.  wm 


Benign  and  Malignant  Growths  of  the  Uvula  and  Soft  Palate. 

Benign  Orowths.  P»pUlom«.  This  is  \\w  most  frcr  m  <.f  the 
l,..|ii)iii  iiiowtlis  occiirriiin  ii>  this  rcKiuii.  I'iipilldiiuita  in..y  Iw  .-ithiT 
.r^iii'  nr  |MMhiiiciiliit<Ml,  iiii.l  .listril.uliMl  in  jrnmps  ..r  siiifjiy  mi  any 
..•lit  i.r  tli«'  soft  palat.',  uvtili,  !Ui<l  !>illars  of  tli.-  faiin-s.  W  h.-ii  scssil<' 
'mil  sinnl.'  thfv  cause  no  >vniiiti.ms.  but  wiicii  apiiiiiatiMl  or  iit.hiu- 
iiiiatfci  they  may  pnxhicc  symptoms  of  a  foreign  hotly.  a.s  tickiiiijt 
c.iu^th  or  frciiuriit  clrariiin  "f  tiic  throat. 

Angioma.  Aii>.'iomata  are  rarcaml  s(.mctimi's  fouml  tolx' assoc;  ted 
with  a  simihir  ooiulitioii  in  the  othiT  portions  of  llic  respiratory  act. 
These  tumors  iiiav  !)<■  sinnle  or  consist  of  a  .series  of  small  on.  "(  .t- 
tere.l  over  the  IKilatr  and  uvula.  In  one  of  the  writers  c  .the 
tuii.ors  were  scatteri'.l  over  the  soft  palate  and  cheek  of  one  side, 
hut  in  the  larynx  they  were  collected  into  a  very  dehnite  tumor 
iiivolviiift  the  false  cord  on  the  <ame  side. 

They  seldom  cau.se  anv  svmi)ton!s  or  require  any  interference: 
i.ut  if"larn-c  and  thev  lend  to  he  a  •  -  ce  of  recurriiiR  hemorrhages, 
then  they  are  Im-sI  treated  hy  nwa"-  of  electrolysis,  although  there 
are  many  who  advocate  their  remova    .>y  either  the  cold  or  galvano- 

cauterv  snare. 

Simple  adenoma  of  the  soft  palate  is  rare,  more  commonly  f»ucli 
tumors  being  mixed,  as  tibro-adenoma  or  myxo-adenoma.  These 
tumors  are  u.suallv  sessile  or  |«'(lunculated  and  covered  with  normal 
mucous  membraiH".  and  do  not  tend  to  inva.le  the  surrounding  struc- 
ture- Their  |)resence  is  not  attended  by  any  painful  sensations, 
tuit  usuallv  those  of  a  foreign  body  in  the  throat.  Hemoval  by 
. Means  of  the  cold  wire  snare  or  by  scis.sors  an-  the  best  wi-ys  of  dealing 

with  them.  .      •  i    •     »i  • 

The  following  rare  benign  tumors  may  also  be  met  witli  in  tins 
region;  dmnoid  rusts.  U^HitmUt.  )ihro-clwii<lr»viat<i.  and  uhtw.n  ecu 

"'waUgnant  Orowths.  ^hllignant  tumors  originating  in  ei  !'(r  the 
soft  palate  or  uvula  are  not  of  fre.iuent  occurrence,  but,  as  ■  cNten- 
si„ii  of  the  disease  from  neighboring  structures.  !'re  not  ui."'  vunon. 

Carcinoma.  Carcinoma  of  the  soft  palate  u.  .  i'-  aj-pear.  e.  t he 
f,,n„  of  epithelioma.  The  disease  shows  itself  i  ly  i-ortion  of  the 
uvula  or  soft  jialate,  and  in  the  early  sta;:e  makes  itself  known  by  a 
definite  ..welling  of  the  part  invaded;  the  mucous  membrane  covering 
it  is  sli<rhtlv  injected.  To  the  t<.uch  it  is  firm  and  the  overlying 
vtructuiTs  iiitimatelv  adherent.  TIktc  is  gradual  enlargement  until 
the  surface  is  brokeii  ami  an  ulcerating  surface  presented,  th<"  granu- 
litioMs  of  which  are  inten.selv  red,  bleed  easily,  and  the  edges  hrm 

Symptoms.  In  the  earlv  stage  the  symj)t()ms  are  those  of  impaired 
movements  of  deglutition  and  sijoech.  The  pain  may  not  be  severe 
ui.til  ulceration  takr-  place,  when  it  is  .ipt  to  be  severe,  especially 
during  the  process  of  deglutititm,  the  pain  radiating  toward  each 
.'•ir  should  the  growth  be  situated  in  the  uvula  alone  or  m  the  centre 


1 

'5 

: ' '  i 

■'if 


c 


U 


9510 


SOSi:  A.\D  THROAT. 


of  tlic  soft  palate;  but  if  to  one  side  of  tlio  niuldlc  line,  tlx'ii  tlic 
pain  shoots  into  tlic  car  on  the  corrcspondiiift  side.  It  is  a  disease 
usually  of  advanced  at;e. 

Sarcoma.  Sarcoma  of  these  structures  is  rare,  the  most  common 
variety  Ix-iufr  the  fibroid:  less  connnon  arc  lymphoma  and  the  melan- 
otic variety.  Sarcoma  may  in  its  early  existence  i)resent  a  .swelliiifr 
of  the  invaded  structures  not  unlike  carcinoma:  liut  the  mucous 
memhrane  coveriiijr  it  is  not  so  liyperaMuic.  It.s  course  is  slower  than 
that  of  carcinoma,  and  the  lympliatic  jjlands  are  fre(|uentiy  not  in- 
volved.    It  is  a  disca.se  found  nuicli  ;  arlier  in  life  than  is  carcinoma. 

Symptoms.  The  symptoms  may  in  every  respect  resemble  tin i.se  of 
carcinoma. 

Treatment.  JudfinuMit  in  operating  u])on  all  malijinant  cases  in 
which  the  .soft  palate  and  uvula  are  primarily  involved  must  be 
treated  according  to  individual  conditions  jm-sent.  When  the  disease 
is  well  limiteil  to  either  the  uvula  or  soft  palate  com])lele  removal 
is  to  be  strongly  advised.  .\ny  glandular  involvement  will  also 
re(iuire  removal  by  surgical  measures.  In  the  tn'atment  of  sarco- 
mata the  use  of  ("oleys  serum  ha.s  found  many  strong  sujiixirters, 
and  it  is  only  one  of  those  measures  which  are  advocated  when 
.surgical  measures  seem  to  be  out  of  the  (|uestion. 


DISEASES  OF  THE  TONSILS. 

Tht>  tonsil  is  a  collection  of  lymjihoid  tissu<'  upon  whose  free  surface 
are  a  number  of  depressions  (crypts  or  lacuna'),  .sejijirated  from  each 
other  by  follicles,  and  is  covered  by  a  nuicous  membrane  which  dips 
into  tlii'se  crypts.  I)e|)ending  upon  the  situation  of  this  collection  the 
tonsils  have  received  various  names — faucial,  |)liaryngeal,  and  lingual. 

The  faucial  ton>ils  are  two  in  number,  one  on  either  side,  between 
the  anterior  and  jxisterior  pillars  of  the  fauces.  In  .size  and  shape 
they  may  v.-uy  very  nnich  in  different  individuals:  ordinarily  they  are 
about  the  size  and  shape  of  an  almond  fruit.  If.  when  inspecting  the 
f.aucial  tonsil,  the  anterior  pillar  is  dntwn  forward,  outward,  and 
slightly  downward,  a  fold  of  mucous  membrane  will  be  seen  exten<l- 
ing  from  its  edge  downward  and  backward  to  the  tonsil.  This  i- 
known  as  the  plh-ii  Iriininiilaris  iTIisi.  Immediately  above  this  is  ;i 
lecess  or  fossa  to  which  the  n:\u\f  yii pnilinisillfir  fos.-^a  has  been  given, 
.•uid  this  recess  is  found  to  extend  backward  and  sometimes  forward 
into  the  substance  of  the  soft  palate. 

Acute  Catarrhal  Tonsillitis.  In  this  alVection  the  nmcous  mem- 
brane covering  the  tonsil  is  the  p;trt  chiefly  alTected,  and  is  nearl\ 
alw.Mvs  ;i  part  of  ;ui  acute  |)haryngitis. 

Etiology.  This  disease  is  most  common  in  chiMren.  Sudilcii 
changes  in  the  temperature  and  exposure  to  cold,  gastro-intesiina! 
affections  and  manv  of  the  acute  exanthemata. 

Symptoms,  The  symjjtoms  may  b(>  ushered  in  by  ;i  sense  oi  chilli- 
ness, and  ill  young  children  even  by  a  convulsion.     This  is  icCPom|)a- 


DIsfJASKS  OF  THE  OROl'llARYSX  AXI>  yAaOPJIAlirXX.    <J91 


iiicd  l)V  liciidaclic,  pcncral  depression,  temperature  raiiftiiip  from 
1(1(1°  to"  102°:  i)ulse  full  and  bouu.'ing.  deglutition  is  painful,  and  the 
muscles  of  tlie  neek  ami  the  cervical  glands  may  he  tender.  Ipon 
(  N.iminatioii  in  the  early  stage  of  the  disease  the  surface  (if  the  tonsil 
and  surrounding  structures  present  a  marked  degree  of  hypera'inia, 
and  later  on  a  very  thin,  whitish  exudate  may  Im- seen  at  theoix-nings 
u|  the  crypts.  The  disea.se  usually  runs  its  cour.se  in  about  four  days 
il  unattenih'd  to.  and  may  by  its  extension  involve  the  middle  ear 
111  ;ui  acute  intianuuatory  |)roce.ss,  attenth-d  either  with  or  without 
-uppuralion. 

Treatment.  Begin  with  a  purgative,  such  as  calomel  and  soda  in 
■■niall  doses,  gr.  j  each,  freijuently  repeated  If  the  temperature  be 
high  and  the  jmlse  full  and  bounding,  small  doses  of  tincture  of 
aconite  iM.  1'.),  1T|i.i  "'very  two  hours,  will  be  of  service.  ('oi<l  alka- 
line sprays  such  as  the  following  will  t>i'  found  to  give  relief  to  the 
-ymptoms  in  the  early  stage  of  the  disease: 

Sudii  bictirboiiatts. 

Sodil  biboretis,  »ft    nr.  ix. 
01.  cinnainomi,  lll'j 

Aciiiac.  'iv 

.\pplications  of  a  solution  of  nitrate  of  silver  (gr.  xxx  to  .^j) 
(iiice  a  (lav,  or  guaiacol  in  its  ])>ne  state,  to  the  surface  of  the  tonsil 
.iiid  into  the  cryjits,  are  stningly  recommen(l(>d.  Should  the  di.sease 
progress  to  such  a  (legre(>  that  the  inflammatory  process  shows  by  its 
inlensitv  that  the  lUKh'Hying  structures  have  been  invaded,  then 
local  depletion  (scarification)  is  advisable.  The  .-^pray  then,  or  gargle. 
-Iiould  be  used  hot. 

Acute  Lacunar  Tonsillitis.  This  affection  is  an  inflammation  of  the 
crypts  or  lacutue  of  the  tonsils,  and  is  characterized  i)y  the  fliling-ui) 
nt  these  cryjits  with  inflammatory  products,  which  appear  on  the 
-miace  as  ;i  white  or  yellowi.sh-white  exudate,  accomjianied  by  an 
iiivolveinenl  of  the  adjacent  and  deeper-lying  structures  in  the 
lutlamniatory  jirocess. 

Etiology.  Among  predisposing  catises  a  lowereil  state  of  the  general 
<vsleiii  st;inds  pre-eminently  first.  Sudden  changes  in  the  temix-ra- 
iiire.  unlicaltli\  <i:iidition  of  the  tonsils  themselves,  and  ;is  exciting 
rauses,  in  the  liglil  '  jiresent  bacteriology,  certain  bacteria,  notably 
I  he  pvogeiiir  cocci,  are  found  to  be  the  cause  of  such  inflammatory 
.•iiiiditions.  Other  exciting  caus(^s,  as  iniperf(  1 1  sanitation,  close, 
overheated,  and  foul  atmosphere,  so  fr(>(|uently  met  with  in  the  out- 
dnor  clinics  of  many  large  hospitals,  give  rise  to  this  condition,  and  is 
uvnerally  known  as  "hospital  sore-throat."  This  disease  is  more 
roiimion  in  young  and  middle-aged  individuals,  and  less  fre(|uent 
ill  advance(l  life.  It  is  not  unconinion  to  find  this  form  of  ton.sillitis 
attacking  individuals  in  a  house  where  scarlet  '  ver  i.-  jiresent.  One 
attack  is  apt  to  predispose  to  future  attacks. 

Symptoms.  The  disease  is  usually  ushen^d  in  by  headache,  pain  in 
the  liack  or  extremities,  chilliness  or  even  rigor.    The  throat  is  painful. 


992 


-VavA'  AXD  THROAT. 


\ 


e>s|)cci;illy  when  swallowing,  and  ovoii  speaking  may  l)o  painful.  Tlip 
pain  extends  upward  to  the  ears  if  hotli  sides  are  involved,  and  to  one, 
on  the  same  side  as  the  atTeetion,  if  limited  to  one  tonsil.  The  tem- 
perature varies  from  1(K)°  to  10;]°  or  104°:  the  pulse  is  rapid  (100-120). 
full  and  bounding.  I'sually,  the  disea.se  begins  on  one  side,  and 
within  a  time,  varying  from  ;i  few  hours  to  a  day.  the  otiier  side  is  m 
vaded.  The  submaxillary  glands  are  frecjuently  swollen  and  tender. 
The  inflammatory  eMudition  may  extend  to  the  parenehyma  of  the 
toii>il,  when  the  sym|)toms  beeome  .somewhat  more  intensified  (par- 
enehymatous  tonsillitis).  Tjion  examination  the  tonsils  are  seen  to 
be  swollen  and  hypera'inio.  and  if  the  i)arenehynui  if  involved  the 
hypera'mia  may  be  of  a  livid  hue.  On  the  surfaee  of  each  tonsil  are 
to  be  notieed  small  isolated  spots  of  exudation,  their  size  and  .shape 
corre.sponding  very  often  to  the  opening  of  the  crypts.  This  pxu- 
dated  materi.-il  varies  in  color;  it  may  be  white,  yellow,  or  gray.  The 
exudation  may  be  limited  to  tht  openings  of  the  crypts  or  may  extend 
and  coalesce  with  that  from  the  neighboring  crypts,  giving  to  it  in  some 
ca.ses  a  distinctly  membranous  appearance.  The  exudation  may  l)e 
so  slightly  organized  that  it  may  be  easily  wiped  off  by  means  of  a 
cotton-wool  swab,  or  it  may  be  so  dense  as  to  be  adherent  to  the 
mucous  membrani>,  and  re(|uire  theu.se  of  a  |)airof  forcep.s  to  loosen 
it,  and  when  loosened  it  exposes  an  underlying,  very  hypera'inic,  and 
even  superficially  ulcerateil  area. 

In  persons  who  have  suffered  from  recurring  attacks  of  a(  ife 
lacunar  tonsillitis  the  secretion  is  apt  to  have  a  very  fetid  odor.  The 
uvula  is  usually  hyixTa'inic  and  sometimes  .swollen. 

Treatment.  .\  brisk  purgative  of  calomel  and  .soda  should  be  given 
at  the  outset,  alxiut  gr,  iv  of  calomel  andgr.  iij  of  soda.  Small  doses  of 
tincture  of  aconite  ( H.  P.),  ITlij.  may  be  given  hourly  until  the  |)ulse 
and  temiM-rature  are  lowered,  provided,  of  course,  that  the  |)ul.se  is  ;i 
rai)id,  full  and  bounding  one.  The  .salicylates  in  various  forms  have 
in  some  ca.«es  proved  advantageous:  salol  gr.  v  and  phenacetin  gr, 
iij,  given  every  two  hours  in  combination,  have,  in  the  writer's  hands, 
proved  most  beneticiaL  (iuaiacum,  a  much  vaunted  r(>medy,  has 
not,  in  the  writer^  experience,  proved  to  be  esjiecially  efficacious. 
Henzoate  of  soda  in  10-grain  doses  is  waririly  advocate<l  by  manv 
authors,  [.ocally,  the  tonsils  should  be  sprayed  with  a  warm  alkaline 
and  antiseptic  solution,  such  as  one  of  the  following: 


.\<'iili  iHrlKillii, 
H'Klvert's  No.  1) 
Skxiii  birnrbollHtix, 
Afimc, 

Poilil  blrarbiinatis, 

Li^^terine. 

A(iua>, 


«r.J. 

gr.  T. 
Sj. 

gr.  V. 

Sj. 

Sj 


Whenever  possible  it  is  advisable  to  ole.nr  out  the  crypts  of  anv 
retained  serretion,  and  this  cati  Im  done  by  means  of  a  small  curetl>' 
or  scooj).     .\nother  method  of  dislodging"  these  inflammatory  plug 


y^Wi'-Lbii-A'  OF  THE  ORnl'lIARYSX  ASD  SAHOPHARVyX.    <)y3 


wil 
illl|iliS: 


which  the  writer  has  found  lu'iu 'icial  is  to  project  ajjainst  the  tonsil 
hv  means  of  a  syringe  a  stream  of  wjnn  Ixric-acid  solution  (ffr.  xx  to 
.=,i).  In  carryiil't  this  out  it  is  iiecessai.,  »o  have  the  patient  leaning 
a  little  forward,  and  thus  facilitate  the  escapeof  the  fluid  by  the  mouth. 
The  aiipliciition  of  either  sua!  icol,  the  nniriated  tincture  of  iron,  or 
liiicture  of  iodine,  by  means  of  a  cotton-wool  swal),  into  each  cryi)t 
ill  tend  to  cut  short  the  course  of  the  di.seitse  in  many  cases.  If 
sible  to  make  these  applications,  then  these  remedies  may  be 
used  in  the  form  of  frargles;  thus  guaiacol  should  Ije  used  as  a  1  per 
cent,  solution,  the  tincture  of  iodine  in  the  same  strenjith,  ami  the 
niuriated  tincture  of  iron  mi  doses  of  lUv  combined  with  gr.  iv  cf 
chlorate  of  pota.ssium  to  the  drachm  will  bo  found  efficacious. 

.\s  to  a  clioice  of  any  of  the  above-mentioned  remedies  as  a  local 
application  there  does  iiot  seem  to  be  one,  in  the  writer's  e.xperienco, 
each  drug  having  its  own  adhenuit.  As  tliere  is  in  all  jjrobability  an 
inlcctious  character  about  these  acute  inflammatory  [)rocessps  of  the 
tonsil,  such  ciuses  should  iis  a  precautionary  mea-sure  be  isolated.  In 
iio'.ises  where  there  is  a  fnvjuent  occurrence  of  these  attacks,  investi- 
gations should  be  made  into  the  conditions  of  the  drains  and  sanitary 
surromidings;  in  all  cases  a  cause  should  be  looked  for,  and,  if  possible, 
he  removed.  Any  existing  diathesis,  as  rheumatism  or  gout,  should 
he  corrected  by  suitable  remedies.  The  course  of  the  disease  is  usually 
favorable,  terminating  in  recovery  in  about  four  or  five  days.  Com- 
plications of  a  more  or  less  grave  character  are  rarely  met  with,  and 
when  they  do  occur,  they  indicate  a  general  infection.  The  occur- 
rence of  joint  affections  and  canliac  complications  ha.s  led  to  the  sup- 
position of  a  very  close  iussociation  between  rheumatism  and  tonsillitis. 
Tonsillar  and  Peritonsillar  Abscess.  Depending  upon  the  situation 
of  the  accunmlation  of  the  inflammatory  products,  so  is  the  affection 
named.  In  the  one,  the  suppurative  process  is  situated  in  the  sub- 
-tance  of  the  tonsil,  and  in  the  other,  in  the  tissue  surrounding  it.  The 
former  affection  is  comjjaratively  rare  and  the  latter  (|uite  frequent. 
Peritonsillar  abscess  may  occur  at  any  age,  but  is  especially  associated 
with  adolescence  and  a  strumous  habit. 

Etiology.  Acute  lacunar  ton.sillitis  is  apt  to  be  a  precursor  of  either 
tonsillar  or  ])eritonsillar  abscess,  chronically  enlarged  tonsils,  retention 
of  secretion  within  the  ciypts,  especially  in  the  supratonsillar  fossa. 
Symptoms.  The  symptoms  are  those  of  an  acute  lacunar  tonsillitis, 
though  they  are  apt  to  be  more  intense;  <leglutition  is  more  difficult 
and  more  pai"ful;  the  pain  in  the  ear  is  apt  to  be  more  constant  from 
the  swelling  of  the  .soft  palate,  extending  often  up  to  the  mouth  of  tlie 
JAistachian  tube.  There  is  marked  difhculty  in  opening  the  mouth, 
the  opening  being  so  limited  in  severe  cases  that  a  thin  tongue- 
depressor  is  with  difficulty  inserted  between  the  teeth.  Thesecreticm 
of  saliva  is  much  increased,  and  with  the  other  glandular  secretions 
it  hccoiiies  verv  tenacious  and  difficult  for  the  patient  to  get  rid  of; 
ill  fact,  attempts  at  its  removal  are  so  painful  that  many  patients 
allow  it  to  dribble  out.    The  breath  usually  is  very  fetid,  and  especially 

(>3 


I  i. 


994 


XOSE  AXD  THROAT. 


is  this  so  when  suppiiratiiiii  iius  occuricd.  Tlic  t('in|)('i'iituro  at  this 
stage  is  apt  to  he  more  elevated  (101°  to  102°) :  the  patient's  voice  he- 
coiiu's  very  tliick,  speeeh  is  with  diHicuit}-  carried  out,  and,  oe  account 
of  its  ciiaracter,  dithcult  to  understand.  Tiiere  is  often  oDstructed 
i)reathing  tiirough  tiie  no^trils  on  tiie  affected  side,  and  the  patient 
lias  a  sense  of  fuliu  w  at  the  haciv  of  tlie  nostril,  and  freiiuently  tries 
to  clear  it  hy  making  a  snorting  noise.  This  obstruction  is  due  to  a 
swelling  of  the  ui)per  surface  of  the  soft  palate  posteriorly.  There 
is  a  marked  tenderness  of  tlie  sulmiaxillary  and  cervical  glands,  and 
there  is  often  a  markeil  fulness  behind  the  angle  of  the  lower  jaw. 
I'Yoin  the  inability  of  the  patient  to  take  nourisliment  there  Is  loss  of 
weight,  and  the  facial  exj^res.sion  is  that  of  acute  suffering.  The  ex- 
amination in  many  cases  is  carried  out  with  a  great  deal  of  difhculty. 
owing  to  the  inability  of  the  j)atient  to  open  his  mouth  sufficiently 
wide  to  make  the  examination  thorough.  In  tiiose  c:uses  which  allow 
tiie  examinat'on  to  be  made  it  is  noticed  that  there  is  a  definite  and 
distinct  .-wellmg  in  the  soft  palate  just  above  the  tonsil  of  the  affected 
side.     (Mite  WIX.) 

The  imicous  membrane  covering  it  is  of  varying  intensity  of  color, 
from  either  a  rose  to  a  iivid  hue.  The  tonsil  it.self  is  pushed  inward 
and  downward,  atid  to  such  an  extent  in  severe  cases  that  its  inner 
surface  looks  directly  over  the  epiglottis.  The  uvula  is  swollen, 
(vdematous,  and  |)ushed  •■eyond  the  median  line,  and  .sometimes  in 
contiict  with  the  tonsil  of  the  oi)po,site  side.  If  it  is  possible  to  ex- 
amine the  swelling  digit.ally  the-  is  a  full,  ten.«e,  and  deep  fluctuating 
sen.sation  to  i)e  felt. 

Treatment,  if  the  patient  be  seen  in  the  intlanunatory  stage.  i>efore 
suppuration  has  taken  place,  there  is  nothing  better,  in  the  writer's 
experience,  than  a  deep,  free  incision  into  the  substance  of  the  .«oft 
palate,  just  a  ijuarter  of  an  inch  above  the  anterior  palatine  arch,  and 
made  at  right  angles  to  it.  This  gives  relief  to  the  tension  and  allows 
of  the  free  e.«cape  of  accumulated  infiannnatory  products,  .•uid  the  local 
depletion  adds  very  much  to  the  relief  of  tlie  symijtoms.  No  thera- 
peutic measures  seem  to  relieve  tliis  condition,  .'^hould  the  stage  of 
supl)urati<.n  Im'  i)resent  wlien  the  patient  is  seen  then  the  pus  shoultl 
be  allowed  to  escape  by  means  of  an  incision  Tuade  as  above  described. 
In  either  ca.se  the  kind  of  knife  and  its  method  of  u.'*e  are  of  some  con- 
siderable iin|)ortance. 

The  useof  a  curved  bistoury  is  not  advisable,  because  it  is  iiiijxi.ssible 
to  tell  where  the  point  of  the  instrument  may  be :  preferably,  a  straight 
back,  nainiw-bladed  knifi'  is  il'e  better.  The  knife  should  be  held 
with  its  blade  horizontal,  and  the  cutting  'mI^c  directed  toward  tin 
middle  line.  \\\  m;ikiiig  the  incision  in  this  way  its  edges  are  more 
likely  to  be  kept  apart,  and  thus  f.acilitate  the  escape  of  pus,  than  il 
made  vertically,  when  the  edges  come  together  and  close  the  wound. 
The  juis  wiiich  e.srai>es  has  usually  a  very  fetid  odor.  IVc-.-ure  on  th' 
region  of  the  abscess  will  facilitate  tlie  contents  being  thoroughl} 
evacuated.     The  subse(|uent  treatn.ent  is  merely  the  useof  an  anti 


IM.Al-f:    XXIX, 


1 


I'lTlllMl'^ll  llll      All  - 


Aulhc  .rV  in^.',  i 


uii;i:Asi-:s  of  the  oropuarysx  asd  XAsoj'iuiiy.sx.   »jy5 


s«>i»tic  pirfilc  nf  listcriiic  (1  ilraclmi  to  the  ounce),  or  a  weak  (2  j 


I'lit. 


oarholic  so 


ilut 


ion.  I.cland  stroiifily  advocates  the  rcadiing  of 
these  al)sc(>-ses  tliroujih  a  very  free  incision  made  into  the  substance 
of  the  tttnsii,  and  sul)r.'(|uentiy  using  tlie  finger  to  enlarge  tiie  opening. 
In  several  of  this  chtss  of  ca.ses  the  writer  has  found  thesupjmrativp  pro- 
cess to  have  been  cau.sed  by  ca.^eous  products  retained  in  the  supra- 
nsillar  fo.ssa,  and  by  siin[)ly  drawing  the  anterior  pillar  of  the  fauc 


111 


cs 

forward  and  downward  by  means  of  a  bent  |)rol)e  the  collection  of 
pus  has  been  allowed  to  escape,  with  relief  to  the  symptomsand  with- 
out further  operative  interference.  It  is  therefore  always  well  to  in- 
vestitrate  tlie  possibility  of  the  |)us  being  thus  retained  before  |)ro- 
cced  ..g  to  inci.se.  fpon  recovery  this  p:.cket  can  be  dealt  with  by 
providing  free  drainage  and  curetting  the  cavity. 

The  duration  of  this  affection  if  left  to  it.self  is  usually  from  five  to 
seven  days.  The  danger,  however,  of  allowing  a  coMection  of  this 
kind  to  go  on  until  the  pus  finds  an  exit  for  itself  is  that  it  may  e.sca|)e 
during  sleep,  and  produce  alarming  symptoms,  if  not  suffocation  itself. 
If  the  pus  has  burrowed  very  extensively  it  may  erode  the  a.scending 
|ih:iryngeal  or  internal  carotid  artery,  producing  alarming  or  even 
fatal  hemorrhage.  Septic  thromboi)hlebitis  is  also  known  to  occur, 
and  is  generally  a  fatal  complication.  The  infiannnatory  condition 
may  extend  downward  and  ])roduce  an  (vdenia  of  the  laryn.x.  I'sually 
only  one  side  is  involved  in  ton.sillar  or  periton.sillar  ab.scess,  but  the 
process  may  (jccur  in  both  sides. 

Acute  Ulcerative  Tonsillitis.  This  is  the  title  of  an  affection  of 
tiie  tonsils  given  by  Moure  to  a  condition  seldom  int  t  with,  and  char- 
■icterized  by  the  occiUTence  of  ulceralioiis  involving  only  the  .super- 
hcial  structures  of  the  tonsil.  It  is  benign  in  its  nature,  althoi  zh  the 
healing  jjroce.ss  is  slow.  The  ulcers  may  iii)pear  either  single  or  mul- 
tiple on  any  portion  of  the  t(:nsil.  The  affected  area  is  covered  with 
.1  grayi.sh-white  exudate,  and  on  removal,  which  is  easily  done  without 
bleeding,  it  ex])oses  an  underlying  superficially  ulcerated  surface, 
the  edges  of  which  are  clearly  defined  and  not  indurated:  the  sur- 
rounding area  of  the  ulcer  is  nnich  inflamed. 

The  symjjtonis  are  tho.se  of  a  mild,  acute  lacunar  inflanunation, 
,111(1  the  treatment  consists  of  the  frc(|uent  (every  two  hours*  use  of  an 
alkaline  and  antisejjtic  spray,  such  as  Dobell's  solution.  Thr-  daily 
,il)plicatioti  of  a  weak  .solution  of  silver  nitrate  (1  jier  cent.)  will  stimu- 
late the  ulcer  to  heal.  The  affection  may  jKi.ssibly  be  mistaken  for 
malignant  ulceration  or  primary  syphilitic  infectior;.  Careful  ex- 
amination, however,  into  the  clinical  hi.story  of  the  case  will  lead  to  a 
definite  diagnosis. 

Membranous  Anginae  (Non-diphtherial).  I'nder  this  heading  is 
included  se\ cral  forms  of  angina  characterized  by  a  membrane  involv- 
ing either  the  tonsils,  soft  palate,  or  jwisterior  wall  of  the  |)harv!ix. 
separately  or  collectively.  The  condition  is  an  infectious  one.  and 
may  be  due  to  any  of  the  following  bacteria:  staphylococcus,  strepto- 
coccus, the  bacillus  of  Freidliindcr,  pncumococcus,  the  bacillus     .■" 


uoa 


-Yo.sA-  .l.\7*  TintuAT. 


it 

1 


i    t 


and  the  fiisil'cirm  l)acilliis  tif  N'iiicciit.  Tlic  inciiihraiK',  wliicli  is  dc- 
jxisitt'il  ill  till'  various  lucatiuns  just  niciitinncd,  is  citiicr  whitisii  or 
yt'llowirli  in  culnr,  and  in  liiicknos  varies  from  a  tiiin  ixHicIt'  to  one 
of  considcralilc  di'<;rci'  and  toufilintss,  hut  never  attainiii};  that  tiiiek- 
ne.-s  ami  loujriiriess  cliaracteristic  of  dipiitlieria.  it  is  fairly  adiierent 
to  tlie  underlyinj;  mucous  memlirane,  and  wlien  removed  leaves  a 
lileedin;:  and,  in  some  cases,  an  ulc<'rated  snu'face.  The  constitutional 
disturliance  is  usually  siijrlit :  hut  in  some  cases,  especially  the  strepto- 
coccal, stapiiylococcal,  and  pneumococcal  infection,  it  may  he  luarked. 
tile  temperature  risinjt  lo  1(11°  or  even  to  101°.  The  pulse  under  .sucli 
conditions  is  rapid  and  full,  and  tlie  suhmaxillary  glands  swollen  and 
teiitlor:  tliere  is  sli<;ht  pain  on  deglutition,  increa.sed  salivation,  and 
even  a  fetid  hreath.  There  is  usually  very  little  general  dejjression. 
even  in  tiio  more  severe  forms,  and  in  this  respect  ilifTers  so  markedly 
from  dipiitheria.  The  course  of  tlie  diseiuse  varies.  In  the  form  due 
to  stajihyiococci  and  streptococci  its  duration  is  from  five  to  seven 
liays,  but  when  due  to  the  presence  of  the  other  mentioned  bacilli, 
it  may  be  from  one  to  four  vveeks  before  the  membrane  htis  entirely 
di.sapiieared. 

Clinically,  its  appearance  resembles  closely  dipiitheria  or  syphilis, 
but  bacteriological  examination  will  clear  uj)  any  doubts  a.s  regards 
the  former,  and  the  personal  history  and  anti.syphilitic  treatment  will 
correct  any  doubt  ius  regards  the  latt<'r. 

The  treatment  consists  in  the  use  of  antiseptic  sprays  or  gargles, 
such  as  a  solution  of  boric  acid  (gr.  xxv  to  .^ij),  bichloride  of  mercury 
.solution  (1:  10,000),  antifelirile  mixtures,  when  indicated,  and  subse- 
([uently  general  tonic  treatment. 

Hypertrophy  of  the  TonsUs.  This  is  a  condition  which  may  be 
found  in  all  ages,  from  the  younge.st  infant  to  the  oldest  adult.'  It 
is  usually  an  evidence  of  a  strumous  diathesis,  and  is  in  many  cases 
hereditary.  Several  local  conditions  are  apt  to  lead  to  a  chronic 
hypertrophy  of  the  t(msil,  and  especially  in  those  tonsils  where  there 
are  recurring  attacks  of  tonsif'is  due  to  di.sea,sed  conditions  of  the 
crypts  (retention  of  secretion,  chronic  lacunar  tonsillitis,  tonsillar 
and  jieritonsillar  ab.scess).  .Mouth-breathing  dependent  upon  nasal 
obstruction,  all  inflammatory  affections  of  the  throat — whether  due 
to  local  or  systemic  causes  (infectious  fevers) — will  ])roduce  chronic 
enlargement  of  the  tonsils.  In  young  individuals  the  condition  is 
usually  ;i.<sociated  with  the  existence  of  enlargement  of  the  pharyngeal 
tonsils  (adenoids);  but  in  older  individuals  this  is  not  alwavs  the 
ca.se,  the  strumous  condition  having  apparently  centred  itself  in  the 
enlargement  of  the  faucial  tonsils  alone.  Two  tyjies  of  enlarged 
tonsils  are  usually  recognized,  tlie  one  which  is  .soft  and  lymphoid 
in  character,  and  the  secon<l.  which  is  firm  or  fibroid.  The  former 
is  usually  the  one  found  in  voung  children  and  the  latter  in  adult 
life. 

Symptoms.  When  the  tonsils  are  considerably  enlarged  they  pro- 
duce mouth-breathing,  thick  speech,  and  freijuently  cough  when  the 


iust:Ash:s  OF  THE  onoi'iiAHYsx  A.\i>  yAsoriiMiyw'    yjjy 


patient  is  lyiiift  down,  thrdU^h  tlic  lower  part  of  tlie  tonsil  heiiiR 
-iiliieiently  eiilarjied  as  to  irritate  the  ii|)|M'r  part  of  the  I'liijrlottis. 
In  lesser  (lefirees  of  hypertrophy  there  may  he  no  sytnptoins  or  ineon- 
venienee.  ( »ni'  tnusl  always  have  in  mind  that  the  ahove-nientioned 
svinptoms,  esp.eciaily  in  ehildren,  are  apt  to  1)0  iissoeiated  with  an 
inlarneinent  of  the  pharyngeal  tonsil  (adenoids).  In  adults,  tlie  pres- 
ence of  enlarged  tonsils  i.s  apt  to  produce  fatigue  of  the  voice,  oitlier 
ill  speakiii);  or  vocidiziiin.  Frei|uently,  patients  eomi)lain  of  notieinR 
white  spots  on  the  tonsil,  and  upon  manipulation  of  the  tonsil  itself 
lliese  spots  are  extruded  in  the  form  and  shape  of  a  small  pea  wiiieh, 
when  crushed,  produce  a  very  tlisanreeahle  odor.  The  effect  on  the 
licarinj;  is  indirect  and  largely  due  to  the  interference  witli  the  action 
III'  the  palatal  muscles,  and  not  to  direct  pressure  upon  the  opening 
111'  the  i'lustad'  .n  tubes. 

rpon  examuiation,  the  ton.-dl  may  Im-  found  enlarged  to  various 
degrees,  fidiii  just  beyond  the  edges  of  the  pillars  of  the  fauces  to 
niceting  each  other  in  the  median  line.  The  tonsil  in  the  lymphoid 
varietv  is  usually  soft,  of  a  pale  rose  color,  and  the  .surface  smooth. 
Ill  tli('  fibroid  variety  it  is  hard,  paler  in  color  than  the  other  variety; 
tlie  surface  irregularly  divided  liy  bands  of  fibrous  tissue,  and  the 
crv|>ts  widely  oi>eii  and  sometimes  filled  with  caseous  [ilugs.  The 
nilargeiiKnit  (if  either  variety  may  be  either  in  the  antero-jiosterii  r 
or  vertic:il  plane.  Pynchon  lias  given  the  name  "submerged"'  Id 
that  condition  of  the  tonsil  which  is  hidden  liy  a  large  hypertrophied 
I'uid  of  the  anterior  pillar  spreading  over  the  tonsil.  Sonie'imes  the 
.Ulterior  and  even  posterior  pillar  may  lie  adherent  to  the  hyper- 
trophied mass,  and  this  conilition  may  be  easily  overlooked  if  n<  t 
carefully  investigated  by  means  of  a  bent  probe,  whereby  the  ante- 
rior pilhir  of  the  fauces  may  bo  drawn  forward,  and  thus  allow  of  a 
more  cireful  examination.  Sometimes  it  happens  that  the  mouths 
(.1  tiie  crypts  being  do.sed,  we  have  then  a  coiKlition  produced  known 
as  a  ••retentioti  cyst,"  which  shows  itself  as  a  white  or  yellowish-white 
spot  covered  by  thin  f.iucous  membrane.  In  size,  they  may  vary 
I'idiii  that  of  a  jiin's  he.-id  to  that  of  a  large-sized  pea. 

Treatment.  Before  beginning  treatment  for  hypertrophy  of  the 
toiisii.one  must  ask  the  (|uesti(m.  Does  the  ca.se  call  for  treatment? 
.iiid.  based  upon  this,  mu.st  the  case  be  dealt  with.  It  fre(|uently 
happens  that  patients  present  them.selves  with  enlarged  tonsils,  in 
whom  they  jiroduce  no  symptoms  at  all,  and  sitnply  because'  they 
are  en'arge(l  is  their  re;i.son  for  having  them  removed.  Only,  then, 
if  there  are  tangible  symptoms  referable  to  the  enlargement  of  the 
tonsil,  is  interference  called  for.  Mach  ca.se  mu.st  be  dealt  with  upon 
its  own  merit  and  the  treatment  best  adapted  for  the  relief  of  the 
symptoms  carried  out.  Local  medicinal  treatment  is,  in  the  majority 
of  ca.ses,  useless.  When,  however,  the  cause  of  recurring  attacks  of 
loiisillilis  is  due  I"  the  retention  of  ca.-.eous  plug.-  within  the  lafUlliP, 
and  the  tonsil  it  if  is  not  enlarged,  it  sometimes  is  of  u.se  to  clear 
out  these  crypts  of  their  contents  and  ajiply  the  following  application; 


W8 


AUSi:  A  so  TUJIUAT. 


Irallnl, 
Pot  l<«1  , 
Ulycerinl  pur  , 


■r.lU. 


or  solid  nitratp  of  silver  fused  on  the  end  of  the  probe.  These  inens- 
ures  may  l)e  tised  in  patients  who  will  not  submit  to  more  radirnl 
treatment;  but  what  may  appear  to  the  patient  to  be  a  less  formid- 
able measure  than  removal  is  the  followinj;:  Thoroughly  o|M'ninK  "" 
the  erypts  by  means  of  scissors  or  a  suitably  curved  knife,  and  of  cut- 
ting through  every  band  of  tissue  which  serves  to  partially  divide  the 
crypts  from  one  another,  and  then  applying  either  solid  nitrate  of 
silver  or  the  galvanic  electrode  to  the  floor  of  the  spaces  thus  ojM'ned 
uj).  A  better  result  is  often  obtained  by  using  a  jtair  of  punch  forceps 
(Farlows,  Fig.  .515),  and  directly  removing  piecemeal  the  offending 

Fiu.  &13. 


Punch  f'lroepp. 

portions  of  th"  tonsil.  Especially  is  this  method  of  uso  in  those  tonsils 
in  which  this  condition  (retained  .secretion  within  crypts)  exists  and 
are  well  retracted  within  the  fauces,  and  difficult  to  get  at  by  other 
means.  In  such  ca.ses  it  will  re(|uire  the  use  of  a  tenaculum  to  draw 
the  tonsil  up  from  its  t)e<l  into  the  fielsl  of  operation.  This  methoil 
of  treatment  (niorcellement )  will  also  be  found  useful  in  freeing  the 
supratonsillar  fossa  of  tissue  which  dams  uj)  any  secretion,  and  thus 
allowing  better  access  to  treat  the  pocket  in  the  fos.sa,  which  so  fre- 
quently retains  secretion.  This  pocket  wlien  thoroughly  exposed  and 
drained  is  best  treated  by  the  api)lication  of  solid  nitrate  of  silver, 
the  galvanocautery  point,  or  the  use  of  the  curette. 


DJSEAHEti  OF  THE  UHul'IURYyX  ASD  XAHOPUAHr.W.    yya 

( )ft('ii  uiKiii  I'xuiiiiimtioii  the  (.itPninRs  of  tlieso  vTy]tU  iiro  not  rptwlily 
sc<>ii  anil  ri'<|uir»'  on*-  to  ciinluUy  cxaiMinc  the  tonsil  l»y  mvam  of  ii 
prolic  wliocc  end  is  JM-nl  at  right  angles.  Hy  means  of  this,  hands 
of  tihrous  tissue  iiiav  he  drawn  to  one  side,  rcvoalinR  tilled  erypts, 
and  (siH'ciallv  should  tlie  anterior  pillar  of  the  faiiees  Im*  drawn  for- 
ward and  the  underlvinR  l)ortion  of  the  tonsil  rurefully  examined. 
In  all  tln'se  o|)erative "procedures  the  part  to  be  ojXTaltMl  upon  should 
In-  swahtied  over  with  a  15  per  rent,  solution  of  ei.caine;  the  aiui'S- 
ihetic  aelion  will  lie  present  in  about  ten  minutes  after  its  applica- 
tion. The  subsequent  application  of  a  solution  of  adrenalin  cWoride 
(I  :!(KI<»l  will  moderate  the  ble<'dinji. 

When  the  tonsils  are  so  enlarged  as  to  recjuire  reduction  in  size, 
then  there  are  several  ineuiis  at  one's  disposal.     Tliese  are: 
1.  (iuillotine. 
■_'.  Cold  wire  snare. 

;{.  Illectric  wire  snare  or  electric  guillotine. 

4.  ilnueleation.  •  ■    ■  u 

In  the  selection  of  one  of  these  measures  one  must  be  pudod  by 
the  condition  of  the  tonsil.  In  the  soft  variety,  occurring  chiefly  in 
cliildicii.  the  guillotine  should  be  selecte*!:  but  in  ca.ses  of  the  fibroid 
or  hard  varietv  of  tonsil,  then  the  cold  wire  snare  or  llie  electric 
(•iiiTci't.  as  applied  to  the  snare  or  guillotine.  The  reason  for  thus 
laying  down  very  definitely  such  a  ruh'  is  that  in  the  soft  variety, 
wiiich  largelv  occurs  in  children,  bleeding  is  more  likely  to  be  only 
moderate,  and  ceases  readily  of  its  own  accord,  while  in  the  fibroid 
v.iiiety  the  blootlvessels  do  not  retract  so  readily  into  the  remaining 
substance  of  the  tonsils,  and  the  result  is  that  there  is  a  greater 
teiidencv  to  not  oiilv  primary,  but  secondary  hemorrhage. 

1.  (ii'ii.i.oTiNi:.  tonsillotomy  ill  children  up  to  liftwii  years  of  agi' 
^lioiil.l  be  done  with  the  palieiit  under  a  general  !ina'sthetic.  for,  a-s 
:i  rule,  enlarged  tonsils  are  a.ssociated  with  adenoids,  which  also 
iiould  be  removed  at  the  same  time.  When  sutfieieiitly  under  the 
iiithieiice  of  the  aiuesthetic  the  patient  is  gently  raise<l  to  the  upright 
position  the  mouth-gag  inserted,  then,  by  means  of  a  head-mirror, 
the  tonsils  are  illuminated  by  reflected  light,  and  the  guillotine,  either 
Mathieu's  (Fig.  516)  or  Mackenzie's  mmlification  of  Physick's  (Fig. 
.'AT),  is  held  in  the  left  hand  when  removing  the  patient's  right  tonsil. 


.Mathieu's  tonxlHotome. 


and  in  the  right  hand  when  removing  the  patient's  left  tonsil.  The 
iii.-iruincnt  is  now  made  to  engage  the  tonsil  in  the  ring,  .ind  this  is 
done  bv  encircling  the  gland  from  below  upward.  In  this  movement 
the  ring  of  the  guillotine  must  be  held  almost  horizontally,  thua 


mm 


.\OHE  .1  \l>  rillin.lT. 


iillowiiiK  of  til)'  riioxt  ilc|M<ii(li'rit  |>iirtii>ti  »(  tii<-  tiiii>il  to  Imtoiid'  fir>i 
(•iina>?f<l;  tlirii  l>y  l)riii>;iiiu  llir  ritij;  iiitu  tin-  vi-rtical  ixtsitiini  ih,' 
n-iiiaiiiilrr  nf  tin-  tnn.sil  will  Iw  I'li^ap-il.  HcI'dic  aliscisiiiK  tin-  cnjiajfctl 
jH>rfinn  it  is  wrll  tn  ••xatiiirif  with  tlic  iruicx  liiiRcr  of  Ihc  iliscnjrafft-.l 
limid  ami  a.-iccrtain  whether  all  that  eaii  he  erinajjeii  i.s  well  within 


Kiu. 


M*ekentl«'9  tonilllotome. 


the  riiiji  of  the  jtiiillotiiie.  The  eiijtajtenient  of  the  tonsil  may  some- 
tiiiKs  he  faeili'ati'il  hy  pressiiij;  on  the  jiht'iil  uiideriieatl,  the  aiigli- 
of  the  jaw.  In  ca-se  one  is  usitifj  the  Mackenzie  instrument,  the  hlade 
is  now  jiushed  home  and  the  portion  of  the  tonsil  removed.  In  usin^ 
the  Mathien  instrument  the  fork  is  only  thrust  into  the  substance 
of  the  tonsil  when  it  is  well  en>;af;ed,  i'.nd  the  cutting  hlade  is  then 

Kiu.  51>.. 


Instraments  for  freeing  a(lhe!*if>nfl  bctivccn  the  I'lllars  ft  the  taiice"  and  tonsils     (Maki'EN.) 


drawn  tnwanl  one.  This  hitter  iiislriiment  is  uf  use  when  the  tonsil 
lies  fairly  well  retractijd,  for  hy  u.se  of  the  fork  it  is  drawn  tiut  of  its 
'"'■d.  .•itid  also  the  atnouiit  of  the  •jhuid  to  he  n'Uioved  is  n'f;u!ateii. 
In  many  eases  where  the  tonsil  is  vi'ry  dependent  at  its  lower  portion, 
if  this  he  not  properly  eiifiaged.  the  very  oi)ject  of  its  heinj;  removed 


DISKAUKS  Of  Tilt:  OHOI'UM{Y.\.\  AMt  SASOl'IIAJiiyX.     1(M)1 

iii:i\  Im'  (Icfi'iitftl  f.ir  ill  such  casi-s  tin-  tmiftil  w  iHiuilly  »  wiurcc  of 
iiiii:iti(tii  tti  tlir  stiiictiirfs  iifiir  till'  tip  of  the  f|ii>{l<ilti."<,  ami  itw  jiri's- 
I'lii'i'  |iri)iliii-)'s  :i  tlLHtiii'liiiiK  ami  iiiuiuyiiiK  coukIi 

lii't'iirc  iloiiiK  It  luiisillodiiiiy  Im'  sure  tluit  there  are  no  aillie!<i(in8 
Ixlweeii  the  pillars  of  the  fuiiees  ami  the  tonsil  itself.  W  hen  present, 
ami  it  is  rliieflv  anions  ailiilt  cases  that  such  a  eonilition  exists,  they 
Mir  liesi  freed  hy  the  use  of  sucii  all  iiisiriiiiient  as  imlicateil  in  l''ig. 
.'lis.  U;  'hus  freeing  the  tonsil  it  is  more  readiiV  enjiayi'ii,  ami  there 
i«  also  a     -iM-iieil  danger  of  cutting  the  anterior  jiillar. 

2.  Coi.n  \\  iKi.  SwuK.  The  ordinary  nasal  snare  with  a  regulating 
«(re\v  is  the  iiistriinieiit  ii-ed.  The  instrument  rei|uires  to  Im>  rtrn 
-ii.iiiijlii  made,  and  rather  stout  piano  wire  (.No.  lOi  should  1m'  used. 
Tlic  loop  is  made  of  just  siitliciently  large  size  to  engage  the  tonsil, 
and  when  engaged  it  is  made  taut  ami  slowly  screwed  home,  about 
iliiee  to  live  minutes  iM'ing  occupied  with  cutting  it  through. 

;i.  Ki.KiTRK  rrv  .\.h  Ai'IM.ikd  to  tiik  Wihk  Sn.vkk  nu  (irii.i.oTiNK. 
Tlie  liest  means  of  using  the  electric  wire  snare  is  that  known  a.** 
Knights  electric  tonsil  snare      (Fig.  519.)     In  this  instrument  the 


Kiu.  ftW. 


KntKlil'i  tonsil  itmlviiii<H«iiter>'  ■narv. 


I'latiiiuin  wire  looj)  is  made  a  little  larger  than  the  ring  and  tied  at  its 
lii.-lal  end  hy  nieaiis  of  a  threail.  The  tonsil  is  now  engaged  and  the  wire 
iliawii  closely  around  it,  and  when  this  is  fully  and  thoroughly  accoii)- 
piished  the  current  is  turned  on  and  the  wire  dniwn  slowly  hoim  . 
•luii.ithan  Wright  has  applied  this  means  of  removing  fon.sils  to  the 
iiniiiiary  Mackenzie  guillotine.  The  atlvantagc  claimed  hy  some  in 
the  use  of  these  electric  instruiiieiits  for  the  icnioval  of  tonsils  is 
ili.it  the  amount  and  even  the  possibility  of  hemorrhage  is  mod- 
irated  or  prevented:  mi  the  otlii-r  l..iiid.  the  disadvantage  is  that 
ill  addition  to  the  wound  it.self  there  is  a  cauterized  surface. 

\\'hen  one  decides  to  remove  tonsils  by  means  of  local  aiucsthesia, 
il-'ti  i-ach  one  is  to  !)(>  swabbed  over  with  a  J"  'ler  cent,  solution  of 
■Dcaine.  The  u.se  of  a  mouth-gag  and  an  assistant  to  steady  the 
iicitd  depends  entirely  -pon  the  |iatient's  .self-control.  The  u.se  of 
'•(ic.une  in  no  sense  makes  the  o|)erati()n  a  painh'ss  one.  It  may 
moderate  it;  but  in  the  writer's  experience  the  operation  itself,  even 
with  the  lociil  ana'sthesia,  is  an  extremely  painful  one. 

Heiiiorrliage  at  the  time  of  the  tonsillotomy  is  apt  to  be  profuse 
in  young  children  and  in  adults  wiien  the  guillotine  is  used.  In  the 
case  <tf  el.illrcn  it  soon  eeasen,  hut  in  :>du!t«  it  may  '  troulslesome. 
Tills,  however,  in  the  case  of  adults  is  considerably  le.s.sene(l  by  re- 
moving the  tonsils  by  ineuiis  of  the  cold  wire  sna;'    electric  snare,  c" 


1002 


NOSE  A\D  rUROAT. 


i'loctric  guilldtiiic.  As  prccmitioiiary  incasurcs,  it  is  ;i{lvi>;il)l('  that 
the  patit'iit,  sulwoqucnt  to  tiic  i)])('rati(iii,  be  not  allowed  to  lie  down, 
but  a.ssiiiii(' a  scinirccinnhcnt  position:  tliat  tiic  blood  ho  allowed  to 
escape  from  the  mouth  without  any  effort  on  the  part  of  the  patient; 
tiierefore,  all  cleariuf;  of  the  throat  should  he  avoided,  and  the  use 
t)f  the  voice  abstained  from  (secondary  hemorrhage  two  chiys  after 
the  operation  lias  been  met  with  in  the  writer's  experience,  due  to 
the  want  of  the  lu.st  observation).  Food  in  as  concentrated  a  form 
a.s  possible,  and  re(iuiring  but  little  mastication,  should  form  the  diet. 
The  hemorrhafie,  wiien  moderate,  is  usually  arrested  by  tiie  use  of 
iced  cold  drinks  or  small  pieces  of  ice  held  in  the  mouth.  Locally, 
a  solutioti  of  adrenalin  chloride  (1  :  KKM)),  applied  by  means  of  a 
pledget  of  cotton-wool  held  against  the  bleeding  surface,  will  in  some 
cases  act  well. 

A  mixture  of  g.-illic  and  taimic  acid  in  the  proportion  of  one  to 
three,  with  sufficient  water  to  make  a  thick  i)aste,  applied  by  means 
of  the  index  linger,  lias  also  |)rove(l  of  use.  The  use  of  the  |)erchlonde 
tincture  of  iron  nnist  be  a|)plied  with  caution,  the  cotton-wool  swab 
should  not  be  smcharged,  as  otherwise  it  will  then  flow  into  the 
pharynx  and  cause  unpleasant  symptoms.  If.  howe\<T.  the  hemor- 
rhage be  very  |irofuse.  these  measures  are  of  little  a\ail:  then  one 
must,  with  good  illumination,  carefully  .search  for  the  l)lee(|ing  i)oiiit 
and  catch  it  by  means  of  a  pair  of  long  artery  f()rce|)s.  and  if  possible. 
a  ligatvire  ])la("ed  around  it:   it'  not,  then  the  stump  of  the  tonsil  must 


i      1 


Butt's  tonsillar  becmoBtat. 


be  well  drawn  out  and  a  strong  ligature  placed  around  its  ba.'se. 
Butt's  tonsillar  ha'inostat  (Fig.  .')2())  has  been  found  of  .service  in 
arresting  hemorrhage. 

Wingrave  has  drawn  atteiitiui!  to  the  occurrence  of  a  rash  (either 
papular,  roseolar,  or  erythematous  in  tyjie)  following  tonsillotomy: 
but,  as  many  of  the  patients  operated  upon  v.cre  taking  sodium 
salicylates  and  |>otassiuni  bromide,  the  importance  of  its  occurrence 
can  be  of  little  moment. 

The  .'ifter-tre.'itmeiit  of  cases  of  ton^illotoniv  is  absolute  rest  in 
beil  for  two  or  three  days,  the  use  of  soft  food,  and  on  the  third  day 
an  alkaline  and  antisei)tic  spray  or  gargle.     The  reaction  is  usually 


liI.'iEASES  OF  THE  OROPIIARi'yX  AXD  yASOrilARYyX.     100;i 


slijrlit,  and  on  the  sccouil  or  tliinl  day  a  thin  white  pellicle  is  seen 
on  till'  surfai'o  nf  the  cut  toiisii,  wiiicli,  however,  soon  disappears. 
(iiMicral  tonic  treatment  is  especially  indicated  in  strumous  children 
aitrr  such  opi-rat've  procedures. 

1.  i;.\i  (i.KATKJX.  In  order  to  carry  out  this  method  of  removing 
the  tonsil  the  anterior  pillar  is  drawn  to  one  side,  and  hy  means  of 
tiic  index  finger  the  tonsil  is  removed  from  its  bed.  This  may  be 
liirther  assisted  by  lifting  out  the  tonsil  by  means  of  a  pair  of  forceps; 
the  bleeding  is  u.sually  free  but  eiusily  arrested  by  pressure. 

Foreign  Bodies  in  the  Tonsils.  These  may  be  of  atiy  kind  or 
nature,  the  most  common  being  fish-bones,  s|)icula'  of  bone,  bristles 
of  a  tootii-brush,  and  husks  of  grain.  The  most  conunon  site  is  the 
centre  of  thi'  tonsil:  but  fre(|uently  they  are  hidden  behind  the  ante- 
riiir  i>illMr  of  the  fauces.  By  repeated  swallowing  the  foreign  body, 
Mild  cspcci.'illy  in  the  ca.se  of  fish-bones,  is  apt  to  be  driven  deeply 
into  tiie  substance  of  the  tonsil,  leaving  a  very  minute  portion  of  it 
exposed.  Sometimes  this  portion  is  covered  with  secretion,  and  at 
lirst  sigiit  the  foreign  body  may  be  overlooked.  It  will,  therefore. 
brconic  necessary  when  there  is  dilliculty  in  finding  it,  to  mop  otT 
;iii\'  serrction  which  may  be  covering  the  tonsil.  The  removal  of 
loieign  bodies  in  this  region  is  easil\-  lu'complished  by  means  of  a 
pair  of  forceps,  giving  immediate  relief  to  the  symptoms  produced 
iiv  its  presence. 

Tonsilloliths.  Fre(|uently  the  retained  cheesy  secretion  in  the 
<iypts  undergoes  calcareous  ilegeneratioii.  constituting  what  it  known 
,i<  a  calculus  or  tonsillolith.  They  vary  in  consistency,  chemical 
cimposition,  and  size. 

SymptoKS.  '{'he  jiresence  of  a  cnlculus  may  produce  no  symjjtoms 
at  all,  and  may  be  accidentally  discovered:  usually,  however,  there 
i-  a  sense  of  fulne.ss  .alxiut  the  tonsil.  fre(|uent  attacks  of  subacute 
tonsillitis  and  cough  may  also  be  ])resent.  The  existence  of  such  a 
condition  is  usually  discovered  by  probing  the  tonsil,  although  the 
calculus  it.self  may  .sometimes  be  visible  within  the  crypt. 

Treatment.  Single  and  small  calculi  m;iy  often  be  dislodged  by 
means  of  a  curette  or  probe,  or  it  may  be  so  engaged  in  the  tonsil 
that  it  is  neces.su-y  to  enlarge  the  ojjcning  freely  in  order  to  extract  it. 

Benign  Tumors  of  the  Tonsils.  Hie  most  common  of  the  benign 
l\nnors  of  the  tonsil  are  the  jmpilh.-"  it,  filiriwia,  ftbrochotidroma,  nnqi- 
imiti.  and  crhitioforniK  ci/sls  also  occur.  These  tumors  may  be  either 
scs>ile  or  jK^dunculated.  When  sessile  they  cause  little  or  no  dis- 
turbance: but  when  pedunculated  they  may  produce  symi)toms  re- 
llexly.  such  as  cough,  s])ii.s!n  of  the  glottis,  difficulty  in  .swallowing, 
attacks  of  dyspno-a,  and  even  a.«i)hyxia.  Their  removal  is  easily 
ai-coiiiplished  by  either  the  scissors  or  snare. 

Malignant  Tumors  of  the  Tonsils.  These  embrace  sarcomata 
Mvninhosarcoma  and  librosarcon.a)  and  nircinomnla. 

Sarcomata.  Sarcoma  of  the  tonsil  may  occur  at  any  age,  but  is 
usually  found  in  young  individuals  between  the  ages  of  fifteen  and 


1004 


twciitv-tivc 


yotllC  AM)  TIJRn.lT. 


years.  It  is  said  to  Ix'  more  coiiuiioii  in  incii.  hut  in 
the  writer's  cases  (six)  tiiey  were  all  in  females,  and  the  ajjes  were 
between  tii'teen  and  thirty  years.  Tiiis  disease  only  attacks  one 
tonsil. 

Symptoms.  The  symptoms  are  usually  those  of  a  mild-  attack  of 
tonsillitis,  for  which  the  patient  is  continually  treated,  or  it  is  even 
regarded  as  an  enlarged  tonsil,  and  when  the  tumor  becomes  defin- 
itely pronounced,  it  is  then  regarded  and  treated  its  a  case  of '•(juinsy." 
The  pain  in  sarcoma  is  not  a  marked  feature,  and  when  jjre.sent  is 
not  a  continuous  one,  but  is  of  a  rather  dull  character,  in  contradis- 
tinction to  the  sharj)  lancinating  pain  of  carcinoma.  There  is  ;i 
feeling  of  fulness  about  the  throat,  and  deglutition  is  difficult,  whicii 
gradually  increases  with  the  .size  of  the  tumor.  The  voice  becomes 
thick,  and  as  the  case  advances  respiration  oecomes  difiicult,  necessi- 
tating traclu'otoniy;  deglutition  at  such  a  stage  is  usually  impossible. 
Emaciation  is  not  a  marked  synijjtom  in  the  e.-trly  stage  of  the  dis- 
ea.se,  but  tin  ■  patients  usually  are  •  v. y  ana'inic.  There  is  little 
tendency  to  ulceration,  and  hemorrhages  are  therefore  rather  infre- 
quent. The  lymjjhatic  glands  are  not  usually  enlarged.  In  ad- 
vanced cases  there  is  often  some  febrile  disturbance.  Ipon  examina- 
tion in  the  early  stage  of  the  disease  the  tonsil  shows  a  little  fulness: 
it  is  pushed  toward  the  median  line,  and  the  soft  palate  in  its  innnc- 
diate  neighborhood  shows  a  slight  fulness,  and  the  bloodvessels  become 
more  mnnerous  and  dilated.  ( Plate  .\\.\.,  Fig.  1.)  The  condition 
gradually  increases  until  the  isthimis  of  the  fauces  is  dosed. 

Diagnosis.  In  the  early  stage  sarcoma  of  the  tonsil  often  resembles 
a  subacute  |iarencliymatous  tonsillitis  or  a  hypertrophied  tonsil,  but 
the  inflammator\  condition,  in  spite  of  all  treatment,  still  continuing: 
should  lead  to  suspicion.  The  (juestion  of  a  ginnmatous  infiltnttion 
is  easily  solved  by  the  use  of  antisyphilitic  treatment. 

Treatment.  In  the  ea.  stage  the  tmnor  may  be  ermcleated  bv 
incising  the  cajjsule  with  uie  galvanocautery  kni'fe:  in  the  more  aii- 
vanced  stage  of  the  affection  a  more  extensive  operation  by  means 
of  pharyngotomy  may  be  undertaken.  Uut  for  ste|)s  involving  sucli 
ojH'rative  procedure  reference  to  standard  surgical  works  is  advisi^d. 
In  this  kind  of  malignant  growth  Coley's  serum  has  been  used  in 
some  cases  with  benefit;  in  two  of  the  author's  c.-i.ses  this  methoil  of 
treatment  proved  of  no  avail.  In  hopeless  cases  palliative  measures 
are  called  for,  and  tracheotomy  may  be  needed  as  a  relief  to  the 
ilyspncea. 

Carcinoma.  In  carcinoma  of  the  tonsil  the  afTeetion  usuallv  s1ma\> 
itself  as  an  epithelioma.  .\s  a  primary  jirowth  it  is  rare,  usually  being 
an  extension  from  the  surroun<ling  structures.  It  is  a  disease  of 
middle  and  advanced  ages;  the  tmnor  rapidly  enlarges,  ;uid  may  pre- 
sent it.self  as  an  .apparently  enl;irged  tonsil  (Plate  .\.\.\..  Fig,  2' :  but 
upon  a  careful  exainin.ititin.  wlu-n-by  the  posterior  and  internal  sur- 
faces of  the  tonsil , are  thoroughly  exposed,  an  ulcerated  con<lition  mav 
be  observed.     (I'l.-ite  \.\.\.,  Figs. ;{  and 4.)    The  pain  is  ofi:-n  markell 


PLAT!-:   XXX. 


^    l» 


/ 


f 

1 


/ 


(.,,,.  I. .,11, 1  J.  l'Miiiar\  fCpilh.iii  ■ma  .  ■!  Ton.^^il,  -h'ivs  MiJ  llw 
iiHUal  -ia(|.v  hiM  .i  1  !..■  111.  .M  atiMl  ."Mil  la.  !•  Ex|M  .-'■'I.  Fu).  'f 
Sii.  .\\  iiHi   ih..    L;m.-ii~i.  .11   .  >l   111.-   L.->i.>ii.     !  A  HI  hill  V  .a^.'. 


■Hi 


■M 


t  ^ 


i 


i>isi:a.si:s  of  nil-:  onoi-UAUvyx  and  XAsoriiAKvyx.    ioo.> 


1,1, i  l:iii(iii;iliiin  ill  cliaiactcr,  cxtciKliiifi  into  tlic  car  mi  the  same  rtiilc, 
liXtrnivali'il  liy  ilifjlutitioii,  hut  occiirrin';  iiulcpciKlciitly  of  it.     The 


lU  111'  r^aliva  IS  iiicrcascd 


and  tlic  (liscliai<;c  from  the  ulccratfi 


urfii 


,-  u>iially  fetid,     (ilaiidular  iiivolvcnicnt  is  early  and  tlie  prufiress  of 
lisease  rapid,  involviii>;  tliv  adjacent  structures.    Tiie  etTects  upon 


Ihe 

I  he  ciiiistitutioii  are  mar 


ked 


aiia-nua  aiu 


I  cachexia. 


^vi 


Diagnosis.     The  disease  may  bo  confounded  witii  primary  or  tertiary 

ijiililic  maiiifi'stations,  hut  treatment  directed  toward  this  as  a  pos- 

cMiise  will    clear  up    tiie    (luestion.     .Microscojjic    examination 


:il>N 


lit  ion  will  assist  m  an 


liii^  tl 


lie  dia};iiosis  m  iiianv  cases. 


(il  a  por r-    -  r. 

Treatment.  Dealing;  with  these  cases  by  means  of  the  snare  and  gal- 
vMiiocautery  knife  are  not  to  he  advocated,  hut  the  more  thorough 
>uijrical  measures  are  indicated,  and  reference  should  he  made  to 
>laiidard  siirpeal  works  for  the  methods  of  operative  technique. 

The  Lingual  Tonsil.  This  tonsil  is  situated  at  the  root  of  the 
IniifTue  and  just  in  front  of  the  einplottis.  In  .structure  it  is  similar 
In  the  f.iiicial  tonsil  and  belongs  to  the  ring  of  lymi)hatic  tissue  de- 
-rrilH'il  as  the  "  Ring  of  Waldeycr."  In  some  .ses  the  tonsil  is  divided 
by  a  median  line,  thus  giving  to  it  an  appearance  of  two  distinct 
riands.  This  tonsil  is  subject  to  many  of  the  same  affections  which 
attack  the  faucial  tonsils,  especially  tlie  acute  catarrhal,  lacunar,  and 
l.hlcjrmonous  infiammation,  mycosis,  tuberculosis,  and  syphilitic  niani- 
te^tations.  The  api)earance  of  these  conditions  is  similar  to  thase  seen 
ill  the  faucial  tonsils,  and  repetition  of  either  their  subjective  or  objec- 
tive symptoms  and  treatment  is  unnecessary. 

The  commonest  form  i.f  atrection  of  this  tonsil  is  hypertrophy.  The 
afteciion  is  one  of  adult  life,  and  is  more  common  in  females  than  in 
inaies.  It  is  fre(iuently  met  with  in  hysterical  subjects,  and  is  pro- 
iluctive  of  the  condition  known  as  -'glofjus  hysterictis."  It  produces 
-vmiitoms  of  a  feeling  of  a  foreign  body  in  the  throat,  irritating  cough, 
and  a  weakness  of  the  voice  in  many  cases.  The  treatment  is  carried 
,>iii  on  the  same  lines  as  that  for  hypertrophy  of  the  faucial  tonsil,  and 
.(insists  in  the  use  of  either  the  galvanocautery  or.  in  ca.ses  where  the 
nilargement  is  considerable,  of  the  guillotine  especiall}  devised  for 
tliat  purjiose.     (Fig.  521.) 


FKi.  .i21. 


Lingual  K>iill'>tine. 


The  lingual  tonsil  may  also  he  invaded  by  the  followirig  tumors: 
riliroTua.  ]iapill"ma,  lipotna,  aiigivinui.  aiu'  cyst-^.  A  p'Ttinn  nf  the 
thyroid  gland  may  in  some  cases  he  .seen,  and  is  then  due  to  a  previous 
st.ite  of  the  thyroglossal  duct. 


mmmmmmm 


■MM 


um 


XOSE  AM)  TIlltOAT. 


I 


■  I 
>  i 


A  "viiricosc"  coiiilitidii  of  tlic  veins  ;it  tin'  l)!isc  nf  the  toiijiuc  is 
soiiictiincs  met  witli,  and  its  picsciicc  in  some  cases  pniduces  a  t'eeiinK 
of  a  foreign  Ixxly  in  tiie  throat  and  often  paia'stliesia.  \eiv occasion- 
ally these  veins  may  l>e  the  source  of  henionhap':  and  this  has  <;iven 
rise  to  the  opinioi.  that  the  i)atient  has  had  an  lia'nioptysis.  The 
a|>plication  of  thegalvanocautery  jioint  will  relieve  many  cases. 


Kiu.  ba. 


V/'- 


jihowingthe  imsi>|.hiirynx  hihI  Ihe  lur>tiKr)phiir>-nx opeiirrt  troiii  tiehind.    iMrxlified  fn™ 
'irtiy's  Anatomy.) 

The  niiKophiiripLr  lies  hetween  the  liase  of  the  sknil  and  Ihe  lower 
edfre  of  the  soft  palate.  Into  this  space  the  foiiowinj;  openinf;s  are 
ul.xTVed  till-  |)o.siciioi  narcs  ( iwo),  and  the  months  of  the  i']u<lachiMn 
fulies  (two),     iVifr.  r)22. 

The  oraphirunx  is  that    portion   of   the  pharynx  visible  when  tin 


I>lt;EASE^  OF  THE  OROPUARYSX  AM>  XASOHIAHiWX.     KK)7 


iiioiitl'.  is  i>;:vn  ami  the  tuiinuc  (loprt•^s(•^l  to  the  lloor  of  tlic  iiiouth. 
I  l'i>;.  iyZi.)  ' 

Till'  l(inin!i(>phitn/iis  I'Xtciuls  from  a  lin<'  drawn  horizontally  back- 
wanl  to  ilic  posterior  wall  of  the  pharynx  from  the  root  of  the 
toujriic,  and  extends  to  the  iip])er 

border   of    the    cricoid    cartilage.  '■""•''■-''• 

'Tij;.  .V-'2.i 

Malf ormations  and  Deformities 
of  the  PhaiTnx.  A  congenital 
iiialforTnation  rarely  met  with 
consists  of  the  pharynx  endinj;  in 
:i  cul-de-sac  below  tlie  level  of  the 
cricoid  cartilage,  and  the  (esopha- 
gus terminating  in  the  posterior 
surface  of  the  trachea, 
congenital  condition  is  th( 
niice  of  diverticula;  they 
found  in  the  lateral  wall  of  the 
pharynx,  and  are  due  to  .somi- 
modification  in  the  closure  of  the 
lirst  post  mandibular  visceral  cleft. 
Tlicse  diverticula  may  be  single 
oi'  iiuiltii>le  and  corres|)ond  with 
that  of  Meckle  in  the  intestine. 


Another 
occur- 
ire 


1.  .Viiterlor  plUur.  J.  rosttrior  rillar  :!. 
Tousil.  4.  I'vula.  .V  Tongue.  6.  Piwlerlcir 
wall  of  |>harynx.  7.  Sofl  palate.  ».  Uarrt 
Iialate. 


Fi(i.  524. 


1.  Tenaor  palati. 


2.  Levator  jsilnti.    a.  I'alatoRlossus.    4    i'iiliit.ipharyngeus. 
6,  UHmular  process     7.  Toiignc. 


AzyRos    uvule. 


1008 


Ao.sf;  Axi>  nil: OAT. 


Pharyngocele.  This  (•(iiiilitinn  cniisists  nf  a  |)(Hicli-likc  fniiiiation  in 
the  lowiT  |>art  nf  the  pliarynx.  said  tn  lie  linc  to  a  weakness  of  tlir 
coiistrietor  iiiiiscles  in  one  place. 

Tlie  symptoms  wliicli  occur  in  these  cases  of  (hverticnla  or  pharyn- 
pK'cle  ari'  piactically  tlie  same.  Food  fails  to  reach  iheslomach.  and 
is  rejiui-fiitated  in  small  (|uantities  from  lime  to  time.  If  a  houf;ie  is 
passed  it  is  arrested  in  its  coin-si'  to  the  (esophagus  liy  entering  one  of 
the  poiichi's.  The  existence  and  situation  of  such  pouches  are  very 
materially  demonstrated  hy  tlie  use  of  the  iioentften  rays,  a  Ijougioor 
other  foreign  hody  having  first  heen  pa.ssed  into  the  pouch. 

Stenosis  of  the  pharynx  may  occur  primarily  as  the  result  of  disease 
(syphilis,  tuberculosis,  scarlet  fever,  di|(htheria,  smallpox,  and  ery- 
sipelas), or  tniuma'icaliy  as  the  result  of  injuries  incident  to  the  swal- 
lowinj;  of  corrosive  li(|uids  (carbolic  acid,  lye,  etc.),  of  scidding  water, 
or  inhalations  of  steam  in  considerai)le  (|uantity,  or  secondarily,  lus 
the  result  of  i)ressuro  from  the  following  conditions:  retropharyngeal 
abscess,  spinal  caries,  glandular  enlargements,  and  e.si)ecially  when  the 
thyroid  gland  intervenes  between  the  trachea  and  upper  part  of  the 
<i'sophagus,  as  the  writer  has  .seen  in  .several  ca.se.s  of  enlarged  thyroid. 

Wounds  of  the  .soft  palate,  toasils,  and  pharynx  frecpiently  occur 
as  the  result  of  the  action  of  corrosive  li(|ui(ls  or  of  the  entrance  of  a 
foreign  body  through  violence  applied  to  it.  Among  such  foreign 
bodies  are  ))ii>e-stems,  pieces  of  wood,  or  metal.  Injury  involving 
i'oinplete  perforation  of  the  soft  palati>  an  1  partially  involving  the 
posterior  wall  of  the  pharynx  has  been  seen  by  the  writer  in  two  Ciises: 
in  one  it  was  due  to  the  child  falling  while  he  had  a  pea-shooter  in  his 
mouth,  the  other  occurred  in  a  man  falling  while  in  an  intoxicated 
condition  and  striking  his  pipe,  which  he  held  in  his  mouth  at  the  time 
of  the  accident.  In  some  ca.ses  the  injury  may  be  of  such  a  nature  as 
to  involve  im|)ortant  bloodvessels  in  the  throat,  and  when  this  does 
occur  hemorrhage  may  lead  to  a  fatal  result. 

Anomalous  distribution  of  the  ascending  pharyngeal  arteries  is  some- 
times to  be  s(>eii  in  the  posterior  wall  of  the  i)harynx.  The  most 
oommon  anomaly  is  to  see  the  artery  coursing  upward  on  the  posterior 
wall  do.se  to  the  lateral  wall  of  the  pharynx.  It  may  occur  on  one 
or  both  sides;  less  fre(|nently  it  ha.;  been  ob.served  coursing  trans- 
versely from  one  side  to  the  other.  The  internal  carotid  artery  has 
been  found  to  take  an  irregular  course  and  apjiear  just  under  the 
mucous  membrane  in  the  lateral  wall  of  the  pharynx  (Kelly)  Such 
conditions  would  render  operative  mea.sures  in  this  region  very  dan- 
gerous. 

DISEASES  OF  THE  PHABYNX. 


Acute  Phar3aigitis.  Etiology'  Among  the  causes  of  an  acute 
inflammatory  condition  of  the  pharynx  may  be  mentioned  sudden 
exposure  to  "cold,"  the  existence  of  a  chronic  catarrhal  pharyngitis, 
the  extension  of  catarrhal  conditions  from  the  nose  and  nasopharynx. 


DISKASfS  OF  THE  OROrilARrXX  AND  yASOl'JlAJliWX.     10()9 

a  K<'"ty  '"■  ili<"iiii!itic  (liiitlicsis,  jjiislric  nr  intostiiial  (lisonlcr!*.  acute 
iiilVctimis  fevers  (measles,  scarlet  fever,  smallpox,  typhoid  and 
uphus);  sometimes  the  use  of  certain  drugs  may  cause  it,  such  as 
UHlide  of  jxttiissium,  mercurv,  antimony,  arsenic,  and  occstsionally 
the  salicylates;  the  excessive  use  of  tohacco  or  alcohol,  highly- 
M'at^oned  food  and  confinement  in  close  and  ill-ventilated  rooms. 

Symptoms.  These  are  usually  ushered  in  i)y  a  chillines.s  and  feeling 
of  malaise;  the  throat  is  sore,  especially  when  swallowing,  the  jiain 
extending  upward  to  the  ears;  there  is  a  feel-ng  of  irritation  and  a 
desire  to  friMjuently  clear  the  throat.  The  general  disturbance  de- 
pends uixiii  tlie  severity  of  the  local  conditions.  I'pon  examination 
tlie  color  of  the  mucous  memhrane  covering  the  soft  palate,  uvula, 
pillars  of  the  fauces  and  i)osterior  wall  of  the  pharynx  is  seen  to  he  a 
inight  pink  or  livid  hue.  Its  surface  in  the  early  stage  is  dry,  and 
numerous  dilated  vessels  are  visible;  the  uvula  and  edge  of  the  soft 
palate  may  be  slightly  (i-dematous;  later  on  the  secretions  form 
wliich  at  first  are  clear  mucus,  but  later  become  nmcoj    rulent. 

Treatment.  In  severe  ciu^es,  and  even  in  mild  ca>  -  occurring  in 
frail  individuals,  confinement  to  bed  is  advisable,  .vi  the  outset  a 
mercurial  (gr.  iij  calomel)  followed  hi  six  hours  by  a  Seidlitz  powder 
is  to  be  given.  ShouM  the  tem|M'rature  be  elevated  and  the  pulse 
full,  iincture  of  accmite  (B.  P.)  in  two-minim  doses,  hourly  admin- 
istered, will  greatly  relieve  the  discomfort  experienced  in  the  early 
stage  of  the  <lisease.  Salol  (gr.  iij)  combined  with  i)henacetin  (gr.  iv) 
or  Tx'nzoate  of  soda,  or  salicylat«  of  soda,  will  l)e  found  beneficial 
where  there  is  a  rheumatic  history.  Locally,  small  pieces  of  ice  to 
suck  or  ifc-bags  to  the  throat  will  be  found  comfortable.  The  dryness 
s-i  fre(|uently  complained  of  may  be  relieved  by  steam  hihalations 
(if  compound  tincture  of  benzoin  (one  drachm  to  the  half-pint). 
The  use  of  an  oil  spray  such  as  the  following  will  give  relief  to  the 
pain: 

Menthol. 

<  dmphonc.  44    gr.  Ij. 

01  gBUltherlffi,  lllj- 

Altxilinu.  Sj. 

Hi;     I'sc  «»  a  I  hn«t  spray  hourly. 

When  the  secreticms  have  begun  to  form,  then  an  alkaline  spray 
is  indicated,  such  as: 

.So<lii  bioHrbonatis, 

Sotlii  birborrtlls, 

aKiii  ohloridl,  Sft    gr.  lij. 

AllUlB.  Sj- 

Later  on,  when  the  secretion  has  become  mucopunilont,  then  a 
slightly  astringent  spray,  used  about  three  times  daily,  is  indicated: 


Llq.  liydrastli, 

mxv 

Tr.  lavandulit  Co., 

miij. 

\<inx. 

B"!        ",j 

Chrcnic  Pharyngitis.    This  may  be  defined  as  a  chronic  inflam- 
mation of  the  mucous  membrane  of  the  pharynx  and  adjacent  .struc- 

<i4 


. 


1010 


XOSK  AM)  riHiDAT. 


tiircs,  attt'iiilaiit  with  structural  cliaii^irs  in  the  ^laiidnlar  cli'incnt  or 
(••miicctivc  tissui'.  It  may  he  cniivi'iiiciitly  considi-rcil  undfr  tiircc 
licai  lilies: 

1.  Simple  chrotiic  pliarynjiitis. 

'J.  Clirdiiic  >;ramilar  pliaryiijtitis. 

'.i.  Atrojiliic  pliarynjiitis. 

Simple  Ghronic  Pharyngitis.  Etiology.  This  may  Im-  tht>  s(>(|ucnci> 
of  .-iiihafutf  or  acute  attacks  of  pliarvri>;itis  as  thi'  result  of  an  exten- 
sion of  ciironic  na.sal  catarrh,  the  existence  of  nasal  and  pharyngeal 
conditions  producing  huccal  n'spiration:  the  ahuse  of  tohacco  and 
alcohol,  the  use  of  hinhly-seasoned  foods,  gastric  and  hepatic  di<- 
turliances,  aiueniia,  tuherculosi-;,  and  syphilis  all  act  as  etiological 
f.'ictors;  occup.'ition,  wiiere  a  great  deal  of  dust  or  irritating  vapor 
is  present  in  the  atmosphere. 

Symptoms.  Tliey  are  thctse  of  an  acute  pharyngitis  considerahly 
modified.  The  most  prominent  .symjitom  is  the  clearing  of  the  throjit 
to  such  a  degree  that  the  pati<-nt  may  retch  or  even  vomit  in  his 
end<'avors  to  clc;ir  the  thr()at  of  secretion.  This  retching  as  the  result 
of  such  efforts  is  usually  found  in  those  indiviiluals  who  indulge  too 
freely  in  the  use  of  alcohol  au(i  tobacco;  the  voice  may  hecome  liusky, 
and  frequent  efforts  are  made  to  clear  it.  In  those  who  sing  there 
is  often  a  dilliculty  ex|K'ricnced  in  reaching  the  higher  notes  of  the 
register.  Cough  may  he  present,  especially  when  associated  with  an 
elongated  uvula:  re|M'ate(l  efforts  of  cougliing  or  clearing  of  the  throat 
m:iy  lead  to  a  slight  ru|)ture  of  niimite  hloodve.s.M-ls  and  show  itself 
as  miinite  s])ecks  of  blood  in  the  expelled  secretion.  I'pon  e\;uuina- 
tion.  which  not  infrequently  is  made  with  dilliculty,  on  account  of 
the  extrino  irritation  of  the  iimcous  membrane,  one  observes  the 
mucous  tnembraiie  of  the  |)illars  of  the  fauces,  soft  palate,  and  uvula 
to  be  very  hyp(>ra'mic.  The  color  may  vary  from  a  bright  red  to  a 
livid  hue.  The  posterior  wall  of  the  j)harynx  shows  muneious  dilated 
vessels,  and  its  surface  is  covered  with  a  very  tenacious  mucous 
secretion. 

Treatment.  The  basis  of  treatment  in 
in  the  correction  of  faulty  habits;  the  u- 
should  l)f>  strictly  interdicted:  a  gouty  or 
reci'ive  ])roi)er  attention:  heavy  and  high  living  individu.als  should 
be  advised  as  to  their  ])roper  dietary,  and  any  existing  n;is;d  or  naso- 
pharyngeal condition  likely  to  produce  buccal  respiration  should  be 
corrected.  Ijocally,  .after  the  throat  has  been  cleared  of  any  adherent 
mucus  by  moans  of  an  alkaline  spray,  a  solution  of  nitrate  of  silver 
(gr.  X  to  3J1,  protargol  (gr.  xv  to  5j),  or  zinc  chloride  (gr.  xx  to  3j) 
may  be  applie(l  by  me.ans  of  a  cotton-wool  swab. 

"'•xonic  Orantilar  Pharyngfitis.  Thi.s  is  characterized  by  a  chronic 
inflammation  of  the  nmcous  membrane  with  hypertrophy  of  the 
lymphoid  follicles. 

Etiology-  In  enumerating  cau.ses  for  this  affection  one  recpiires,  to 
a  great  extent,  to  repeat  those  acting  as  causes  in  chronic  pharyn- 


■  m.ajority  of  cases  lies 

stimulants  and  tobacco 

iii'umatic  diathesi-;  shoulil 


IflSk'ASES  OF  Till-:  itROPIIARV.W  AS  It  .V.|.SO/'//.l«  J'.V.V.     1011 


til 
••I  I 


ll 


iriii-.  aiitl  fiir  tlicsi'  mic  is  rrfcrrcd  to  that  scctidii.  In  addition,  the 
iiii|iii>|KT  use  if  tlic  viticc,  I'ithcr  in  siM'akinj;  or  sinjiinj;,  will  a<'t  a.n 
a  cMiiw.  Tliis  ha,-*  It'd  to  the  "  "cli-rjiy man's  sorc-throaf  "  being 
>^i\('ii  to  it. 

Symptomi.  Then  is  a  ftH'Iinj;  of  inorc  or  less  discomfort  in  the 
ilu":il,  fri'i|iicnf  clearing  away  of  a  rather  tenacious  mucous  secretion, 
tjie  voice  is  often  husky  or  weak  and  the  use  of  it  leads  to  a  feeling 
111'  fatiftue  anil  an  aching  sensation  of  the  muscles  of  th<'  neck.  One, 
however,  tmisl  not  l)e  mi.sled  that  in  each  patient  in  whom  such 
symptoms  an-  jiresent  they  nec(s.sarily  an-  of  local  origin.  The 
writer  lielieves  that  many  of  the  local  symptoms  and  conditions  pro- 
ijiici'd  in  singers  and  speakers  are  due  to  impro|)er  methods  of  voice 

(nluction.     rpon  examination  the  posterior  wall  of  the  pharynx 

lows  the  glandular  element  to  he  distinctly  enlarged  and  hypera'tnic; 

le  I'lilargenient  varies  in  size  from  that  of  a  pin's  head  to  that  of 
,  pea.  The  surrounding  mucous  memlirane  is  pale,  and  on  ifssurfao«>, 
•nursing  toward  these  so-called  "granulations.  "  are  several  tinehlood- 
\issel>  This  collection  of  "graimlations"  is  oftrn  very  marked  in 
\iiuiig  children  who  ace  the  suhjects  of  jtostiia.sal  growths.  (Fig. 
'.'.'•.)  I'n'i|uently  hands  of  hyiK-rtrophied  tissue  are  to  he  s(>en  on 
rie  Literal  wall  of  the  pharynx  and  just  behind  the  posterior  pillars. 
I'lie  hy|)erlrophy  continues  into  the  nasopharynx  with  the  salpingo- 
iharyngeal  fold.  This  condition  is  called  by  many  autliors  "  pharyn- 
.'iiis  lateialis  hy|)ertrophica." 

Treatment.  This  shoulil,  as  in  the  case  of  all  local  troubles,  l)o 
ilirected  toward  the  investigation  of  the  g  ral  health  for  causes, 
niiil  these  corrected.  .\ny  aiucmic,  litha'- 
I'lic,  or  gouty  condition  should  receive 
proper  attention,  and  the  use  of  alcohol 
and  tobacco  should  be  prohibiteil  if  act- 
inn  as  an  exciting  catise.  Naso|)haryn- 
i^cal  iDiiditions  should  be  c:trefully  inves- 
!i;:ated  and  s\iital)Ie  treatment  a])plied. 
1. neatly,  in  pronounced  ca.ses,  the  best 
Idiin  of  treatment  is  the  application  of 
I  111'  galvanocautery  to  each  granule  and 
dr-tniying  the  bloodvessels  which  supply 
ii.  This  should  be  very  carefully  done. 
Theapiilicatioii  of  chromic  acid,  trichlor- 
acetic acid,  or  silviT  nitrate  fuse  1  on  a 
probe  is  also  advocated:  but  the  ajjpli- 
ration  of  any  such  escharotic  is  not  so 
easily  limited  as  the  u.se  of  the  galvano- 
c.iutery.  The  galvanocautery  point 
<hiiuld.  when  being  used,  be  brought  only  to  a  dull  red  heat.  Mayer 
lias  very  successfully  used  a  s|H'cially  formed  curette  for  removal  of 
these  gramilat'ons.  and  claims  to  have  had  very  .satisfactory  results. 
The  curette  a-,    ised  by  him  is  seen  in  Fig.  5'J6. 


Cimnntar  pharyngitis.    (Coaklky.) 


: 


1012 


A04A'  .I.V/»  riUlO.tT. 


I'rcccdiiij;  the  use  nf  ;iiiy  (Uic  of  (lie  fonnniii);  rnctlKMls.  cacli  'graii- 
ulr '■  to  Im'  so  trcatril  .xlioiilil  rfn'i\i'  an  applicatioti  of  a  10  [mt  cent 
solution  of  cocainr.  In  the  case  of  the  latiTal  liyiMTtro|)liy  tin-  haml-i 
may  lie  so  thick  as  to  ri'<|iiirc  excision  hy  means  of  scissors  ami  fm- 
ct'ps:  luit  in  this  |iroc<'iliirc  one  must  lie  careful  not  to  exce«'(l  the 
reiiuirements  of  the  cas«'  hy  ovenloing  it. 


Fm.  .fX. 


MHycr'H  ciiri'llc. 


Atrophic  Pharyngitis.  This  is  characterized  liy  atrophy  of  the 
mucous  menilirane  and  glandular  structurr-  containecl  in  it.  It  is 
li"ld  l)y  some  writers  to  he  a  s>  uience  of  a  chronic  pharyngitis,  and 
hy  others  to  orij;inate  yur  .vc.  i,  may  tollow  .severe  ca.s's  of  di|)h- 
thi'ria  or  scarlet  fever,  or  may  occur  in  the  coin-se  of  diahetes  or 
Mri^ht's  disease.  It  is  usually  an  evidence  of  the  .same  process  exist- 
inj;  in  tiie  no.se  and  nasopharynx.  .\  dry  condiiion  of  the  pharynx, 
not  necessarily  atrophic,  may  he  produced  hy  niouth-hreatliing  and 
excessive  smokinn. 

Symptoms.  The  symptoms  are  those  of  a  feelini;  of  dryness  in  the 
throat  and  a  desire  to  fre(|uently  cle.'ir  it.  ['p<m  examination  the 
wall  of  the  pharynx  looks  dry  and  glazed.  The  |)harynx  looks  spa- 
cious in  many  cases,  iind  the  mucous  meinhraiie  is  covered  with  a 
thill  layi'r  of  hardened  secretion  which,  when  removed,  reveals  often 
a  rather  conj;ested-lookin}:  mucous  inemhrane. 

Treatment.  The  peneral  state  of  the  [)atient's  health  nuist  he  care- 
fully investiftated  and  treatment  directed  to  ;iny  existing  di.«oases 
which  might  ])ossil)ly  act  either  asanexcitingorapredisposingcau.se. 
Locally,  the  use  of  alkaline  s|)rays  such  as  Dohell's  solution  or  Seiler's 
tahlets  will  assist  in  some  ca.ses  to  remove  the  h.ardened  secretion. 
The  suhse(|uent  application  of  a  mixture  such  as  the  following  will 
be  of  henefit : 

Ifxiini, 

(ilycLTiiii, 
Ai|iia'. 


«r.  T. 
Kr.  IJ. 
SiiJ. 


Steam  inhalations,  such  as  compound  tincture  of  henzoin,  one 
drachm  to  the  li;ilf-pint,  or  the  following,  will  he  of  use  in  relieving  the 
dryness: 

creH-sote.  ill'xxi. 

.MuKiH-siie  farUtiiis  leviK.  u'r.  x!. 

Aiiiue,  sj. 

Sis.    One  l'.-a?iK;ni;fui  .v.  hulf  a  pint  nf  boiiing  water.  mu\  u-c  u.-  „i,  |j,|ja!iit;nii  ni^lii  khU  iiio-niiii; 

Those  inhalations  give  the  most  henefit  wheti  the  |)harvnx  has  heei 
thoroughly  cleared  of  any  dried  secretion.     One  must  i)ear  in  inui.' 


lUSEAHES  OF  THE  HHOl'UAHYSX  AS'l)  \AiiOril.lJty\.\.     1013 

tli:it  tlic  :il)<»vf  iiK'ifuri's  an-  only  a  iiicans  to  make  tlw  patient  luon' 
riiiufortalilr,  for  ihc  ilw'a."*'  in  its  atlvantrd  form  is  prat-tifally  in- 

rlllllliii'. 

Acute  PhlegmoaooB  Pharyngitia  (Ludwig's  Angina).  Senator  d.- 
tiiio  tiiis  condition  as  "a  difTiise  purulent  intlainination  in  the  dee|K>r 
ti-siies  of  the  pharyngeal  niiicous  rneinlirane,  which  thence  is  prttpa- 
)iuled  to  the  larynx  and  tlie  ((lands,  and  s<'condarily  involves  also 
other  organs.  Tlie  di.s'a.-*e  has  attackeil  jhtsoms  jireviously  in  full 
health  and  without  any  etiological  factor  iK'infj  demonstrable."  As 
a  primary  di.sea.xe  it  is  rare  and  often  fatal. 

Symptomi.  The  onset  is  marked  hy  a  rigor  or  chilliness.  The  first 
>yiiipt(im  referable  to  the  throat  is  dysphajfia,  which  suddenly  sets  in. 
This  is  closely  followeil  hy  hoarseness,  tlyspniea,  and  even  lurvngeai 
,-tridor.  There  is  considerahle  difficulty  in  Retting  rid  of  the  .xecre- 
lioiis  of  the  throat,  which  are  very  tenacious  in  cliar;i(  ter.  The  fever 
i-'  lii^rh  ( l(l.'{°to  l().'»°),  .and  the  pulse  rapid  and  weak.  I'pon  examination 
either  one  or  both  tonsils  and  the  pharynx  on  one  side  or  both  show 
evi  leiices  of  acute  intlammatioii :  the  color  is  of  a  very  deep  red  or 
livid  hue.  This  condition  may  extend  downward,  involving  tlie  epi- 
glottis and  the  aryepiglottidean  folds.  These  parts  lu'come  swollen 
Miiil  distended,  accounting  for  the  inrrea.«ed  dysphagia,  stridor,  and 
tlie  deeply-pitclied  tone  of  the  voice.  Kxternallv,  a  board-lik-  hard- 
ness of  the  ti.'isues  isapprecial)le  on  palpation. 

Treatment.  The  condition  is  always  a  verj'  grave  one.  and  stinui- 
lating  and  supporting  fn-atment  from  the  out.set  is  indicated.  Iron 
and  (|uinino,  in  large  doses,  should  be  given;  cold  to  the  throat  by 
nie.'Uis  of  ice-bags  or  I.eiter's  ice-coil  should  fx-  use<l.  Fre(|uently 
■^c.irification  of  the  epiglottis  and  arvepiglottideati  folds  will  reduce 
tin'  -:\\(llinf;  of  these  p.srfs  and  n-nder  the  (h>;)hagia  and  stridor  Ic-^s 
marked.  When  symptoms  of  obstruction  to  respiia»ion  s(  t  m,  trache- 
otomy is  calh'd  for. 

Gangrenous  pharyngitis  is  a  rare  disea.<*e,  and  is  found  occurring 
as  a  se(|uenco  of  a  .severe  attack  of  scarlet  fever,  measles,  diphtheria. 
Ml-  smallpox.  It  may  not  be  limited  to  the  pharynx  itself,  but  have 
liad  its  beginning  in  the  soft  palate  or  tonsils,  and  extended  to  the 
|ih;iiynx,  or  vice  versa,  (ieneral  sustained  and  stimulating  treatment 
is  indicated,  with  cleansing  of  the  local  condition  by  the  use  of  anti- 
septics. 

Herpes  of  the  Pharynx.  This  affection  is  characterized  by  the 
jircseiice  (tf  small  vesicles  on  either  the  soft  palat<',  uvula,  tonsils,  or 
iiiiccal  mucous  membrane,  .and,  more  ran^ly,  the  pharvTigeal  wall,  epi- 
jrlottis,  and  larynx.  It  occiirs  as  the  result  of  exposure  to  cold  or 
si|itic  influence.  In  the  writer's  experience  it  occurred  in  three  cases 
during  the  cour-^e  of  an  attack  of  la  grippe.  It  may  attack  one  or 
Iw-th  sides. 

Symptoms.  H<'fore  the  a[)pearance  of  the  vesicles  there  is  a  feeling 
of  heat  and  pain  in  the  mouth  and  throat,  increased  salivation:  the 
febrile  disturbance  is  market!.     There  is  considerable  pain  when  mas- 


. 


1014 


A'«*'£'  A  SI)  Til  Hi)  AT. 


it 


!i 


apix'iir  MS 
( Fij;.  r,27 1 


':^m 


Fin 


ticatinn  (ir  swallowiiip;.     Ipoii  cxaniiiiatiDii   the  vesicles 
siiuill  ijlisters.  varying  from  a  pir/s  head  to  twice  that  size.     (  Fij;.  027 
Tlie  coiitciits  (if  the  vesicles  are  at  lirst  clear,  hut  in  a  few  hours  he 
come  turhid  and  yellow.     They  then  hreak  and  leave  an  underlying 
liyperaMnie  area. 

Treatment.  Nothiiif:,  either  jieneral  or  local,  has  heen  found  to  ap- 
parently curtail  the  course  of  such  an  affection.  General  tonic  treat- 
ment is,  of  course,  indicated  and 
locally,  the  only  remedy  which  the 
writer  has  found  of  u.se  is  the  a|)pli- 
cation  of  orthoform  to  e.-ich  spot. 
The  di.sea.se  is  a  vorj' tedious  one  and 
the  course  apt  to  be  prolonged. 
This  affection  may  also  be  seen  in  a 
chronic  form,  where  the  vesicles  ap- 
pi'ar  aufl  disajipear  only  to  reap|M'ar. 
The  vesicles  may  coalesce,  and  the 
exudate  may  appear  as  a  thm,  yel- 
lowish-white membrane.  Th(>  con- 
dition is  unattended  by  any  jieneral 
disturbance.  In  one  ca.se  .seen  by 
the  writer  it  occurred  in  an  elderly 
man  wlio  had  been  operat(>d  upon 
for  a  larjie  sarcoma  of  the  neck,  and 
the  occurrence  of  the  lieri)es  was 
probably  due  to  injury  of  some  of 
the  nerves. 

Another,  j)prhap.«!,  somewhat  allied 
affection  is  p(>mplii^is.  This  shows 
itself  in  the  eruption  of  largo  bulla> 
on  the  soft  palate,  uvula,  and  posterior  wall  of  the  pharyn.x  or  laryn.x. 
Rarely  ar(>  the  bulhe  .seen,  for  they  are  generallv  ruptured  by  the 
slightest  contact,  and  their  previous  presene(>  is  shown  by  areas  of  a 
thm,  white  exuilato  varying  in  size.  In  a  case  s(>eii  by  the  writer  it 
was  att(>iided  by  a  bullous  eruption  on  both  forearms.  '  No  treatment 
seems  to  .avail  very  much  in  these  ciuses,  and  it  should  lx>  based  on 
general  [)rinciples. 

Parasitic  Diseases  of  the  Pharynx.  The  most  conuuon  parasitic 
affections  of  the  pharynx  met  with  are:  first,  thrush:  .s(>cond.  mycosis. 
1.  Thrush.  This  .affection  is  u.sually  met  with  in  children  who  have 
bei-n  nnproperly  fed.  It  may  also  occur  in  adults  who  are  in  a  debili- 
tated .stat(>  of  health.  IIy|.eracidity  of  the  secretion  of  the  mouth 
favors  its  development.  This  condition  is  not  limited  to  the  pharynx, 
hut  may  be  seen  on  the  soft  palate  and  buccal  mucous  membrane.'  It 
IS  due  to  the  presence  of  the  oidium  albicans,  the  most  common  of 
vegetable  para.siies  found  in  (he  month. 

Symi'tom.s.    In  infants  and  young  children  there  is  difficulty  in  swal- 
lowing and  a  regurgitation  of  food.     In  the  cjtse  of  infants  tliey  refuse 


Herpes  of  soft  jielate  and  uvula. 
(Author's  caae.l 


i)isEAi>i:s  OF  Tin:  onoriiARYSx  and  yASOPiiARrsx.   ioi5 


fixid,  and  very  .soon  hopomo  badly  nmirishod  in  pniisequoncp.  Upon 
cxainination  the  niuptms  nipnihranp  of  tlic  mouth,  soft  jmlate,  ami 
pliatyiix  may  soem  to  be  dotted  here  and  tliere  witli  immerous  white 
o]ialcsppiit  spots  of  exudation,  whieh,  when  removed,  reveal  tiie 
uiKlerivinj:  mupous  membrane  hypera'iu'e.  The  use  of  the  mier()SC()i)e 
will  show  thepreseneeof  thefilameni  ■  (,i  'he   -idium  albicans. 

TiiKATMKNT.  As  the  disease  is  of .  |  iirasitie  iiafin  ,  one's  pffcirts  must 
be  direeted  to  the  destruetion  o  tin  i'Mfai-ifo.  ";  he  old-fashioned 
remedy  of  borax  and  lumey,  pain  mI  ,n  the  p;.rt  still  ans\vers  very 
well.  "Ajiplieations  of  a  weak  solut  ".  ■.:■  iiiti-up  o'  silver  (jir.  iij  to  oj) 
will  also  be  found  useful.  The  general  liyffit ;.;  of  the  patient  nuist 
also  be  attended  to  as  well  as  that  of  the  oral  pavity. 

2.  Mycosis.  Mycosis  of  the  jjliarynx  is  a  eliro'iie  affeetion  charaeter- 
ized  by  the  a])pearanee  of  small  white  sjMits  on  the  tonsils,  jxisterior 
or  lateral  walls  of  the  pharynx,  and  due  to  the  ))resenpe  of  the  vege- 
table  jiarasite  leptothri.v.  It  is  usually  met  with  in  adult  life,  and  is 
more  eommon  in  women  than  in  men.  All  catarrhal  ponditions  of  the 
pharvngeal  mucous  membrane  favor  its  develoimient,  as  also  do  debili- 
tated conditions  of  the  system,  dental  caries,  and  acidity  of  the  saliva. 
It  may  occur  on  any  or  all  ])ortions  of  the  •Mym];hoid  riiif;"  of  Wal- 
deyer;  therefore,  it  is  .seen  on  the  faucial,  lingual,  or  pharyngeal  tonsil, 
or  on  the  posterior  and  lat(>ral  walls  of  the  pharynx  and  pillars  of  the 
fauci's. 

SvMPToM.s.  A'ery  freiiuently  there  are  no  symptoms  until  the  pa- 
tient has  appidentally  dispovered  the  ])resence  of  "white  spots"  in 
the  throat  and  has  bep>)me  uneasy  about  them.  Sometimes  these 
])atients  coniplain  of  a  feeling  of  a  foreign  body  in  the  throat  and  of  a 
di'sire  to  swallow  repeatedly,  or  fre<iuently  clearing  the  throat.  Upon 
examination  "  wliite  spots,"  varying  in  number,  are  seen  varicmsly 
distributed  on  the  tonsils  (faucial  and  lingiuil),  posterior  and  lateral 
walls  of  tlie  pharynx,  and  in  the  na.sopharynx.  These  spots  look  like 
white  bristly  points  standing  out  a  very  short  distance  from  the  mu- 
cous membrane  of  the  invaded  jiarts  and  to  which  they  tenaciously 
ailh(>re.  Any  doubt  as  to  the  nature  of  the  affection  (liable  as  it  is  to 
be  confounded  with  such  affeetions  a.s  tonsillitis  or  diphtheria)  is  .set 
at  rest  by  the  miprospo|)ic  examination.  In  this  affection  there  is 
an  entire  absence  of  any  general  disturbance. 

Treatment.  This  affeetion,  like  .some  of  those  occurring  at  the  base 
of  the  tongue  (moderate  hypertrophy  of  the  lingual  tonsil  and 
"  varix"),  is  apt  to  occur  in  neurotic  and  run-down  individuals,  and 
ther(>fore  atte  'on  to  the  general  health  is  the  most  important.  WTien 
demanding :.  ference.  which  is  seldom,  the  use  of  the  galvanocautery 
points  to  eacii  s])ot,  whiph  is  a  tedious  process  when  the  .spots  are 
numerous,  and  excision  of  the  hivaded  parts,  where  po.ssible,  aie  the 
only  means  to  be  relied  upon.  The  use  of  loeal  antiseptics  (parasiti- 
cides), in  the  ujiinion  of  the  writer,  avails  nothing. 

Hemorrhage  from  the  pharynx  is  a  condition  occa,sionally  met 
with,  and  may  be  mistaken  for  ha'inopty.-.is.     It  is  usually  due  to  a 


1016 


\OSi:  AXD  THROAT. 


>'lo.  ,i28. 


small  vesst'l.  oithor  on  tlii-  postc-rior  wall  of  the  pharynx  or  root  of 
tlic  toiifiuc,  hciiij;  nipdircd  througli  violent  efforts  to  elear  the  tliroat, 
or  of  retchiiij?.  In  two  cases  the  writer  met  with,  it  oeeurred  always 
with  menstruation.  Cases  of  hemorrliufte  of  the  tliroat  must  he  seen 
at  the  time  of  occurrenee  in  order  to  he  sure  that  it  is  not  (hie  to 
pulinonarj'  disease.  When  ti>e  hleediiiR  |)()iiit  is  located  the  applica- 
tion of  the  galvanocautery  point  will  usually  sufhce. 

Foreign  Bodies  in  the  Pharynx.  Foreign"  bodies  which  are  found 
in  the  pharynx  may  1k»  of  any  nature,  hut  are  usually  fish-hones, 
spicuhe  of  hone,  bristles  of  a  t()otli-l)rush,  coins,  nut-shells,  false 
teeth,  husks  of  grain,  etc.  They  may  become  lodged  in  the  sub- 
stance of  any  of  the  tonsils  in  the  case  of  .sharp  penetrating  objects, 
behind  the  pillars  of  the  fauces,  in  the  epiglottic  fos.sa',  in  the  pyri- 
forin  sinus,  and  in  any  part  of  the  a'sojjhagus,  hut  especially  at  a 
!)oint  oi)i)()site  the  cricoid  cartilage,  or,  through  efforts  at  coughing 
or  atteini)ts  at  dislodgement,  they  may  Ix!  found  in  the  nasopharynx. 
The  symptoms  present  dei)end  upon  the  nature,  size,  and  situation 
of  the  fonngn  body.  Discomfort  from  a  feeling  of  irritation  in  the 
throat,  a  constant  desire  to  swallow,  even  to  inability  to  swallow, 
and  when,  from  its  size,  it  is  either  situated  at  the  entrance  to  the 
larynx,  and  is  i;i  such  a  way  as  to  interfere  with 
the  ingress  cr  e;ress  of  air,  or  when  in  the  opso- 
jihagus,  and  sufficiently  large  to  press  upon  the 
posterior  wall  of  the  trachea,  symj)tomsof  dy.sp- 
n(ra  may  be  present.  In  the  ca.se  of  a  foreign 
body  being  lodged  in  the  nasopharynx,  which 
is  a  very  unusual  ■ccurrence,  there  may  be  no 
syin[)toms  present  at  all,  either  from  its  small- 
ness  or  situation,  or  it  m!:v,  wiien  largo,  pro- 

ihor'9ca-e.)  tion.     In  the  writer  s  case  of  a  foreign  body  in 

the  nasopharynx,  it  was  an  ordinary  tailor's 
brass  thimble.  (Fig.  o2<S.)  This  at  first  was  in  the  lower  part  of 
the  pharynx,  and,  perhaps,  on  reaching  the  entrance  to  the  larynx, 
it  was  blown  into  the  nasopharynx  through  violent  efforts  of  coughing. 
It  was  lodged  in  this  region  for  eighteen  years,  and  had,  when  the 
writer  saw  the  p.itient,  produced  a  chronic  nasopharyngitis  a?id  con- 
comitant symptoms  affecting  the  hearing.  One  must  be  sure  of  the 
exact  location  of  the  foreign  body  before  any  attempt  is  made  to 
extract  it,  because  rccasionally  symptoms  are  produced  simulating 
the  presence  of  a  foreign  body,  but  which  are  entnely  due  to  the 
scratching  (ir  abrading  of  the  ii'.ucous  membrane  by  the  pa.ssage 
of  the  foreign  body  downward  into  the  crsophagus  anil  stomach.  If 
the  foreign  body  be  situate<l  in  the  lateral  walls  of  the  pharynx  or 
the  upper  j)ortion  of  the  oesophagus,  its  ex.ict  locality  may  l)e  more 
ch'arly  deluied  by  ma'dng  the  |.atient  n-tch  while  under  oli.servation. 
The  removal  of  a  foreign  body  occurring  iti  any  portion  f>f  the 
pharynx  can  readily  be  do!-'-  by  fon-eps  suitably  adapteil  for  the 


i)isi:.[si:s  OF  Tin:  onoi'iiAiiYsx  axd  xahoi'iiakiwx.    1017 


ri'jiioii  ill  wliicli  it  may  I  ■■  situated.     This  should  alwiiys  bo  uiidcr- 
lakcii  with  tlic  rejfiou  ])i'    utIv  illuniiiiatcd. 

Olio  must  he  careful  in  not  mistaking  pertain  anatomieal  points 
for  foreifin  hodies.  One  case  has  been  met  witli  in  the  writer's  expe- 
lieiice  wiiere  th<'  family  physician  mistook  the  asceiidiiifccormi  of  tlii! 
Iiyoid  bone,  whicii  was  very  jiromiiient  heiieatl!  the  pharynx,  for  a 
-iipposed  foreifin  body,  and  in  a*  '  t  the  sharp  point  of  the  haiii- 
ular  jirocess  of  the  pterygoid  plate  of  the  sphenoid  iione  had  bi en 
mistaken  for  a  {)iii  sujjposed  to  have  been  iini)acte(l  in  the  naso- 
pharynx. 


Forceps  of  Buck,  oi>ening  aiitcnvjiosterinrly. 


Fio.  KIO. 


Forceps  of  Fauvol.  opening  laterally. 

Tumors  of  the  Oropharynx.  Both  benign  and  malignant  tumors 
may  involve  this  jiorticm  of  the  pharynx.  In  the  case  of  malignant 
jirowths  they  usually  ar(>  an  extension  into  the  pharynx  from  disease 
ill  the  neighboring  structures.  Primary  carcinoma  of  the  jiharynx 
is  rare.  The  growths  most  commonly  met  with  in  this  region  are 
considered  under  the  parts  they  especially  invade,  viz.:  soft  palat(\ 
uvula,  and  tonsils,  to  wliicii  section  the  reader  is  referred.  Tumors 
of  the  nasopharynx  will  Ik"  dealt  with  when  considering  diseases 
of  tliat  region. 

Retropharyn^^eal  Abscess.  Primary  retropharyngeal  abscess  is  a 
suppurative  process  which  takes  place  in  the  lymphatic  nodules  sit- 
uated b<'tween  the  prevertebral  fascia  and  the  tunica  pharyngea 
externa. 

Etiology.  The  disea.s<'  occurring  primarily  is  an  affection  of  infancy, 
between  the  ages  of  six  months  and  one  year.     It  is  uncommon  after 


1018 


AUHE  ASD  rHKU.IT. 


throo  yt'iirs  of  ago,  and  tho  reason  of  this  is  said  to  bo  that  after  threo 
years  of  age  the  ciiain  of  lynipli  nodules  most  marked  up  to  that  ap 
rapidly  disappears.  It  may  Ik'  aeute,  as  tiie  n'sult  of  adenitis  and 
from  tiie  intimate  eoimeetion  between  the  iymi)haties  of  the  jjharynx 
and  those  of  the  soft  palate  and  tonsil,  or  it  may  be  a  s(!(|uence  of 
an  inflammatory  condition  involving  these  regions  fron»  any  cause 
whatsoever.  The  di.sease  may  occur  in  tubercular  and  rhachitic 
children.  Retropharyngeal  abscess  when  occurring  secondarily  does 
so  ,is  a  s<^(iuence  of  .spinal  caries,  and  is  then  chronic  in  its  nat-- 
In  this  form  the  disea.se  is  more  freciuent  in  adults,  and  the  p 
situated  'uetween  the  .spinal  column  and  the  |)revertel)ral  mu.snes 
and  ligaments.  It  may  occur  traumatically  from  the  impaction  of 
a  foreign  body  in  the  posterior  wall  of  the  pharynx. 

Symptoms.  The  sym])toi:i  first  showing  itself  is  tho  n'fusal  by  the 
infant  to  continue  to  take  nourishment,  evidently  frotn  the  paiii  and 
ditliculty  of  swallowing.  The  child  is  restless  and  feveri.sh.  As  the 
case  j)rogres.ses  there  is  difficulty  in  breathing,  either  through  the 
no.se,  if  the  abscess  be  seated  in  the  na.sopharynx,  or  through  the 
larynx,  if  it  be  seated  low  down  in  tl  ;>  laryngopharynx.  In  the  first 
case  the  mouth  is  widely  open,  and  th  >  chi'd  snores,"and  in  the  .second 
case  there  is  laryngeal  stridor.  The  voice  'i;is  a  nasal  character  and 
the  noise  like  a  hen  clucking  accompanies  respiration;  the  neck  is 
rigid,  and  the  head  is  held  toward  the  affected  side.  Cough  is  fre- 
quently present.  There  is  sometimes  a  marked  swelling  in  the  neck 
on  the  affected  side  between  the  sternocleidomastoid  muscle  and 
the  angle  of  tho  lower  jaw.  The  abscess,  when  due  to  lymj)h  nodules 
breaking  down,  forms  ra])idly,  but  when  duo  to  bone  disease  develop,- 
slowly.  In  .some  ca.ses  there  is  only  a  lymphadenitis,  and  then  tho 
symptoms  are  much  less  jjronounced  and  not  as  urgent.  When  one 
proceeds  to  tho  inspection  of  the  throat  this  should  bo  done  verj- 
gently,  as  rough  handling  may  -mexpectedly  rupture  the  abscess, 
with  jiorhaps  unpleasant  if  not  fatal  results.'  It  may  bo  noccs.sary 
to  insert  a  mouth-gag  in  order  to  carry  out  this  inspection;  this  too 
should  bo  gently  done  for  the  same  rea.snn.  When  tho  i)harynx  is 
well  illuminated  a  swelling  occupying  either  a  central  or  lateral  posi- 
tion on  the  posterior  wall  of  the  pharynx  is  obser\-ed.  It  bulges 
forward,  and  may,  if  large  enough,  throw  tho  soft  palate  forward; 
tho  swelling  is  decidedly  hypera-mic,  and  upon  examination  is  found 
soft  and  fluctuating.     rPlafe  XXXI.) 

Diagnosis.  The  disease  has  been  mistaken  for  croup  and  quinsy: 
but  a  can'ful  consideration  of  the  general  symptoms  and  insi)oction 
and  palpation  of  the  swelling  will  readily  load  to  a  correct  diagnosis. 

Treatment.  In  ca.ses  where  there  is  only  a  lymphadenitis  and  the 
symptoms  present  very  mild,  the  application'  of  hot  fomentations 
and  .tononv!  tonic  troatiTtojit  have  led  to  theaiisorption  of  the  itiflam 
nia'ory  condition.  When,  however,  there  are  distinct  evidences  o! 
l»us  being  i)resent  operative  measures  are  at  once  indicated.  Then 
are  two  methods  of  dealing  with  such  cases:  first,  by  an  incision 


I'l.ATi:    XXXI. 


K''ii.,|,iia,  \n.|<-.'il    Al,~.  ,.■-,.      ,  Auili..]--  ,.;,-,, 


i 


DISEASES  OF  TUB  ORoPlIABYXX  ASD  NASOl'llARYW.     1019 

ilirmifjli  till"  pharyngeal  wall,  or,  secoiul,  by  an  cxtcnial  incision  in 
tiic  neck. 

I.  The  first  method  is  aeeoiiiplished  as  follows;  The  child  is 
wrapiH-d  in  a  blanket,  and  by  this  means  movements  of  the  arms  and 
Icjrs  are  restricted.  The  nurse  holds  the  little  one  in  her  arms,  with 
tilt'  child's  head  resting  on  her  left  shoulder;  the  head  should  then 
be  steadied  by  an  assistant.  The  mouth-fiag  is  introduced  and  genily 
iipiMied.  With  the  swelhuR  well  illuminated  a  vertical  inci.sion  is 
ni;i,|e  into  the  centre  of  the  swelling;  l)y  means  of  a  straijiht-backetl 
knife.  The  exit  of  pus  is  rapid,  and  'ii  many  eases  consi(leral)!e  in 
quantity,  and  as  a  forethoufilit  to  such  an  occurrence  the  child's  head 
is  immediately  held  well  forward  and  downward  to  allow  the  pus  to 
iM.ipe  throufili  the  mouth,  which  otherwise  mijiht  find  its  way  into 
ihc  larynx  and  jjroduce  .suffocation.  In  a  day  or  two  a  re-collection 
may  take  place,  necessitating  reopening  of  the  abscess.  In  rare  cases 
tlii'Opening  of  the  abscess  may  not  give  relief  to  the  symjitonis,  and 
ihcii  one  must  make  a  careful  examination  for  the  possible  exi.stonco 
di'  another  abscess  lower  down. 

This  method  of  oijcrating  has  its  many  advocates,  but  there  are 
many  objections  to  it.  The  abscess  cannot  be  properly  drained, 
and  any  drainage  that  may  take  |)lace  is  swallowed  l)y  the  chihl; 
ihe  opening  may  close  too  soon  and  pus  reaccunmlate.  Proper  anti- 
septic precautions  cannot  be  taken,  and  there  is  always  a  '^ngor  of 
suffocation  from  the  pu.s,  for,  no  matter  how  carefully  Hone,  one 
cannot  tell  how  rapidly  the  pus  may  escajx-. 

2.  iU-  an  external  incision  (Hilton's  method):  This  operation 
should  "be  carried  out  with  all  the  u.sual  steps  of  strict  a.sepsi.s.  The 
incision  is  made  Ix-hind  the  sternocleidomastoid  muscle,  beginning 
one  inch  below  the  tij)  of  the  mastoid  process  and  extending  down- 
ward for  one  inch.  The  skin  and  f'.iscia  are  incised  until  the  nmscles 
t'ciming  the  floor  of  the  posterior  triangle  of  the  neck  are  reached. 
'I'lien  carry  out  the  rest  of  the  operation  by  means  of  blunt  instru- 
ments jiassing  l)ehind  the  deep  ve.s.sels  and  nerves  of  the  neck.  This 
is  l)est  done  bv  means  of  a  grooved  director  and  with  one  finger  in 
the  pharynx.  "When  the  absces,s  cavity  is  reached  and  opened  a  pair 
of  forceps  should  be  inserted,  closed,  and  when  within  the  cavity 
ojiened  and  withdrawn  in  that  state:  this  will  enlarge  the  opening 
freely.  A  careful  examination  by  means  of  the  finger  will  enable  the 
<iperator  to  further  ascertain  the  existence  or  non-existence  of  any 
further  complication.  A  drainage-tube  of  good  size  is  then  inserted 
and  the  usual  a.septic  dre.ssings  applied.  Subsequent  washii.g  out 
of  the  cavity  with  boric-acid  solution  may  be  neces.sary  for  a  few 
days,  and  at  the  end  of  a  week  the  tube  may  usually  l>e  withdrawn 
and  tlie  wound  allowed  to  close. 

Tiie  writer,  in  his  experience,  Itelieves  this  to  be  a  better  method 
of  operating  than  the  former,  on  account  of  the  better  drainage.  l)etter 
asepsis,  and  that  the  operation  once  done  is  completed.  It  is  also 
a  more  surgical  and  more  scientific  method  of  procedure.      "" 


This 


! 


ii 


1(120 


sunt'  A.\D  TJIHOAT. 


imcIIkuI  (if  (ipcratiiij;  is  the  only  one  wliicli  slioiil.l  hv  .•idoptcd  when 
(Ifiiliii;;  with  the  flimriic  luriii  of  rctropliaryiiftcnl  :il)sccss  .-issocijitcd 
with  spinal  caries.  In  these  ease.-,  such  jmrt  nf  the  caries  as  it  is 
pDssilile  tn  remove  should  Im-  dealt  with.  Suhserpient  to  any  "iM-ra- 
tive  measures  the  patient  always  re(iuires  general  tonic  treatment. 


DISEASES  OF  THE  NASOPHARYNX. 

Acute  Nasopharyngitis.  The  afl'ection  localized  to  the  nasopharynx 
itself  is  very  seldom  met  with,  and  its  e.\istenee  as  a  primary  di.seaso 
is  douhted  hy  many,  it  usually  heinj;  concomitant  of  an  acute  rhinitis. 

Etiology.  Isually.  it  is  an  extension  of  the  inflammatory  atVection 
from  the  nose  or  pharynx.  Children  in  whom  there  is  an  enlar<;e- 
ment  of  the  lymphoid  tissue  ;ire  especially  prone  to  it.  It  may  occur 
in  the  course  of  any  of  the  e.yanthemata:  sudden  climatic  changes 
may  also  act. 

Symptoms.  The  symptoms  may  in  severe  cases  he  ushered  in  hy 
a  chill  or  feelinj;  of  m:dais(>;  there  is  a  sense  of  f  ih ess  in  the  heall 
and  slight  tinnitus  aurium.  dryness  at  the  hack  of  the  nose,  and  deglu- 
tition is  painful.  Later  on,  that  is,  in  the  course  of  twenty-four  to 
thirty-eight  hours,  there  is  a  thin  mucous  discharge,  very  tenacious 
and  stained  with  lilood,  which  .sul)se(|uently  becomes  mu<'opurulent. 
At  this  st.-ige  of  the  disease  there  is  on  the  part  of  the  patient  a  desire 
to  hawk  and  expectorate,  and  the  voice  may  heconie  a  little  husky. 
In  children,  the  onset  is  marked  hy  decidedly  febrile  distin'bance, 
rapid  jMilse,  and  liigh  temjierature  ("l()_'°  to  104°  F.);  further,  many 
children  become  temjMirarily  mouth-breathers  because  of  the  involve- 
ment of  the  pharyngeal  lonsil  in  the  acute  inflammatory  proces-s. 
rpon  examination  with  the  rhinoscope  in  adults  there  is  iii  the  early 
stage  marked  swelling,  redness,  and  dry  appeanmce  of  the  mucous 
nuMnbrane  of  the  vault  and  po.sterior  w;il!  of  the  pharynx.  When 
the  stage  of  .secretion  has  set  in  the  mucous  membrane  is  bedecked 
with  a  mucous  or  muco])urulent  secretion.  In  children  it  is  often 
impossible  to  make  a  .satisfactory  rhinoscopie  examination:  but 
when  it  is  permitted  (>ii(>  ob.serves  t  Jie  lymphoid  tissue,  and  especially 
the  phary  <'eal  tonsil,  to  be  much  swollen,  hypera'mic,  and  glazeel, 
and  sometimes  small  spots  of  exudation  are  seen. 

Treatment.  Should  the  di.sease  be  concomitant  with  an  acute  rhin- 
itis, the  treatment  as  detailed  under  that  disease  should  be  followed 
out.  One  shouM  begin  with  a  mild  mercurial  purgative,  such  as 
calomel,  gr.  iij,  to  be  followed  m  the  course  of  eight  hours  hy  a  Seid- 
litz  powder;  phenacetin  in  small  doses  (gr.  ij)  every  two  hours  will 
relieve  the  febrile  condition.  When  secretion  has  set  in,  an  alkaline 
lotion,  such  a.s  bicarbonafe  of  so<la  igr.  x  to  ^JK  may  be  used.  In 
cases  where  the  postnasal  syringe  is  tolerated,  this  is  the  best  wav 
of  using  the  solution:  but  in  other  cases  one  must  be  satisfied  by 
spraying  through  the  anterior  nares.     In  the  e.arly  stage  steam  in- 


uisE.Lsi:^  OF  TUi:  oRopii.myyx  axd  .\aso1'Jiary.\x.    1021 

li:il;iti()iis  of  ('(mipouiid  tincture  of  hcnzoiii  (  5j  to()ss),aii(l  tlic  sul)sc- 
,|ii(iit  :i|)plic:itioii  of  a  weak  solution  (f;r.  ^•  to  ;*)j)  of  nitrate  of  silver 
will  moderate  thi'  amount  of  secretion.  In  diiidreii  very  little  local 
treatment  can,  as  a  rule,  he  carried  out  with  muchelTect.  However, 
I,  '  writer  has  found  tliat  a  small  .luaiitity  of  the  following'  ointment 
ii.trodut-ed  into  each  nostril  three  or  four  times  a  day  seem*  to  give 
relief: 

Hydrantiri  oiidl  rubri,  (jr.  v. 

I'HraBln,  Kf   vlij. 

Vuel.  alb.,  il 
M.    Ft.  ung. 

Chronic  Nasopharyngitis,  "^hi;  afection  is  a  chronic  inflanmm- 
tioii  of  the  nasopharynfjeal  mucous  memliraiie.  It  is  es.sentially  a 
<li.-^ease  of  adult  life,  and  the  .symptoms  of  a  chronic  nasopharyiifiitis 
in  childhood  are  indicated  hy"  the  presence  of  adenoid  vepetatioiis. 
Etiology.  I're(iui'iit  and  neglected  attacks  of  acute  na.s()i)hary'if;itis, 
clian-res  of  climtite,  syphilis,  tuherculosis,  rheumatism,  gout,  anaemia, 
j:astro-intestinal  disorders,  ahusive  use  of  alcohol  and  tohacco,  occu- 
pations where  there  are  irritating  pases  or  dust,  overheated  rooms, 
suppurative  disea.ses  of  the  ethmoidal  and  sphenoidal  sinuses,  hyper- 
trojihy  or  atrophy  of  the  pharyngeal  tonsils,  nasal  stenosis  due  to 
.septal  deviation,  .s'purs,  hypertrophic  rhinitis,  polypi,  etc.  Tormvaldt 
has  laid  great  stress  upon" certain  pathological  dianges  in  the  so-called 
Imisa  pharvngea  (i)ursitis)  as  a  very  freriuent  cause  of  postnasal 
catarrh.  I'i)""  this  point,  however,  there  are  many  opinions,  ami 
iintalily  Schwahach,  who  contends  that  the  pharyngeal  bursa  is  nothing 
more  than  the  persistence  of  the  median  cleft  in  the  phiiryngeal 
tonsil.  .Adhesions  between  the  edges  of  the  cleft  in  the  pharyngeal 
tonsil  may  lead  to  the  n-tention  of  pathological  products,  and  by  a 
complete  inclusion  may  produce  a  cyst,  these  conditions  acting  as  a 
source  of  postnasal  catarrh. 

Symptoms.  The  most  freciuent  symptom  complained  of  by  the 
[latieiit  is  the  presence  of  a  mii  •"purulent  secretion  at  the  back  of 
the  iio.se,  which  <-itlier  droi)s  into  .nc  throat  or  is  of  neces.sity  removed 
by  hawking.  This  symptom  is  especially  prominent  uixm  first  rising, 
aiid  often  attempts  "at  the  removal  of  the  .secretion  are  so  energeti- 
ciHy  carried  out  as  to  jtroduce  retching.  \'ery  frefiurntly  these 
patients  ])ro(liice  a  very  di.sagrec-able  noise,  made  by  sending  a  sudden 
l.iasi  of  air  through  the  ixisteriornares.  as  if  trying  to  dislodge  some- 
thing from  the  naso])liarynx  into  the  nose.  In  many  cases  of  long- 
standing aural  .symptoms  (varying  degrees  of  dulness  of  hearing  and 
tinnitus)  may  be  present.  Through  the  extension  ol  the  catarrhal 
process  downward,  or  the  influence  which  the  condition  has  upon 
structures  below  the  seat  of  this  affection,  huskiness  is  frequently 
met  with,  Indir(>ctly,  dull  headache  (frontal  or  occipital)  is  produced, 
and  there  is  a  tendency  to  repeated  colds  in  the  head.  Upon  exam- 
ination the  nasopharyiix  is  seen  by  means  of  the  rhinoscope  to  l>e 
covered,  either  uniformly  or  discre'tely,  with  a  mucoinirulent  secre- 


Ml 


1(1-22 


.\o.st-:  AM)  III  Hum: 


tioii,  or  (Irinl  into  :i  Imnli'iicil  crust.  Tliis  Inttcr  condition  is  ospc- 
cially  to  lie  iiotcil  in  the  ccntri'  of  the  v.iult  of  the  piwiiynx,  iinil  i- 
said  l>y  Tornwaldt  to  Ix-  pathojiiioinonic  of  (hscasc  of  tiic  linrMi 
[•harynfica.  Tiic  secretion  or  crust  when  ri'movecl  shows  the  under- 
lying mucous  ineinhraiie  to  he  either  hypera'Uiic.  or  in  sou'e  cases 
practically  norinal.  IJeinoval  of  crusts  and  a  careful  exaininatioii 
of  the  nasopliaryiix  afterward  is  eswiitial,  as  it  occasionally  hap|M'ns 
that  upon  removal  of  the  crusts  there  is  found  to  Im'  a  specihe  ulcera- 
tion present.  Tiie  pharynjieal  tonsil  is  sometimes  s<>en  to  he  swollen 
or  atrophied,  and  in  many  cases,  throujth  openm^s  left  hy  parti;illy 
adherent  clefts  in  the  tonsil,  ;i  muco|iurulent  .secretion  is  seen  exuding. 

Diagnosis.  The  condition  in;iy  he  mist.-iken  for  suppurative  pro- 
ce.s.ses  invniviiif;  the  sphenoidal,  j)osterior  ethmoidal,  or  (>ven  the 
maxilhiry  siiuis,  ami  to  tlie  cha|)ter  on  these  alTections  tlic  reader 
is  referred. 

Treatment.  In  all  local  atTection.s  one  must  never  forjjel  the  proh- 
ahility  of  a  constitutional  condition  heiiifr  aiiswerahle  for  the  locil 
trouhle:  therefore,  careful  investijiation  into  the  prohahle  existence 
of  any  .such  condition  should  receive  careful  attention,  and  he  treated 
accordiiifrly.  Locally,  the  secretions  should  he  removed  hy  alkaline 
s])rays— hicarhonate  and  the  hihor.-ite  of  soda  (gr.  x  to  oj  water). 
This  may  he  used  hy  niejinsof  an  atomizer,  or.  hetter,  hy  a  postnasal 
syrinKe,  for,  ;is  a  rule,  the  spray  from  the  atomizer  is  not  sulliciently 
stroll}!  to  dislodtre  the  icious  secretion  or  the  crusted  formation. 
When  the  surface  i.-  t  .  from  secretion  or  crusts,  the  itjiijlication. 
hy  means  of  a  cotton-wool  swah.  of  a  solution  of  nitnile  of  silver 
(jir.  x-xx  to  o.i'  or  ehloride  of  zinc  (jir.  xv  xxx  to  7).i)  may  l)eai)j)lied. 
In  makiiifr  such  an  application  the  cotton-wool  swali  should  not  he 
surcharged  with  the  solution  to  lie  useil,  ;is  the  excess  inav  find  its 
way  into  the  larynx,  produciii};  what  may  appear  to  the  inex|H'rience(!, 
.•iiarmin<;  stridor.  In  adults,  where  the  disease  is  dependent  ujion 
an  atrophied  condition  of  the  pharyngeal  tonsil  retainiii}!  secretion 
♦hroufih  .adhesions,  the  removal  of  the  tissue  hy  means  of  a  (iottstein 
curette  is  indicated.  Some  .autiiors  recommend  the  application  of 
solid  nitrate  of  silver  or  the  fialvanocautery  point  to  ohtain  the  same 
result.  A  cyst  or  suhmucous  ah.scess  may  he  dealt  with  hy  either 
of  the  foregoing  methods. 

Atrophic  Nasophar3mgitis.  This  condition  is  always  !v.s.sociateil 
with  a  similar  condition  of  the  nose.  It  is  characterized  hy  a  glazed 
and  dry  appearance  of  the  mucous  memhrane  which,  in  many  ca.ses. 
is  covered  with  cnist.-i  of  a  diirk-grnen  or  yellow  color. 

It  presents  many  of  the  .sym[)toms  in  conunon  with  the  same  affec- 
tion of  the  nose,  and  for  the  treatment  of  which  the  reader  is  rpforreil 
to  the  article  under  "Atrophic  Rliinitis. " 

H3T)ertrophy  of  the  Pharjrngeal  Tonsil.  Iti  th(<  mtsophrirynx  then 
normally  exists  lymphoid  tissue  which,  when  collected  together  in 
the  vault,  con.stituti-s  wliat  is  known  as  the  |)haryngeal  or  third 
tonsil  (Luschka).     This  tonsil  may  bo  the  subject  of  an  acute  inflani- 


hisi:.i.sKs  OF  Tin:  DnoriiAursx  asd  .sAsfii-iiAuy.w.    i(»-23 


timiMTiitiin-  ( 101°  fii  l(i;{°  r.).  Tliciv  ij<  iiiJirkcd  dilliculty  in  lucatli- 
iii;;  tliioiiuli  the  nose,  and  the  cliildV  voifo  Imtiuiics  tliirk.  Tliciiii.sil 
-icii'tiniis  arc  lal 


inc  now,  anil  mr  i-iuni  .-■><'"<■  m  <  <mih  •-■  m"  ".       ■  ■•■  ■ 

•(•  later  on  (in  the  course  of  a  !'<)ii[)l<'  of  days)  incrca^'d 

:ind  chanficd  in  cliaractcr,  licin^'  at  first  tliin    •■"■I   "Icir    l.nt  snl.sc- 

lurnilv  Ix'coinc  mucopurulent,     li 
-      i'   I  .. -.1 I 


and   clear,  hut  sulisc- 

1  many  eases  tlie  alTection  may  l)»' 


lurniiv  IxTome  mucopurulent.  In  many  eases  tlie  affection  may  Ix- 
.illend'ed  Willi  an  acute  catariiial  otitis  media.  The  treatment  coii- 
HMs  of  a  inilil  purgative,  the  syrin)rin«  of  the  nostrils  with  an  alkaline 

I  MUtiseptic  solution,  such  as  Dohell's,  and  the  ap|ilication  of  the 

llowin^r  ouitmcnt  within  the  nostrils  every  four  h.ours; 


llyilnirKvri  oxUli  riibri. 

I'ttriiltiii. 

ViiHL'l.  alb.. 


l!r.  j»s-i>.- 
gr  Iv-vilj. 
Slj. 


M.     Kt.  niiij. 


Adenoid  Vegetations  or  Postnasal  Growths.  The  affection  which 
i-  most  commonly  met  with  is  where  the  pharynjieal  tonsil  l>ccoines 
ihronicaliy  eiilarp'd,  and  when  such  is  the  ca.se  it  is  commonly  known 
a>  iiiliniiid  rt(iiliili(iiis,  or  jxistudsiil  <jri>irths. 

Etiology,  it  is  an  atTection  lar>rely  met  with  in  children,  although 
,„r:i-ionallv  met  with  in  adult  life.  In  the  author's  collection  of  ca.^es 
ilic  aires  at  which  sU'-h  a  condiiioii  was  most  frequently  found  were 
l..i\\,rn  three  and  live  years:  the  earliest  aj;e  in  which  it  was  met 
wiih  is  a  sinjrl.'  case  at  three  weeks,  the  oldest  at  forty-five  years. 
.\>  to  sex,  there  is  a  sliiihl  |iredoniiiiaiice  in  favor  of  males.  That 
iirivditv  i'>lavs  some  part,  the  writer  helieves  there  is  no  douht,  as 
ill  his  ti)tal  cases  there  weiv  no  h'ss  than  fifty-three  families  in  which 
Irom  two  to  four  children  were  the  sulijects  of  iiypertrophy  of  the 
|iliarvnfie;d  tonsil. 

In"  the  table  on  pa«e  1024  are  p;iven  the  writer's  statistics,  taken 
(iiilv  from  his  private  practice.  The  total  iiuiiibor  of  ca.ses  was* 
!(■.().-),  occurrinj;  amoiifi  1(),(MM)  patients.  This  represents  Ifi  per  cent. 
n|-  cases  in  which  adenoids  or  adenoids  and  enlarRed  tonsils  were 
found  to  exist. 

.\fter  some  of  the  infortiou.s  fevers,  ospocially  mea.sles  and  scarlet 
fever,  it  would  seem  as  if  the  alTectioii  were  ])recii)ita.ted.  Climate, 
where  there  are  extremes  of  heat  and  cold,  seems  to  1)p  favorable 
to  its  development.  lieiK-ated  attacks  of  acute  nasojiharvnigitis  tend 
to  hvpertrophv  of  the  Ivmphoid  tissue.  The  pharyiifteal  tcsnsil  is  apt 
to  underp.  atrophv  after  puberty,  and  the  writer  has  also  seen  this 
take  |)lacr'  following  a  severe  attack  of  nasal  and  nasop'i.aryngeal 
diphtheria.  . 

Symptoms.  The  existence  of  adenoids  is  very  frotiuently  recognized 
by  the  facial  expression  of  the  child,  altliough  one  must  be  very 


1024 


A'o.sa;  .\m>  riiiiDAT. 


rari'fiil  in  ninkiiiK  a  iliapinsis  Inmi  tlii.-<  alone,  a,«  is  so  often  dune, 
iH'caiise  iii'irked  anii'riiir  nasal  steh  »i-i  may  prnilucc'  a  similar  exiires- 
/u,u  (if  ciiutitenancc.  Cliihlrcn  \\\v>  sutler  I'rnm  ejimnic  enlarnemeni 
of  llie  |)liarvii>;eal  tonsil  an-  of  two  ly|M's:  one  is  of  floriij  cnniitenance 
and  well  ii.".iiri-lie.|  i  Kij;.  5ai),  ami  the  other  isjialeaml  tliin  looking. 


I' ;  ;  I 


A.K'llol.l" 

Ailfli. 

|il«Klllt  t 

lllflllH. 

1               . 

innil  TnUl 

Age. 

tfk« 

1 

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1 

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UX)6 

In  hotli  till'  month  is  o]ien  most  of  the  time,  the  nose  thin,  the 
nostrils  nan-o'v,  the  depression  on  either  side  of  the  ahe  doe|K'r 
than  normal,  the  iipjier  lids  may  droop,  and  the  general  exjiression 
is  often  dull,  listless,  and  idiotic.  I'pon  (|Uestioiiinj;  the  parents,  one 
m;iy  elieit  the  faet  that  the  child  is  a  niouth-hreather,  especially  at 
ni<:ht,  and  it  may  he  so  marked  that  the  child  snores.  In  some  cases 
there  may  be  even  a  struggle  for  breath  to  such  an  extent  as  to  alarm 
the  parents,  and  the  child  may  start  uj)  from  its  .sleep  (|uite  fright- 
•■ned  (nifiht-termrs).  These  symptoms  of  disturbed  breathinj;  are 
moderated  when  the  child  is  turne<l  so  jis  to  sleep  on  its  side.  \'aryin!r 
dejrrees  of  deafness  may  lie  noted,  which  condition  may  pas.s  off  in 
warm  weather.  From  this  very  fact  of  the  deafness  beinji  only  tem- 
porary, and  of  a  sliirht  defrrec  in  some  cases,  parents  jire  .apt  to  pay 
little  attention  to  it.  Hejieated  attacks  •  ■  earache,  foilowed  by  a 
discharfre  in  some  c;ises.  are  f  ■"i|Ui'ntly  met  with,  ("olds  in  the  head 
ail'  of  fre(|uent  occurrenci  i  .sonii  children  it  may  be  said  that 
thi'v  sTOiii  to  have  a  con.-tant  culd  iii  tlie  head.     .\  cough,  esj-K-ciaily 


,tish:.i 


iji'  Tin:  DRoi'ii. 


AltYSX    l.V/)  .V.l.sory/.UJI'.VA 


1025 


vhvn  llu-  .iiil.l  H  asl.'.-i),  i''  n'.t.-. 


Mtit 


I  litMiifhitH  i- 


lis., 


UK 


1    .,,,,1  lialiilitv  to  altiirks  „f  rroui. 
Icri.lf.lly  iliifk  iiiiil 


t  with.     I'll"'  v"i«T  IS  ( 


iihoiii  n'sntiiiiicf;  It  ■'"•1111 


Is  ii"  if  111''  •■liil'l  '""'  -^  '*!'^'"' 


>I>1  ill  his 


hcti'l;  letters  rn|uinii'r 


ir   HJisa 


I  ..hamlHTs  f..r  llifir  ivsoiuiiu- 


roiinlv   I 


iroiiDiiiu'i'' 


CIV  111 


thus 


III 


H'C'OIIH-; 


'1. 


a 


iirt- 


H'l-Kllll'S 


iikfil  fiisi' 


there  iiuiy  l)e  evi 


inlitliriilly  in  I'rea 


thiiiR 


Khi.  Ml 


t 


Typos  of 


the  "  ailf  n""'  '  f'"''''" 


when  oiitinp. 


Ill  !in  ill 


faiit  the  ilitrieiilty  ir 


l.reathiiif:  niiiy  serinu: 


•\v 


111 


tcrfere  witli  Its  nnrsiii^: 


II  a  ( 


use  lit  Mil  III 


l;ilit   three  W(H 


ks  oUl, 


opera 


teil  111 


hv  the  w 


iter,  It  was  w 


the  ihiia  iiiirseil,  haviuf:  i' 


let  CO  its  li"l'l  "" 


itii  .lie  K'ea 
th' 


test  ililiieiilty  that 


e  verv 


(jiii 


iitlv. 


Tt 


e 


talilishineiit 


ic    resii 
of  iia 


iiiaeiate 


lit    was    that    it    soon    < 
sal   respiration.  lUii-sinir  wa: 


'"I'l  .  ,       , 

1,   Imt.  with    the 
thout 


aiiv  I 


htlieiilty,  the  r 


suit 


heiiin  a 


|-IlllUrl^ 


s  carrietl  out  wi 
heil  I'hilil  in  thi-  eoursc 


ifanioiith.     Nin 


-throat  isolteiiniet  with  as  a  coin 


laint.  the  tonsils 


ill  many  < 


hildreii  lieinjl  enlarge. 


1  wit 


h  the  as-iciated  aileiiiiu 


Is.     At- 


tacks 


if  (iiistaxis  are  occ 


asionally  met  w 


ith, 


verv  ri 


irelv  asthmatic 


='^^t;  mouth-hreathin.  .  vei.  .-;;-| -yi-Z-t;;;  ^^^  T^!: 
..ahle  length  of  time  an^ahet^Uo  m  '  .^-l"^,,  ,.,  .,„,,,.  The 
iluceil  III  some  ca.ses,      11k    i-m  I  '^  „„,uth-breathmK 

n=:it''l:;;i^l..si  i;-^ ''"•^^'" ■'" 

„i.l,  is  ,h-  aM..,„i.t  "I.  tl«'  1»"  '''/*„,„„  ,„.wn«M.    In 

tr,,,,,  ti,..  i».:k  "f  .!„■  ';~_t!y,".':|::;;ii:,::':,;;";i;;„„„..fii..-cwij 


102« 


.\().si-:  A.\D  rniioAT. 


"apro^oxia'  rii.'sui.iMa\illarvKlaiulsanMr(S|U(Mitly  f(.un(l<Milarfr(><l. 
The  ('xist.-nc.'  nl'  a.lcnoids  is  occasionally  to  l>c  found  answerable  for 
many  cases  of  [MTsisK'nt  and  recurring  phlyctenular  keratitis  and 
conjunctivitis.  .       i        r  .1 

Diagnosis.  The  recofinition  of  the  existence  ol  hyixTtrophy  ol  the 
pharvnfieal  tonsil  niav  Ix'  carried  out  hy  one  or  two  ineth<ids.  The 
first  "tnethnd  is  hv  i)osterior  and  anterior  rhin(.scoi)y.  Posterior 
rhinosco|)v  is  not  "often  carried  out  successfully  in  many  ciiildren: 
but  when  allowed.  th>  mass  is  recofmized  as  a  rose-colored  jtrowth. 
situated  either  on  the  vault  of  the  pharynx,  on  its  jM.sterior  wall, 

Flu.  i*!. 


\mcro-|H>i!t.T.ur  suitloii  of  the  hoa.i  ..1  hii  adult,  showing  the  .it.miu.ii  hii.I  gr..--,  sinKtim. 
of  hyi«Tirripl>y  nf  tlio  lyini.h»i.l  t;s.«ue  of  tlic  iwi..i|ilmrynx.    :  Zitkkkk.»m.i..  i 

or  on  both.     It  (.l)scures  from  above  downw.-ird  to  a  jrreater  or  lesser 

de.rree  the  posterior  jiarts  of  the  .-.plum  ami  middle  turbinated  bodies. 

"  III  some  cases  even  the  itosterior  parts  of  the  infe- 

,..„,    ,,,  rior  imbinated  bodies  are  totally  hidden,     \\lieii 

^^gHM^^     occiiiiviiis;  the  vault   the  surfac f  the  collection 

^fl^HfiBL^-^    is  eitlier  stal.actite  ( Fijr.  .'»;{.'>>  or  smooth  in  ;ippear- 
!  .^^^BHr*    !    ance.      it  may  be  noticed  in  cases  that   the 

***>^5HlWi^-^     Ivmphoid    hv|M-r1rophv  stretches  across  the  vault 
— ^  and  occupies  Rosenmiiller's  fossM'.     This  examina- 

„v„.„r.,,.H>'^.i- I'l".-  tinn.  if  not  carried  out  satisfactorily,  may  1-  as- 
rynwiiitoiL>ii.  e..iiKN  i  sisted  ill  some  case*  by  anterior  rhinoscopy.  Ilie 
nostrils  h.'iviuix  been  carefully  spraved  with  a  I 
per  cent,  solution  "f  c<icaine.  any  existiiij:  teniporai-y  liy|M'rtro|)hy 
of   the  n,i-al  mucous  membrane  iieinj;  thus  reduced,  will  enable  the 


DISEASES  OF  Tin:  OROPILUIYSX  AM,  yASOVlUHYSX.     1027 


cxaiiiiiic 


:iii( 


to  st'i-  llif  lUiiss,  ill  soiiu-  <'ascs 


l)l()ckiiin  the  jM.stcrior  nan 


1  wlicn  iiiarkctl  tlic  inovniu 


nt  of  the  soft  palate  uiion 


ci 


thor  swal- 


iwinn  or  iilionatiiifi 


■h"  is  not  soon  to  rise  in 


the  normal  manner. 


lould  these  nu 


thods  fail  to  determine  their  exi 


I'xamination  inn 
child" 


,t   he  carriei 


1   out.     This  is  I 


loll 


.Ids  t 


left  arm,  aiu! 
Iiiotectetl  hy 


annssh-mld  l,e  held  l.v  aiu.ther  pers.-n   an 
he  ehilds  head  between  the  lelt  side  ol  his  < 


the  thumb  < 
thick  t(nv( 


■iteiice,  then  digital 

follows:    The 

(I  the  examiner 

n  body  and  his 

iouslv 


„f  the  left  hand,  haviiif:  been  jm'V 

1  around  it.  is  phurd  well  back  between 


he  child's  upiH'r  and  h.wer  mo 


,lars  of 'the  h-ft  side.     The  first  finger 


f  thi'  rifiht  hand  is  then  gently  l 
will  immediately  imi)iiige  uj 


tlv  passed  up  behind  the  soft  pahite.and 


)Oll 


;i  soft  mass  1 


iito  which  it   is  easily 


ibedded.     Hy  mean 


)f  this  examination 


the  extent  of  the  mass 


mav 


1h-  iearneii  by  its  n-kition  to  the  se|.tum  ai 


d  orifice  of  the  Kusta- 


•hiim   tubes.      Ipoii   withdraw 
tingetl  with  blood,  and  sometime: 
nostrils. 

In  ehiidreii  where  the  ton 
,arrv  out  pos 


ral  of  the  finper  it   is  usually  found 


little  blood  may  escape  from  the 


are  en 


iilarged  it  may  be  imposi 


;,<ibie  to 


terior  rhuiospopy  on  .Mccount  o 


f  their  size:  then  digital 


exam 


liiiation  will  be  necessary 


shows  in  many  cases  inai 


„.,,       The  i.osteiior  wall  of  the  pharynx 
ked "hypertrophy  of  the  lymphoid  tissue  m 


the  region  o 

lilar  condition  exi 


ifthe  oropharynx,  aiu 


1  is  of"  itself  very  suggestive  o 


if  a 


<im 

pharynx,     llxamm 
will  show  them  tt 
in  a  VI 


;tiiig  in   greater  ((uantity  m 


the  vault  of  the 


itioii  of  the  tympanic  membraiK 


in  iiianv  cas<'s 


Im>  retracted,  dull,  am 


the  handle  of  the  malleus 


IV  horizontal  position  :»>r, 


sl.( 


luld  a  purulent  otitis  metlia  i)e 


present,  a  pt 


rforation  of  varying  size 


!)(■  iKited.     I'rominenoc 


of 


the  second  cervica 


,1  vertebra  has  Iwen  mi 


-taken  for  adi-noids  when 


tl 


le  examma 


tioii  has  been  ma( 


le  bv  the  rhinosci>pic  mirror: 


but  digital 


exam 


illation  will  clear  up  any  ( 


loubt. 


Prognosis 


Before  giving  a  progi" 


to  the  outcome  of  any 


KM 


•ative  procedure  to  be  im< 


"1 

tlie  various  colli 


lertakeii  for  the  removal  of  adenoids 


litions 


ditioiis  mils 
ill'  iiiqiiirei 


t  ))(-  first  thiiroiighly 


Ithough  this  i: 
-ult  would  pri 


oe   iiiiiK  '  <""' -.11        1 

„f  the  patient  and  other  associated  local  coii- 

.•  eonsidered.     First  and  foremost  to 

,f  anv  ha'niophilic  tendency: 

vet   should  it   be  overlooked  the 


I  into  is  the  pos-ible  existence  o 


are  occurrence 


n 
Ulioll  t 


h,.  symptoms  for  which  the  child  IS  to  r. 


tieiit.     Again,  depending 


lull 


,t    1,,.   based   upon    certain    pi 


ibl 


(■  associ 


h-breathh.gbe  the  most  prominent  symi.tom   i 


ilteratioii  ill  t 


Thus,  if  iiiuut 

be  careful  that  no  .a 

!,('  ], resent,  that  no  iiivtei 

marked  deviation  or  large  spur 


reive  relief .  one's  opinion 

iiteil   local    condilions. 

iiie  must 

) 


na 


he  shajieof  the  upper  jaw  (\ -shape 
narrowing  of  the  nasal  passages,  no 
,f  septum,  be  present:  other\vise.  the 


tural  narrowin 


ipiMiintmeiit  to  the  j 


areiits  a 


^  as  to  the  result  will  be  ma 


iked.     If 


deafiie; 


mem 


be  the  chief  symjit   m,  t 


hen  the  condition  of  the  tympanii 


ibian 

rxi^tence  I 


am 


1  the  tym!>ani  must 


,f  a  sclerosing  oti 


-dia,  militating  against  very 


be  noted  carefullv,  the  ])ossible 

it  it  in 
f  a 


tis  media,  or  a  chronic  supp  iratiye  • 


brilliant  results.    Tiie  question  o 


'^^^'^^f^ites 


1^ 


1028 


NOUE  AND  rilBOAT. 


l)<.ssil)le  recurrence  has  also  to  be  answered,  and  while,  even  after  a 
verv  tlioroujtli  and  ct)inj)let<>  removal,  recurrence  may  possibly  take 
place,  this  must  receive  consideration,  (liven,  however,  an  imconi- 
plicatVd  case,  the  ijni^nosis  is  most  favorable. 

Treatment.  One  must  In-ar  in  mind  that  not  every  case  of  adenoid.^ 
nuist  be  subjected  to  operative  interferenc»>.  The  writer  has  rej)eat- 
cdlv  «een  eases  in  wliich  the  amount  was  so  small  that  attention  to 
geiiiTal  tonic  and  hvgienic  treatment,  the  local  condition  has  1mh-ii 
followed  i)y  such  improvement  as  to  reciuire  no  surgical  interference. 
Thi«  is  especially  the  case  v  S(>re  the  pharyngeal  tonsil  is  found  acutely 
enlarged  from  some  infective  cause.  Presuming  the  ease  is  one 
which  demands  interference,  the  following  are  the  steps  of  procedure, 
as  ado] )ted  h->- the  writer: 

It  is  advisable  to  administer  a  mild  cathartic  the  day  i)revious  to 
the  oi)eration.  and  the  nasal  passages  should  be  cleansed  by  tlie  use 
„f  an  alkaline  and  antiseptic  lotion,  especially  if  there  be  increased 
secretion.     Shall  the  oi)eration  be  done  with  or  without  an  antes- 
thetic"'     The  writer  gives  it  as  his  oi)inion  that  the  operation  for 
removal  of  adenoids,  with  or  without   tonsillotomy,  should  always 
be  un.lertaken  with  the  i)atient  under  an  ana-stlietic.  for  the  reason 
that  as  the  oi)eration  is  done  largely  on  young  children  the  shock 
of  such  an  operation  and  the  fright  attendant  upon  the  sight  of  blood 
are  sufficient  of  themselves  for  avoiding  such  results.     Further,  tl.e 
operation   cannot,   in   the   majority   of  eases,  be  thoroughly  done 
without  an  aiue.sthetic.     ^\hlli  ,.!ia"sthetic  should  be  used?     Of  the 
various  aiuestheties  used,  eacii  has  its  own  advocate.     Chlonform, 
A.  V.  K.  mixture,  nitrous  oxide  gas  alone,  or  the  use  of  the  gas  fol- 
lowed by  ether,  bromide  of  ethyl  and  ether  alone,  have  all  be<'ii  used 
with  good,  and,  unfortunately,  in  some  eases  fatal  results,  the  unfor- 
tunate results  having  followed  where  chloroform  or  .\.  ('.  Iv  has  been 
used.     The  writer  has  op'^rated  on  cases  in  which  the  various  aiues- 
theties  mentioned   liave  been  administereil,   but   invari!d)ly  prefers 
ether.     .Manning  ctTects  were  produced   in  several   ea.ses  in   which 
chloroform  or  .\.  V.  K.  had  been  used,  but  with  no  fatal  result.     With 
ether.  h(iw(-ver,  the  writ-r  has  never  seen  an  unpleasant  result  either 
accoinpaiiving  or  following  its  use. 

,\  great  (leal  has  been  said  against  ether  as  an  aiuesth(>tic  m  this 
operation:  that  by  inciting  increased  s<'cretion  in  the  throat,  danger 
is  added,  but,  if  carefully  and  rnpiiilii  administered  and  not  pushed 
to  profound  aiui'sthesia.the  writer  has  not  yet  seen  the  mucus  in- 
creased to  such  an  extent  as  to  increase  the  danger  of  its  iM-ing  in- 
spired to  such  a  dcg'"<"''  i'^  to  iiriMluce  subse(iui'nt  bad  results. 

The  next  point  to  Im-  consiilere<l  is  the  position  of  the  patient  at 
the  time  of  the  oj)eratioii.  One  has  the  choice  of  three  methoils: 
thi'  upright,  the  lateral,  and  the  Hose.  In  the  upright  positicm  the 
p.,li,.„t  is  first  auM'sthetized  m  thf  reeumbent  posture,  and  then 
slowly  elevated.  To  facilitate  this  method  French  has  devised  a 
chair  well  suiteil  for  this  purjiose.     As  a  substitute  the  patient  may 


DISEASES  OF  THE  OROPUARY^X  AND  NASOPUARYXX.    1029 
,    i„.l.l  on  the  kiieos  of  an  a.ssistiint,  the  hoa.l  resting  on  the  assistant's 

''"■■V.        I   rCe  ,,.*    »  So.   a  t..,»ill»t,m..v  lm»  to  bo  ,lo„o 

"7;;LrL'r;o'^i"r™Kts';;r^auv,xo  ,t  o„..  Tho  .n 

rr:' h^n":  as  i  r l"  "^^^^^^^  The  'proH.ninary  preparations  afon>- 

h,s  hands  as  stmie  as  ,  ^^.^^^^   j^^^^  ^^^^j^j.  ^,^ 

and  crosHt-u  »>>»  •   "  ,.  i^rdiier  v  secured.     In  tnih 

";  on  the  vault  and  ,.osterior  wall  of  the  pharynx,  then 
ens  and  the  curette  will  he  needed. 

„  h.  to  wils  require  ren.oval,  the  writer  prefers  ...H^r- 
"^hem  previous  to  ren.ovinp  the  adenoi.ls,  for  the  n-ason 
o       I      eritim  is  unohscun-.l  hy  hlood,  and  when  this 


alone  wit! 
vault  • " 
hot'       ,• 

I 
at  ill     ' 


j^.jy  SOSE  AXD  TUHOAT. 

localizcl.  aiul  tlu>  f..rcci.s  (  Tifi.  o.So),  lu-l.l  in  lli<>  .liscnRaficd  l.an.l 
pasMMl  up  into  tlic  vault  of  thi'  ].liaryiix,  and  fiuidc.l  to  tlic  adenoid 
1)V  Mi.-ans  of  till'  alrcadv  intPxUurd  tinni-r.     Tlic  mass  is  new  ciifiaKcd 
aiid  the  foiTcps  cioscd,  caiv  hciiifi  taken  that  duriiij;  tins  procedure 
they  arc  maintained  strictly  in  the  middle  line  and  that  the  blades 

Fia.  r>;i6. 


Branilfgee'8  fi)rcev«. 

are  not  thrown  too  far  forwanl  l)y  dcprcssiiif,'  the  haiullcs  too  much: 
otlicrwiso  the  iH.sferior  i)art  of  the  sei)tum  may  i>ccome  enRaRcd 
and  a  pice-  hroken  off.  If  the  forceps  he  rotated  to(>ithcr  side  it 
is  possihle  to  enpase  a  portion  '.f  either  of  the  Kustachian  tul.cs  Hy 
means  of  the  introduced  fin>r<' ■  the  s(.ft  palate  and  uvuia  are  hei.l 
■i\viv  s.)  as  to  i.revent  either  of  tlxMii  hciiif:  en<;as;od  in  the  lila.les 
'„f  the  forceps  when  dosin-  them.  The  writer  Rives  a  pivierence  to 
slnr  cutt;..^  forccj.s  rather  than  to  dull  ones,  because  should  the 
growth  Ix'  somewhat  til.rci.l  it  is  thoroufiiily  cut  through,  and  there 
is  no  danger  of  tearing  the  mucous  memlirane  when  the  forceps  are 
withdrawn,  which  is  very  apt  to  occur  in  the  use  ot  dull  cutting 
forci'ps  Thi'  forceos  are  reintroduced  as  often  as  is  necessary  to 
remove  anv  remaining  portions.  That  ])art  of  the  adenoi.l  winch 
is  not  read'ilv  removed  l.v  th.>  f(.rceps,  and  especially  when  situated 
(.n  the  i.osteri(.r  wall  of  "the  pharyn.x,  is  l.est  removed  l.y  the  (iott- 
stein  curette  (Fig.  o.%),  which,  when  introduced,  is  passed  well  up 


Fiii.  r.sB 


4;olts[ein  curetic 


to  the  H  ptum  1)V  depressing  the  handle.  Finn  pressun-  is  now  made. 
.,11(1  hy  elevating  the  hanille  the  cutting  portion  of  the  instrument 
is  thus  made  to  sweep  from  above  downward,  removing  any  hyper- 
trophied  lymphoid  tissu.'  which  may  remain  in  the  vault  or  on  the 
posterior  wall  of  the  i)harynx. 

The  patient  is  now  i|uicklv  turned  face  downward  to  allow  the 
blood  and  clots  to  escape  into  a  basin  jireviously  placed  below  the 
naticnfs  head  for  that  purj.ose.  While  the  patient  is  in  this  position, 
•m.l  after  the  flow  of  blood  has  moderated,  the  index  finger  of  the 


VI^EA^ES  OF  THE  oUOPIUUrSX  a:  O  SASOI'IIAHYSX. 


1031 


l.y  „u.ans  ..f  tl...  tinp-r.       t  .        <    "'^  ^        .  ^,.,„„,.,.,,_     xh."  patient, 
xvlu.lo  mass  ..t  a.l.'nuuls  la.  '"■•' \     *'[  f,  !;,.,  ,„,,.  ,,.st  tl.eiv.  l.inR 

,.  t..  hrin,  ahou:     '-;■'";!;,; ;;;;,;^V^ot  a.lvisable  to  intnuluc 
When  up.Tat.n>r  up-n      "  »^ ;''';,  ^.  .,,„,,  „,ijji,t  ,1..  soricus  .lan.ap.- 
l,.,th  linger  an.l  n.strunu-nt  ^^J'  j'  \\,,  ^^     •„,,  tlu>  instrument 

,,y  stn-tehing  an.t  t.'ar.njr  "  £  ,  ^  io.  Tlu hemorrhage  att.-n.l- 
i"t"  tl"-  vault  ">;:^r  "'•  •'^,^'^;  "irii  adenoids,  ,.s,H..Mally  when 
='"*  ^'1"''\''''\'''  t  ni  omV  is  apt  to  lu.  eonsiderahle  and  even 
•■'""•>"""'  r''  '  ;  n  h^io  is  a„.l  nee.ls  no  interference, 
alarmmg.  Imt,  as  a  lule.  it  ^""^  ^'  ,..,„.f,,llv  insDect  for  the  source 
Should  it  iH"  alaruung  then  om-  "»;     •  ^^^^']      ,!„  ,,,,  „„.thods  for 

arrestmg  it  as  .....l  <Io\m»   in    ""  the  hemorrhage  s  Ix'st  arrested 

tried.  If  it  be  from  ];";•;;-:•;  Xdi^Hi'liodofo^  gauze.  After 
l,v  plugging  this  space  xMth  ^^•""='''     ,  '  "    ,      ,,  ;„  i„.,i  and  allowed 

'''-'l•''••'^^'''•'^'^'"^''■'^'^'ndSSo  wae"^  Alter  that,  if  th. 
nothing  for  thre..  hc>urs  un  es.  a       nkf.^^^  the  parents  with  the 

vomiting  has  •••'"^[^'^-'^  \ ''':;,,,, ..Jt  of  blood  will  take  place- 
,a,.t  that  th.' vomitmg  ot  a  '''l^;^^t''^ ^^  ,„ilk,  b.rf-tea.  chicken 
„,,,a  nourishnuM,t  may  be     ;--|;, -jj' f;,,,,,   ,;,,  acceptable  to 

:;::^-.^t;:e  n^U  ^^nts .... .  ;..^^^     ^,,^.^  .,,^,,  ,„., 

A»,solute  rest  in  bed  is  ve       '     J^'  ,  /,  '^;,  .  „,•,,,,  .,ay,  when  the 

„.,  .liet  is  gradually  •">':;;  ,^  ,""![,;!"  It  lent    must    be   .-autioned 

,ti.-nfs   usual    diet    .>   •';;'.;,,,,  ,tv-f...ir  h..urs,  as  any  undue 

,prinstbl..wingthen..s.-fortl.ehn^   '«  ">  __^j^,^,,,.  ^.^^ 

,flort  in  this  way  may  force  ''        ;\     ,,7'"if  ^i.e  nostrils  l>ecome 

„„,  nn.bably  set  up  an  '«'"''    'V    ".'nti-.i    this  i-^  b.-st  dislo.lge.J 

•  ,,s,nict,.d  by  the  presence  o  ''J-  <  ^  Vl  v  Iwi  g  the  open  one  into 
l,v,.l..singeachn..str.lseparatel   .a-g^^^^^^^ 

al,ovvl.  In  the  majori  y  o  '"'»'*•";;  ""."^^,^.i  „f  tlu-  nasal  secn-tion 
is  ttecessary.  but  ^  -"''J  '^j^^,,^:,'',  "as  1  obeli  s.  should  b,.  use.! 
an  alkaline  and  antiseptic  ^'' ".;;.,,,,, t  is  occasionally  neces- 
„ifjht  and  nu.rmng.  (.eneral  '"^^  '  ,;  •'  '  ,,,,ti,  is  „ot  promptly 
sarv  wh..n  the  impn.vement  of  '^    '    "      ^,,,,,,,1,.   slidd.   but 

h,,.etite.l  by  the  o,K'ration.  "      ;\\  "  ;)o  ,,-.,  .r.'as  the  wnter 

......asionally.the  tem,H.ra,ure  nu^>  .i>.   to  UK.  ^  ^^  ,^^  ^^^^^^^^  ^^^.^^_^ 

has  seen  it  m  tw..  cases.  *"  J'"-  .  "^  '  ^^^,,.,,  The  following  day 
,„„.ation.  The  <^;^;;;£ J;,^,  "'n:,asi.many  theiv  nmv  W  a 
these  symptoms  ha\e  '"^''I'l' ;""  ,  .^  „f  ^^,^  .n-ck  coniulauied  of, 
slight  stifl'ness  of  the  muscles  of  the  i.  ■  K 


10:l2 


\()SK  AM)  rilROAT. 


and  even  a  torticollis  lias  !)een  met  witii  in-  tlie  writer-  Im,  tlies' 
soon  ilisa|i|N'ar. 

The  cliilils  voiee  is  sometimes  a  little  nasal  in  eliarartei,  i  iie  1.) 
a  temjMirary  paresis  of  the  palatal  mnseles,  hroujiht  ahout  liv  t!;,  ir 
hein}!  stretehcil  at  thi'  time  of  the  operation.  This,  however,  sf.on 
(lisap|«'ars  and  the  voiee  liecomes  natural.  Xa.sal  respiration  is 
usually  soon  estaliiished  alter  the  removal  of  adenoids,  provided  no 
other  nasal  obstruction  coexists.      Hut  if  na.sal   respiration  is  not 

estahlished  it  may  Im-  assisted  by  iyin<; 
"■'"  ^"^  the  child's  chin  nji.  as  shown  in  the  accom- 

])anyinK  illustration  I  i-"i)i.  o.iTi. 

Adenoids   occurriuf;    in    younj;   adults 

may  Im'  removed  under  local  ana-stlu'sia 

i)y  forceps  or  nasopharyngeal  snare.     In 

\T^/    /'i,       '',^''.-i  -"i^'h  fii.ses  the  operator  re(|uires  the  co- 

-^-'/     (<''Y'  -  *'?<ii  ojieration  of  the  ))atient,  and,  therefore, 

it  can  only  Im'  undeitaken  in  very  tract- 
able individuals.      The  oropharynx  and 
na,sopluirynx  ai-e  to  be  swablx'd  with  a  10 
jjer  cent,  solution  of  cocaine  applied  by 
means  of   a  cotton-wool    swab   suitably 
curved.     This  re(|uires  to  be  done  twice 
within  an  interval  of  about  ten  mituites 
The   patient    is   instructed   to   hold   his 
"  the  mouth  by  means  of  a  depressor, 
f  the  operator's  w;ty;  then,  by  means 


Mt'ihod  of  lying  up  the  chin  to  favor 
nasal  respiraiioii. 


l)et\veen  each  application, 
toriftue  well  down  to  the  floor  o 
the  handle  of  which  is  well  out  ( 

of  the  rhinosco|)ic  mirror,  ilie  forceps,  which  should  be  .sharp-cuttinff 
or  the  snare,  is  >;uided  into  the  naso{)harynx  and  the  p,oi-tion  of  the 
adenoid  removed.  Tliis  is  repeated  as  often  a.-  necessary  until  the 
ma.ss  is  thoroufrhly  removed.  The  jfreal  lirawback  to  such  an  inider- 
takinj:  is  the  heinorrhagi',  which  is  often  considerable  and  <ibscures 
the  tield  of  ojM'ration.  thus  !imitin<;  the  anioinit  ti;  be  removed  at 
each  sittinj:  and  nece.ssitatinjr  n-peated  operations,  Tiie  operation  i> 
not  by  any  me.-ms  a  painless  one,  even  if  the  cocainiz.-ition  li;is  In-en 
thoroiijrliiy  and  carefully  carried  out. 

Tumors  of  the  Nasopharjmx.  1.  Benign  Growths  liKler  this 
headiiifi  may  be  included  /ihroiiiiitn.  jU.rminicnits  /iDh/pi.  ciisls.  jHiiiilla- 
malit.  and  liie  more  rare  .-ifTections.  cnrliiiitilrniniitd.  c.ro.v/o.vc.v,  linniiuita 
and  <in(iii)iiiiilii.  Of  these,  th  i.se  occurrnif;  in  the  nasopharynx  most 
fre(iuently— althoufrh  by  no  means  common  — are  the  tibniniata  and 
(ibronuicous  polypi. 

Fibromata.  This  class  of  jrrowtii.  fhoujrii  liisiol,)jticMlly  non-maliii- 
nant,  yet  cliiiically  has  such  features  ;is  to  be  almost  reiranled  as 
malifrnatit.  Isiiaily  the  j;i-owth  spriiifrs  from  the  reirion  of  the  basilar 
process  of  the  sphenoid  and  occi|(ital  bones  and  from  the  u!)])er  cer- 
vical vertebra-.  It  (ends  by  its  r.-ijiid  exfensien  to  invade  the  neigh- 
borinjt  structures,  and  its  prolongations  may  1m>  found  in  the  nose, 
fuiKTior  maxilla,  and  orbit.     It  is  a  tumor  found  almost  exclusively 


DISEASES  nF  THE  OROrHAHYSX  ASD  SASOPUiRrSX.     l..:W 


\  few  cases 


■„,  ,„.ilcs  l.<-t%v.-.>i.  tlu>  apes  ..f  ton  aiul  tw<"nty-Hv<>  yean 

•"■::;™.;;^  ''^:^:X>:::'^^^^  this  ,u..u ..... 

.;''";:,;  nasi;  ..hstruHio.0.y,K.rs...n.i,m,n...ll..-...^^^^^^ 
1 


itself 


•;  her    h    u^l       n-H  invasi....  -f  tl.e  orhit  or  by  .ts  •"volv.nR  t he 

V   e     nakl).     l).-af..ess  is  also  p  fre.iuent  syn.ptm...     Death  nsual  y 
.MadU.nii  cerebral  i..v..lv(>n.ei.t.  or  he...orrha{:e.     I  pou 

•    ;    it«  nw.Mlitv    •>...'  ilensitv  of  charaet(>r  ...ay  be  ...ore  carefnllv 
:;:;:rtal:e;;     t^a^^.-!  ^-ases  its  prese..co  is  k..ow,.  by  .ts  appear- 

='"Sa!;<iS;'  mti:a"::;!i!:mv;Lt  the  gn,wth  ...ay  be  n.istaken 
for  Se  oi.ls  1  ut  can'f..l  exa..V.,.atio..  l>y  ...oa..s  of  the  rh.n..soo,K.. 
for     ad.  .lo.'ls,     '  u'^  "  J   ,     ,         ai.u.unt  of  heniorrhage 

';  V  1  i  1^  bee  fou?..l  that  n^trocession  has  t,.ke..  pla--  -  t  - 
frr  V  ns  be.-.,  .lestrov..!  th.-o..ph  sloush...?.  I«  -'•<■"  <'="••>  "  "; 
f,;:;:.l.;„i..    a,ul   eo...,.lete   .-.-...oval   u...l.Ttake,..   tl.e   pn.p.os.s   .> 

''T«t.  This  .....st  IH-  of  an  enthvly  surgical  nature,  a..d  th- 
methods  at  one's  disposal  are  as  follows: 

I'.xtractio..   through  the    natural 


1.  The  galvai.ocautery  snare    ^ 

•_>.  ("old  wi.-e  snare 

;•     i:i:.ctro!ysis 

4.  Mvulsio.i  by  forceits 

o.  External  operation. 


I  I'.xtrac 
f      pass: 


passages. 


-<r3«s»'  "TT.aoi,i'-  nnBT'dT' 


io;54 


yoni:  A.\D  riiiioAT. 


1.  '/'/(.•  (iiilniiiiH-iiiiln-ii  Snare.  In  tlic  .'iiiplicalion  ut'  the  1<hi|i  altoiit 
till'  luiiHir  cuiisiilcral)!!'  ilitliculty  may  Im^  cxixTiciiccd  in  scciirinfi  it 
almiit  the  Kasc.  This  is  csprcially  so  wlicn  llic  tiiinnr  i~  sc-  ilc.  ami 
less  su  when  in'ilunciilatcil.  It  may  Ix'  iiilniduccil  ciiIhi-  lliniii<;li  tli^' 
antcridi-  tiarcs  ur  tliniii;;li  the  (irnpliaiv  ii\  witli  tlic  soli  palate  wfll 
rrtractcii.  ami.  I)y  the  aiil  of  the  lirst  fin^rcr  in  tlic  plian-  i\.  mailc  to 
cni'irclc  tiic  };i""\vtli.  When  well  in  position  tlic  wire  is  tiftlitcncd, 
tlic  cun-ciit  tiitncil  on,  and  tlic  wiic  drawn  slowly  home.  The  dilli- 
ciiltv  in  pcil'onnin;;  this  method  of  operatiiif;  is,  Ix'sidcs  that  ahovc 
mentioned,  that  of  seciirinji  the  loop  around  the  hase.  and  that  the 
wire  mavhreak.  In  lieatinirthc  wire  to  .1  dull-red  heat  (•onsiderahie 
dithcultv  may  he  cxiM-rienced  in  cuttiiifi  tlirou>;ii  the  frrowth.  while 
with  a  white  heat  it  is  cut  tlirou>;h  so  (piickly  that  the  attcii(hiiit 
hemorrhacc  is  tlicn  consideralilc. 

2.  Colli  W'iir  Smii-t'.  This  is  api)lieil  in  either  of  the  ways  men- 
tioned in  usinji  the  jialvaiiocauti'ry  snare,  and  the  .same  ditiiculty  is 
also  c.\|)ericnccd  in  the  ap])lication  of  the  looj).  When  used  tli<'  snare 
must  he  a  most  powerful  oni'.  such  as  Farlow's,  and  the  wire  .slioulil 
Ik-  No.  S  or  1(1.  When  in  position  the  wire  is  screwed  lionic  very 
slowlv,  occupying  a  couple  of  hours,  and  its  use  is  always  attended 
witii  a  jrreat  deal  of  pain,  ami  the  amount  of  liemorrhafp'  is  u.sually 
considerable.  The  advantasic  of  the  steel  wire  is  that,  throujih  its 
rijridity,  the  growth  is  more  easily  included  and  retained  than  the 
galvaiiocaiitcry  loo]). 

.\  method  of  includiii};  the  <trowtii,  as  suggested  and  adopteil  by 
(Jreville-Macdoiiaid,  is  as  follows:  "With  a  li<'loc(|'s  caiuila  or  soft 
Kustachian  catheter  a  piece  of  thread  is  carried  into  the  pharynx 
through  till'  nose,  and  to  the  buccal  end  of  this  two  terminations  of 
■a  jiiece  of  \o.  (i  piano  wire,  measuring  IN  or  20  inches,  are  attached 
in  such  a  manner  tliat  on  being  drawn  upward  through  the  nose 
they  will  not  abrade  the  surface.  Hy  me  i"s  of  the  thread  the  ends 
of  the  wire  are  then  drawn  into  the  na.sop!  arynx  and  nose.  As  soon 
as  they  project  from  the  anterior  nares  ■  le  bent  ends  arc  detached 
with  a  pair  of  wire  nijipers,  .so  that  thr  wire  can  i)e  threaded  into 
the  barrel  of  tlic  snare  to  be  employed,  which  is  thrust  well  into  the 
nose  before  the  wire  is  made  fast  to  the  instrument.  In  this  manner 
a  large  noose  is  left  in  the  pharynx  whicii.  with  the  help  of  the  fore- 
finger, can  be  insinuated  behind  the  tumor.  Once  this  is  cfTected. 
there  will  lie  no  difficulty  in  working  the  snare  on  to  the  highest 
portion  of  the  tumor  and  tightening  it  as  it  is  advanced  u])ward. 
The  growth  can  then  be  cut  through  by  gradually  shortening  the 
wire." 

The  advantage  claimed  for  this  method  of  encircling  the  growth 
is  that  it  prevents  the  doubling  up  of  the  loop  when  introduced  through 
the  anterior  narcs  and  the  necessary  weakening  of  the  wire  by  its 
thus  being  doubled. 

3.  Elirtrolifxis.  This  method  may  be  applied  in  two  ways.  ('()  uni- 
polar, and  (/>)  bipolar.     In  the  first  way  both  iiuedlos  are  inserted  into 


uisEA^^J^s  n,  til:  onoruAuysx  aso  sA^oriiAHYSX. 


1<«> 


!•  .     .1...  iw.int  wticrc  it  is  t'iiil><'<l<l»''l '"  ^'"' 

,„,.wtl..  IS  well  iiisal:it.M  .     liith'  ^     [\    ,        i,,,,,-,,",,,.).  a  sp.mnr.  is 
UvH  is  ins..r,M  int..  th<.  n J..       u  'I    -  ^^^^^^ 

"''-""'  -i.l...n.  sl.u..k  tu  ,1...  ;;V7  r'l    ,      \,,  ,„ss  tor  lonp.r 

.nilliauMH-vs.      Tl.-  .•urn-nt  f-  ',,;,! ',,,,,  ,l„.'si„in.'s  sl.oul.l 

"'-'  "•"  '"  ';"•■":  ';"::'  ::k-u^a'  "allow  tlu.sl..u,l.  to  sn.arat... 

|„.froni  tcn.laystot\v..w<"Kr..nu  _^^^^^j     ,^.^^,,. 

1    /,>»/./../,,  Tl.is  iM..tl.o.l  is  rarruMl     .    <  i    <  r  '^       ,,^. 

!/„  rapines,  as  ..sp-Mally  ^"'='1       '  ^  ^  J'^^^       .,    ..ivoVat.-s,  l.ut  unless 
carruM    out  can'luiiN   an  .  «"■•  f,ai,.,v('.l  hv  s<'r  ous  coniplica- 

::'!j:;;;;;vSa;;r  •  norl  .'d^  -y  t..  aforon„.ntion...i 

•''•ft;.n.,/r>,....;:.,Hythisn.th.ltlK..^ 
tl.o  oropharynx  hy  a.v..Un,  tl...  >         ;^'  ^^^    \  ,.  ^„„,-„.  is  .xtir- 
palat..,  ana  hy  .n-a,^  ol  -"*->:  ^J^^J'Jt  ...vltninary  tra.-h.- 
,  .,t..a.     The  h.-niorrhajt-  is  so  ^" '>'";,'*''     ,^\. ,,,,,,, ,s. .fa  sp-mp' 
!,,..Hyanaplu,,i..«.;t  ''-7^™;;      ;      ;*^1^:.;;;  Vas  intro<hi-a  a 
^^,,   „,,,,s..ary.      Inst-aa  'f   ;. ;     '^'    ;'"  ,',tranVo  of  l.loo.l  into  th- 
,„,,ap,.  apparatus  ^vl'';:'\,  '' V^'/'^,,.    ?,,!  '  neth...l  aaoptc.!  is  to  1h> 
larynx.     Hnnorrha,..  '''>^     "f^.  ;'';.;;,  J.^ts  an-  loft  aft'.-r  any  oiHTa- 
,..,„„,,„,a  hy  P.VSSU.V     ^\';    ;f    ;"'ia,.s  of  tlu.  galvanocaut.-ry 
five  procP<lur('  arc  tu  he  tnaicu  o^ 

'"''"*•  P„i«.i     Tlu's<>  growths,  acconlinfl  to  Jonathan  Wrij;ht 

TibromucouB  Polypi-      H":^  M^  ^j  •  ,  ^        ,„,co,n.-  a>a..matous. 

an>"til.ro.nata  ot  a  slui^m-^h  K  •  '  J,  [.;;,,^  ,„,^,.  tlu'  nasal  fossa., 
Thoir  orifiin  is  R..n..rally  m  h  .•;-I'^:>^  ^,^,,,^.  ,.,iu„eulat..a  ai.a 
i„t.,  which  they  may  ;:>^ -'"'^      ;     >  ''tuc      "n''«'»M>r...lua-.l  may 

,,.,  „„t  invaac  ^•."••••"""  ".^\  ,  ;"  ,^t  arc  th.;  ..  of  nasal  ohstn.ction 
vary  with  the  si^c  of     1    t     v,r,    m^  ^^  ^^„„. 

,vi,h  its  ''"'""'  ="'\r,f;,r  i  l^^n  ocoupving  the  nasopharynx, 
translucent,  pcaunculat.'-l  ♦"'"['„.,„„„.,<•„,•,  into  that  region  may 

i:Uc:"'its  ";n;:"r;s':::s;".?;;;mS-^  ••>•  ---  -^  ^'«'  -'*' 

^^fiaignantOrowths.  < >f ';;f iSl! IT^^t ''''S^Su 
,,,rro.K,  an.l  rnrci,,>,>w  occur  >;^,^'*,i ';,,:.  ,,„,,,„,,,,  pn.aucc.l  arc 
is  usually  the  vault  of  the  P^^^jy^-'^J^^  ,  iJi,,  ,,Jak  a..wn  a..! 
similar  to  thos..  of  hhron.ata.  T^'' ;'  ^[;^,  /^^^  ^, ,,  suhmaxillary  glan.ls 
i-aacsurroun.  ...strucnm.^  -•;»--, ^  ,,ses,  unfortunately 
arc  early  myolvca.     As  re^-ini  /r^  ^^^^^  oix>rative  mtcrfercncc. 

there  is  httl.'  to  1k>  aone.    Jj; J^.  ^^bv  the  snare  or  forceps  or  the 
;^t;!;S^ni=:olS:n:are\,f  the  satne  sad  nature. 


CHAPTER    XXIII. 

NEUROSES  OF  THE  NOSE  AND  TIIUOAT. 

By  KMIL  MAYER,  M.D. 


NEUROSES  OF  THE  NOSE. 

Tn.vT  the  olfactory  .sonso  wa.s  capable  of  a  high  dogroo  of  cultivation 
was  i<iio\vn  to  the  ancients.  The  Romans  p(i.ssess«'{|  slaves,  iM-autiful 
in  form  and  fipiire.  who  prepared  their  baths  with  perfumed  waters, 
.anointed  themselves  and  their  masters,  and  kept  incense  burning  .so 
that  every  pleasure  that  sweet  smells  might  induce  was  theirs.  That 
these  added  to  their  sexual  enjoyment  they  were  amply  convinced. 
In  recent  times.  .1.  \.  .Mackenzie  has  called  attention  to  the  direct 
relation  of  certain  areas  of  erectile  mucosa  in  the  no.se  to  the  sexual 
apparatus.  Hobbs'  claims  to  have  cured  two  ca.ses  of  chronic  pri- 
apism by  the  insufflation  of  cocaine  in  tiie  no.se.  Wright-  has  .shown 
the  great  amount  of  erectile  tis.sue  in  the  na.sal  mucosa  of  the  bull  as 
compareil  to  that  of  the  steer. 

Perhaps  no  one  thing  in  medicine  is  .so  remarkable  as  the  strange 
and  jwculiarly  intimate  relations  existing  between  the  nose  .and  tiic 
genital  organs.  These  are  emlnxlied  in  the  investigations  of  .^chifT, 
in  coiilirmation  of  Fliess'  statement  regardingthe.se  relations. 

Mis  ri'searches  go  to  i)rove  that  there  is  an  intiniiite  relation,  prob- 
ably through  the  sympatlietic  nervous  system,  between  cert.ain  so- 
called  iias.al  genital  spots  on  the  anterior  part  of  the  lower  turbinate 
bones,  and  on  the  tubercula  sepfi.  and  the  genital  tract.  Scliiff  made 
practic.'d  use  of  this  fact  by  cocainizing  the.se  genital  sjiots  of  the  nose 
.IS  a  palliative  treatment  for  dysinenorrh(ca.  (  hit  of  47  cases  treated 
the  pains  were  relieved  in  72.4  p<'r  cent.  .\  perm.anent  ( tn-e  is  effected 
liy  cauterization  of  the  s|)(>ts  with  trichloracetic  acid  or  the  galvano- 
cautery.  .Mental  suggestion  w;is  careftilly  avoided,  and  general  ana's- 
lliesia  coii-^idered  to  be  out  of  the  (juestion.  .Ml  forms  of  dysmenor- 
rluea  were  treated,  and  only  tho.se  in  whii-h  .some  abnormal  condition 
of  the  genital  spots  was  pn-seiit  were  amenable  to  the  nasal  treatment. 
The  nervous  or  hystcric-d  form  and  dysmenorrhn'a  due  to  mechanical 
causes  were  not  influenced.  Some  ca.ses  in  which  there  was  a  patho- 
logical condition  of  the  reproductive  organs,  in  aildition  to  the  n.a.sal 
le.-iun.  were  impruvcii  or  t-und  by  trealmcnt  of  the  nose.  It  wa.-.  al.-o 
shown,  exjwrimentally,  that  during  menstruation  or  in  the  presence  of 


LatyngoBcope,  March,  1897. 
(  1036  ) 


'  New  York  Medk'al  Journal,  November  19,  1898. 


yEL-HOSES  Of  THE  XOSE  AXO  TIllinAT. 


iu;{7 


I  t..  lM-li.-v..  that  "»ys.unH.rr^.-:      K  <•-,,>„„„  ..f  „.,.,,„.«- 

„,s,il  spots  wh.<-h  s<-.Mn  to   ^^'    « -^^  "    '  .   ;',^,„..l  l,v  tivat.n.nt  ap- 
,i„„.  an.l  tliat  this  form  ot  the  .hs.  -^^    '    >    >*   ^,     tr.-atnu-nt  must  I..- 

,.arn.-(l  out  with    an  .      i  u  ^^.^  ^.,,,,,   solution 

,h..  s,H.,.ulun^  an.    '-';;;'';  ,J,    Sl'iiific...  if  tlUp<.ts  hav  pr.- 

„.,.  ,n..nstrual  p.-rio.l,  with  <";;'''"'-';;'';^X  '      /v  ■'"  tl"' 

The  Sense  of  SmeU  or  Olfaction. 

f„.l».  i,.l.l»  t..  l.i»  "'''■'"',';>;•  'X  c-nw  "t  the  «■,.»■  ..t  smell 

;:;;;,r::,ir;;T:;i;;in;t':«f;i"-""»r        '"- 

ptunouK  la,  .1.  .......  ,,2,. „i,„.i,los  with  thoso  views. 

porcciv.Mi  as  odors.     A>rton  <<••■"'"  ,       ,    „  ^.,i,:pets  have  the 

"•''■^■'''*-  ..  .  1  r        •  .    ,♦  tJio  nlfaetorv  sense  inrreasps 

Toulous<>  an.l  Va-schale'  f.ni.  ^  U^    Ifaet.)  ^^^ 

up  t..  the  sixth  year  ..t  "f«  ■,;;-;.:.;;!  '"'Sv  dso      nohul..  that  the 
distinguish  ...lors  mereases  «  th  >''-^'^:     '"^'^J.;^  ,^,^  in  all  pn.hal.ility 

;;:;;;^;';li;;r  ^;:;t  ^-^^^  ilSiUS^o t  a.. .- 

,  :  WiiMier  Med  BUlter,  No.  ••i-l'-  "**'• 


i 


1038 


A-o.  K    tA7)  rilHOAT. 


(luriiif;  fxpinifioii.  It  wis  !ll^  i  notcil  ttiat  ciiilcpt'Ks  \\n\i'  ;i«  gn-ni 
oll'acturv  jiuwrr  a-  tlio^,.  ii,.t  iHictcd:  their  iMTcfptivc  |M)\v('r.  Iiow- 
cvcr.  is  (liiiiiiiishcil. 

That  th<-  s<'iisati(iii  of  tur.  plavs  an  iiii;r(irlaiit  part  in  ohaction  is 
shown  liy  Zwaardcinakcr,'  Wu  >i  iti-s  that  th<' tactile  irritatiiui  is  hni- 
itcd  to  the  anterior  half  uf  the  na-al  cavity  and  the  |Missiliility  nf  thi' 
sense  (if  taste  niii.-t  Ik-  addii!  llieret-i.  J.  \V.  I'al  rici<-'adds  that  smell, 
Kislif.  sensati'in,  and  tcin}x'ratiire  n  ust  all  Im'  in  uiiini.  with  the  sense 
of  taste  in  iirder  tn  secun-    '     '.iirhc  '   levelupiiicnt  uf  the  latter. 

I)eviali(ins  frniii  ndriii  il  ,  iiii  hms  of  a  M-nsory  nature  are  nu-n- 
tioned  inider  the  hemiing  "f  - 

DiHturbances    i  Sen^atiiQ  or  of  Olfaction. 

These  are  either  of  th  •  i  •',    ,  \\tv  nv<    the\   arc  exangoratcil  or  en 
tiri'ly  lust.     Those  unuMi:'i  c'i.m,!-!:   u<  i.i  teni     -rarx-  loss  of  the  sen.-*' 
of  smell   or  teiiiporarv  ■  x.ejiaera!  "i   U'liiiji    {•<   the  ;iii<>malies  ami 
merely  lecpiire  mention. 

Hsrperosmia  '  '  h3rperosptu'e8ia,  .-  ■  <    <u$;ei  <iioii  <>i   tiie  sen.sc  (.: 
smell,  rarely  oc<'.i>ions  much  distnrh.iiu    ,  ami    s  .ipt  to  l>e  diie  tu 
idiosyncrasy.     Thus  the  writer  has  seen   \ioleiit   in-adache,  nause;,. 
anil  |)al|iitation  of  the  hear;  n>siilt  from  the  odiv  of  a  I'urninn  cif,':  rctte 
and  the  ^.mie  condition  I'llow  upon  the  im!      ,,(  nitr;  >■  of  ain-l,  fu-.^  i 

oil.  chloroluiin.  etc.  l'retrn;Ult  women  are  |.-.|iiently  \-el  -r  reptilile 
to  odor--  of  ,ill  kin<ls.  and  [x-cnliar  ndor^  arr  ilescrilied  as  >  \i-;tiny;  in 
ejiileptic  aura.  Werner'  mentions  fainting;  and  asihnia  as  syinploms 
followinji  this  condition. 

The  prognosis  is  jiood. 

The  treatment  lies  in  constitutional  measu  ^.  particnl  ul\  \<  lien 
due  to  neura>'lieiiia,  aiucinia,  etc 

Anosmia  or  Anosptaresia.  Tin-  loss , if  the  sen-.'  of  .<m<'il  may  he 
partial  or  compli  le.  dne-sided  or  lii!;iteral.  The  iejtree  '  >\hicli  ii 
exists  may  lie  (juiie  accurately  determined  hy  '  he  us<'  of  an  ..iiactome- 
tei-  Such  instrnnients  ha\<'  Im-cii  devi.-;ei|  and  descrihed  liy  Zwaardi'- 
niaker.  I{eiiter.  \  Stein,  and  .\llierto  I'ini  ]■].  Toiilou-e'  |)roposes 
the  use  iif  flasks  contaiiiing  solmion-  of  (  ii|  '  u.itrr  in  v.'iii"Us 
stren;;t  w  hile  v.  (irazzi' siijr^rcsts  the  use  of  ah  ili  huiic  sohitior  of 
lienzoic  acid  as  tests  for  the  sense  of  smell. 

.\nosmia  may  he  di\  iiled  into  two  t;roups  accordin;;  lo  ( )nodi."  (  iim 
j:i<ui|i  in  which  patholo<;ical  chanjres  occur  in  the  oltactorv  region, 
or  els<'  where  some  injury  has  occurreil      In    second  irroiip  where  the 
lo»  uf  the  s.'nse  of  smell  is  raiher  to  lie  ;rferred  in  in.chanic.-d  inter- 
ference with  nasal  respiration  or  to  fum'iional  disiurii.Ltrco       I'h-  se 


I  Me<l.  Tvischr.  v.  tk'iii'csi'k.  So.  4,  C*:*  -'  iMston  Mu<1.  aii'i  Surg, 

s  Ilfymsr.a  llsn-'.!--  i    !flr    ^■..-    •.s'l^i  s  ^•_.    .•._  j,i,,i„.;...-   p_t;- 

■'  (in/ctta  (leKli '>^tN'<tHli,  MiIhii.  Niivt'iiiN'r  tmc)  {nn'eniix-r   IHW. 
«  ReiMirt  cif  thi'  Thirtwtith  IiitertiRtioiml  Me'lioH!  CoiiKre--*,  Journal  of  I.< 
-VovfiuKT.  law. 


nwl    Jim,-  JO.  IM!I9 
-rriT--.-rr  ■*•.  i  «>il. 


Khin.    aua  Otiil.. 


AT. 


itht-r  rent  nil, 


SEi-noiit:s  ot  TUi.  .  o&£  Ayi>  tun 

,P,.  „.n I  .<H(>i full  ..r  tnir  aiiOHT  .ia.  whi*'!.  nuiy 

||„.  ,„..>t  fp     ...lt..u.^H      ..^^^      ^i„|B,.,H,.  in  alc.hul.  t.'lmr. 

l>tli  -tfti     i.jurvtnth.tifthiimT 

„.,-...  ,..i      Tn-sili»n    n-jM.rts  ii  c•ll^«'  "■ 
\  ,iiim   ^^"iiiiin.  l\Tnty--«(.  >■-■•••'-•'' 

iiKin-.     riu" 

pU-,  HP'     >ll 

To  fhosf  t>v>UTi    inu 


.,  lit    <-:tuw 

M.Tur  II.  lalx-    irnui  th<    ' 

iiiorpliiiif.  foil'  Aiiiilt*"'  '"■ 

Ciic.iiiK    uiiosiiiia   iiiis  I  '  'ii 

..imsinia  followiin:  :i  full    n  »  f,.r   ,  v.-ir 

,„..   in  wl.-.M  tl ns<<  or  s„h.11  wa~    .1...  i.t  for  a  >(ar 

;,:„■„,  p,,w.-rful:Mtis,.,.f..-.th.-  ?>"■■"'■    "i-'Zi'-naoi 


,i„loKicu;  !   'l«  !-  i'«  (K-cttJ'.-ifUijai 


*ini 


..(lllf'il.        Tf  •«'!<«'<'(  HI 

l.y  :itresiii    'I'viati 
iinMii^'rariP,  p<  Ivj". 

Br  ptoBM.    Th«    ' 
<,ii<<-  -.1  the  >«'5,-^'  . 
(ulor,  Ii-  '  iacli.  -.  von 
Prognosis.    Tli'    |ii 
aiiratio:    '>f  t!"       o-i 
.•iiral)lt'  !t  it  li 
;i  case  of      ''■''  :• 
Treatn  In'' 

11,,     hyst.     11    il  Stii        IV 

■u     incur,,  ■!'       S'  !sU 
ii:i-    '   mucosa,   at      a] 
ii.ai 
Parosmia 

anon  ;  v.  "'■ 

uTI'i'.ilii'     oil' 
,.;ii         'I      i'  CI 

the  -inuniR 


r  ol)!<t 
lis  of  '    ■ 
■if 

'  !iiptorii> 
,     smell, 
uip.  etc. 

•lO.-lS   licp' 

Mr  t 
■nosm 
•struct 

ka-n 

lie 


IVC  fi 

■ptll" 

am-: 


■'1! 


I    Wl 

;yi  ■  rtri 


MMII! 


v  lMMM-ca.'<ioii<'(l 
t  the  mucous 

or  partial  ai>- 
.1  a  .iisMKreeahle 


mil  the 
1  W  m- 
re{K>rts 


,     ,  '■  ca\ 

cSv  ""' 

•irs.  !'<■«• 

i.\i-         :iiii_\  years. 

fi  ■         shiniKl  Ix' reino     il.     I*'"!" 

,  ises  Mu^'<'stioii.     The  t a  1.1 'tic  cases 

trvchnine  haw  Im'cii  appl.*'il  to  the 

.1"  the  jialvaiiic  current  have  Ix-en 


rversjoii 

occa-iona 
fferinjr 

,u  i>ri 

if  bin 


1 


sul)tect  Miiells  o<lo! 
lOll-litMHlS,  tlie  |HM 

'■    ithers  !       il  th''  'X*" 
i^TKsnua 

il     'he  totli^i 

..ll: 
s  w 


,  i-Oll 

cry  I' 
s  iiotii 

ipiiiiilaii 


auell    the  substitution  "I'  one  odor  for 
|,eo.iorsui)stitut<Ml  iH'it  -  usually  a  (lis;' 

to  jH-rverted  condition^  in  the  ey 

tt\  folors  .substituted  for  sombre  ones 

nies  tinnitus,  while  the  iiarosnnc 

,.,  heaven,"  and,  as  in  th<'  fi.nnrr 

I  ,mlv  bv  the  individual  sutliTcr— 

,„„.„„„     |„f  it  would  not  be  parosmia. 

<.:usioned  bv  .l.-cay.-d  teeth,  decay.d  matter 

.lisease  of  the  accessory  sinuses,  atlections  ol 

n;:or le  of  these  may  be  present.     Noquet    reconls 

,;  ,„  ,„l.,r  .,f  decayed  animal  matter  followed  an  at  a  k 
X,„  ...  the  insane  and  in  epileptics,  p-    -ma  ,s  o  tre.,u..nt 
,       ;     \.  ,...  t-reatest  sufferers  are  um  -e  wh..  have  hys- 
,,  li.^;,,,,;,       h'  ■'     ase  of  this  latfr  varL'ty  under  the  writer  s 

He.    KH„   W,.l,e,.  ...««.  =Kev.h.b.,om.deLur>'n«o..,Dec.»ber9.,H99. 

Zl..,  urxn  .  Mu  -I.,  1-eccmber,  1««. 

.  B.x,k.ert     Ann.  de  1«  *k..  .1.  1.  Med  .le  0»nd.  3  h^«-.,  im 
Soc  (Vntrali-.le  M.^lechic  du  Nord..  Dcc-mberi).  l".*. 


::,V    b 

cryp' 


1040 


SOSE  AyD  THROAT. 


!! 


care,  a  yotuig  man  insisted  on  the  jjresence  of  a  vile  odor  whieh  ema- 
nated fioni  his  nose.  Although  the  writer  could  never  iletect  it,  tlie 
patient  insisted  tiiat  liis  employer  did,  not  from  .•mything  the  latter 
ever  said,  i)Ut  "the  way  he  looked  at  him.'  The  constant  fear  of 
beiriK  diseharfied  because  his  presence  had  become  unlwarable,  and 
the  dread  of  beinj;  shunned  by  his  a.s.sociates,  made  him  constantly 
miserabh' and  a  most  unhappy  individual. 

\Vhei\  parosmia  accomjjanies  or  follows  anosmia,  as  occasionally 
hai)pens,  after  inHuenza,  Myers'  having  recently  reported  such  a  ca,«<e, 
the  i)rognosis  is  apt  to  i)e  good. 

Treatment  consists  in  diligent  search  for  and  removal  of  the  cause. 

Anssl!iesia  is  »'omi)aratively  rare,  usually  one-sided  and  a.ssociated 
with  hysteria.  In  partial  central  or  peripheral  paralysis  of  the  tri- 
geminus it  is  of  more  freiiuent  occurrence.  If  the  trigeminal  paralysis 
is  complete  there  is.  in  addition,  a  loss  of  sensation  in  the  external 
portion  of  the  nose.  Ana-sthesia  is  indicated  by  the  aiisence  of  sen.«a- 
tion  either  to  vapors  or  touch;  sneezing  is  not  occiUiioned  by  irritants, 
nor  is  there  any  overHow  of  lacrymation. 

Hyperaesthesia  is  conunon,  variable  in  individuals,  some  suffering 
with  the  slightest  touch,  .{emedies  that  soothe  mo.st  individuals 
aggravate  these.  Thus  the  application  of  the  suprarenal  extract, 
of  menthol,  and  of  cocaine,  that  ordinarily  give  great  relief,  is  followed 
by  pain,  sneezing,  hypersecntion,  excessive  lacrymation,  headache, 
aiid  insomnia.  Tlu>re  are  no  means  of  being  forewarned  as  to  these 
idiosyner.'isies.  Hypera'sthesia  is  common  during  pregnancy.  Korn' 
has  recently  reported  a  case  of  unusually  severe  symjitoms.  With- 
out any  recognized  cau.«e,  a  woman  in  the  last  month  of  her  third 
jiregnancy  was  affected  with  .severe  and  almost  incessant  convulsive 
sneezing,  which  lasted  for  four  days  in  spite  of  the  use  of  morphine, 
chloroform,  amy!  nitrite,  bromine,  and  trional.  Ihiring  the  en.suing 
five  days  there  was  but  trifling  abatement :  but  then  labor  pains  set  in 
and  spontaneous  delivery  occurred.  The  (jiiantity  of  li(|uor  anmii 
was  verv  larg(>.  .After  parturition  the  woman  snee;ed  no  more. 
Ball'  in  a  study  of  112  ca.<es  found  one-half  of  thi-m  due  to  asthma, 
evenly  distributed  between  males  and  females  between  the  .nges  of 
twentv  and  forty  years. 

Hypera-sthesia  shows  itself  principally  in  jjaroxysmal  sneezing, 
and  inav  become  excessively  annoying  by  its  contimiance.  In  its 
mildest  form  ••  is  occasioned  by  exposure  to  bright  sunlight  or 
particles  of  dust  and  the  pollen  of  plants.  Certain  drugs  jiroduce  it 
in  susceptible  individuals.  When  n  urcurs  at  certain  se!i.<ons  of  the 
vcar  it  is  known  as  "rose  cold."  The  mucous  membrane  is  apt  to  be 
engorged  or  o'di-matous  during  the  attack,  :iiid  sometimes  exfoliation 
takes  place.  In  addition  to  the  general  symptoms  of  obstruction, 
as  occurs  in  acute  rhinitis,  there  is  much  depression,  without,  however, 
any  aoconipanying  ri.se  in  imiperature. 

I  I^rytiKiwnii*.  M»y.  191(1.  '  FmueDaril,  No.  12,  1900. 

•  London  Lancet.  February  li,  18», 


SEl-UOSES  OF  THE  SOUK  ASD  TUIWAT. 


1041 


Tho  internal   adn.inistratiun   ^\:^f^J^:;j:^;:S::::' ^ 
,.,,:.a.n,a.anaU..:i.;^^aa,>p.^-^^^^^^ 

l.„v...l  l.v  menthol  in  a  ->      J  J  4,,,,,i ,,,.,,,,.,, ti..n.-.l  in  ..r.Irr  t..l.e 

^-^^y^^l^^^'';^^'lfZ^l:^...  .,f  th..  ,ati..nt   in  pvnis 
(ondciniKMl.     It   lint   aiKi.  f„rincr  (•(.nditums  of 

nli"f  f-  ='  f''^^„'"'''"'"^;;,;:;;,l  :n'V';:i.«- 1-bit  „.ayn.aaily 

'"'  '"'""■''   '•  i,  nVa  thuroud.tv  efficient  snl.st.tute  without 

,.xtraet  an.l  its  jn-epa  ations  a  '  "f;    •  ,      ,.,.,..^.,  „f  ,u,,  supiarenals 

i,s  aanjiers.  It  was  u.  euni.eet.o  ^^  "  1  '  . ;,-  ,,„.  ,,,^,,,1,  „f  this 
i„  these  nialaaie^  that  the  wn  .-  ;•';„,;!  ,,,'  i,  ^  relief  following 
„„,a..t  n..ver  seivea  anotl...  P-  ■"   ^     ;  ,^^  4u,a,le  aaai.ion 

i„  ,.se  in  these  '-"'b'!:'"-    '^;;;,    ;;!:';*  .^H.-atioi.  of  the  ,ah a,,..- 

;:;ri'i:;,;;:':;;s;;iveaJ":::rt;;  nasal  i.iii..n^^^^ 

liv  ,.un.  of  the  hypenesthetie  '•';;;; ''; j' ;;.      ^„„„.  ,.,,„„(„  ,„naition.  such 
■  Paresthesia  is  usually  asM..-iat    '  ^ '     ■;  .,,  ,,i,„^,,,  ,tc. 

-;;-;:;:;:t;:;r;;rs'j:ri";:;ltch!;:r'^^ 

,,.,„.,.  except  1"  eoiiiiectimi  witli  la<  '•'"'',*'.       ,  |  f  ^vini.toin beinc 


the  alletfeo  iiui>""'.'   _    ,        , 

,„ove/'  has  recently_rec.n-.l.-u  si.ch_a  c:iM^. 


i>vc/,  iiii.-.n< .■  -  .       ..,.^„ii,    wanci'ited  with  other  forms 

Paralysis  of  the  le.aWr  a^.s     leivdl    ;  ^-'^.„,i„^,    ,,  the 
of  facial  paralysis.     It  o((  us    .ui  >  •<-  ^^,.  „,,,  ,,.^..jt„r 

,„„scles  an.l  laxness  of  th."  oth.  "^^^    '      '     .  ,,  jj,.,„.rallv  in  the 

„f  „,e  highly  ...Hirotic,  ='•'=••'•'  ';;,^'>',,^  ";.onhnarv  purposes, 
ma!.-.     There  is  to  a  1  •MM-a'  ;  ''1  '..^  ''^.f  j,  requirea,  that  no 

'-'  the  iiulivuhKil  '-';;;;  V;^;:^';U   le  can  h.il  some  synipa- 
,„„-  snITers  as  he  .loev.  and  is   ''  1    '^  •  f  ^^,„.      jje  soon  b.-comes 

£;;v;;sr;;:;:t,™i,.«;;S-.'-.M-i  ,* ui,.„...  ..c 

of  ih.'  ihinologisi  unhappy.  ^trvchn•ne  and  bromides 

uiv  the  indications  for  treatment. 

Disturbances  of  Secretion. 

1  Fn^e  M.Hllcale,  January  ii,  1S»9. 
.  Auu.  d«  M»l.  ae  lor.,  etc  P"!..  July,  1S»9. 
(i6 


1042 


Snsi:  AM)  Til  HO  AT. 


tlic  titlicr  pliciioiiiciia,  diarrlid'a,  iiii)ir:iiii<'.  I'tc.  \itkiii'  rofjanls  most 
cases  (if  liydnirrlid'a  to  In-  due  to  i)ar('sis  of  the  vasomotor  nerves  of 
tlic  nasal  iimcosa.  often  reflex,  as  from  adenoids.  Anioiij;  tlie  eaiises 
cold,  winter  weather,  excessive  lacryniation,  and  emotional  ex- 


ari 


citeinent.  errors  in  diet,  uric  acida-mia,  and  dialu'tes.     Kyle  lias  cm- 
lected  11  cases,  to  wliicii  Abate"  has  added  another. 

.M'ter  the  atfeetion  has  histed  for  .-cnie  time  the  mucous  menihrane 
appears  sonjiy:  in  the  early  part  of  the  afTection  there  is  no  visihle 


The 


clianpe.  1  lie  discharge  may  1m'  one-.-'ided,  hut  is  usually  bilateral. 
It  may  ajipear  with  rejiularity  at  c(>rtain  hours,  usually  in  the  inorninfi, 
and  not  occur  for  the  remainder  of  the  day.  The  condition  is  to  he 
<lit1'erentiated  from  cerehro-spinal  rhiiiorrhiea,  and  will  be  considered 
under  the  headin<:  of  the  latter  atTeclion. 

The  prognosis  is  flood,  deiiemlinft  entirely  on  the  cause. 

Treatment.  Treatment  consists  in  the  internal  administration  of 
atropine  for  the  hypersecretion,  and  strychnine  for  the  vasodilators; 
massaf;e  of  the  nasal  mucosa,  the  application  of  solutions  of  protarf;ol. 
Insulllation  of  dryinj:  |)owders,  .-is  zinc  jireparations,  to  which  tnenthol 
or  boric  acid  has  been  ailded,  have  their  value  in  appropriate  cases 
where  no  discernible  cause  exists.  The  mal.ari.al,  rh<'umatic,  and 
litluemic  causes  neeil  proper  treatment,  and  the  errors  of  diet  cor- 
rected. 

Cerebro-spinal  Rhinorrhoea,  I  lie  siiontaneousdiscliar-ie  of  cerebro- 
spinal tluid  from  the  nose  is  of  infre<iuent  occurrence.  St.  Clair 
Thomson'  has  collected  a  number  of  c;uses  in  a  recent  monojtra|)h,  and 
T.  Fisher,'  Schep|M'jirell,'  Ilektoen,"  and  I'reudenthar  have  each  re- 
ported a  case.  That  of  Fisher  occurred  in  a  boy  of  four  years  of  ajr<'. 
Hektoeirs  case  is  interestinji  in  that  what  apjieared  to  be  a  polyp 
was  removed  from  the  nose,  but  proved  to  ho  a  portion  of  a  meninpi- 
c  '  ■.     Cerebral  fluid  escaped  from  th^  opening. 

This  condition  is  due  to  an  oversecretion  of  arachnoid  fluitl  finding 
its  way  down  throufth  the  jierineural  sheaths  of  the  olfactory  nerves. 
Increased  cerebral  pressure  is  always  present:  retinal  changes  occur 
with  fre(|uency. 

The  :iin('!'it  of  fluid  which  escapes  varies.  It  has  been  known  to 
nacli  ;J(M)(»  c.c.  in  twenty-four  hours.  It  ll.^s  an  alkaline  reaction, 
an  averape  sjiecific  gravity  of  KKKi,  contains  cll-irides,  albumin,  and 
at  times  phosphates  and  sulphur  .salts  identical  with  cerebro-spinal 

fluiil. 

.Mental  depression  and  headaches  usually  jirc-exist;  dizziness  and 
one-sided  anosmia  arc  apt  to  occur,  the  heail  symptoms  cciusiiig  when 
the  flow  begins.     The  latter  is  constant  and  one-sided.     An  early 

1  Jnurn»l  Uryn.,  Rhiii.,  Biid  Olol.,  July,  )«99. 

t  Bolletinn  dflle  Malntl  del  Orecchio,  November,  IDOO. 

•  I^rynr^K-ope.  Niivomher.  1R9H.  <  Britiih  Medical  Journal.  November  1«,  1889. 

»  Journal  .\merican  Medical  AiwKisllon,  Febniary  Jfi,  188H. 

■  Indiana  MiHllcal  Jnurnal,  Febniary,  ItWIi 

'  New  York  Medical  Journal,  March  31,  IWW. 


SEl-ROSES  (IF  THE  SOSE  A.\D  THROAT. 


1U43 


.liHjit.usis  is  ..sscilial  in  ov.I.t  tl.at  w  may  prevent  nH-nmReal  aff.  c- 
t  tl.rouKh  tlu-  n..s.>.     Tl...  .•l..Mni<-ai  -xan.n.at...n  of  tl..;  flvn.l.  .is 

!.;,;"  t!'n''yan.l  .m.-si.lo.l  flow  will  help  f.  .litT.-r..nt.ate  ,t  lrun>  nasal 

liyiinin-iiu'a. 

Treatment  is  of  no  avail.  ^    i-     i     i      .  ,i,,. 

Reflex  nasal  cough  ...•<-iirs  in  a  largo  porn'ntagr  of  m.livi.hials  on  tli. 

introduction    of  applications  f.  the  nmeosa  wi.ere  .Ms  oecas.,.n...l 

l.v  patlu.lofrieal  cl.anK.'s.     Tlu'se  latter  shoul.l  1«'  "1'"'  ■''■''  •^,..,,. 
•  Sternutation,     llxeessive  snee7,Hm  nuiy    .<•  aequ.re,    or  "•>'«•  ".■'^ 

It  mav  !..■  oeeasione.1  l.v  .lisease  ..f  the  hrau.  or  nu-.luiia.  of  syphilitic 

..ligiiM.r  not.  and  in  c<Ttain  conditions  of  the  insane. 

NEUROSES  OF  THE  PHARYNX. 

The  posterior  nares  is  the  most  sensitive   portion  of  the  pharynx. 
■n„.  uvula  is  not  at  all  .^ensitiv.-  to  warmth,  ass.-en  m  iarynposcim- 

""it'Si^llio;;  of  the  pharynx  may  l.<.  totally  or  partially  -liminished. 
ind  tliis  is  tei'ined —  .  i       r^       i-   i 

Anesthesia  of  the  Pharynx.  It  occurs  most  frequently  after  d.ph- 
,l„.,ia  an.l  severe  infiaininatory  disturbance  m  the  pharynx:  it  max 
,l.u  he  issociated  with  cpiln'-^y,  gummatous  tumors  miiltiph-  sclen.sis, 
■  nd  pseudol.ull.ar  paraly.sis.  It  may  occur  at  the  nu-nopause  in 
!  .l,.,i  dvsenterv.  md  .liahetes,  an.l  f..llowing  tlu-  use  of  nu.rph.ne. 
;.;;;.ai!;;  Inenthol.ethyl  chh.ri.le.  c'tc.     It  may  l..'  one-,<.ded  or  bilateral. 

"''i;t;:  the'hllmix  ..my  is  involved  and  the  cause  a  min..r  one.  the 
prognosis  is  US.     Where  the  larynx  is  invo  ve.l  there  is  im.n.non 
anger  to  life  from  choking,  or  tl,.'  ....tranc'  of  sukiI   particles  of  food 
ilito  the  bronchi  may  result  in  cat.arrhal  bronchitis  ..r  pneumonia, 
■md  here 'Vc  I.rognosis  is  bad.  ...  i  •   * 

There  is  ..  t.ibe  numbiu'ss in  the  pharynx,  the  principal  complaint 
|„.i„g  a  cough  .luring  every  act  ..f  .leglutiti..n.  Hu.ds  are  swalL.we.l 
s l.!!vi\-.  aii.l  ofttinu-s  the  subject  has  learn.-.l  t..  swall.-w  in  the  i.rone 

'"h1r.lni.(M,tnH.stiinp.>rtancethatf..o<lsshoul.niecarefullyselecte.l, 

..s...  iallv  where  the  larynx  is  involve.l.     The  •"<•"♦'';'-"'''?;;;''"- 
..ughlv  cl.>ane.l  an.l  all  i.articl.-s  ,.f  f..(.d  rem..ve<l  after  f.- .lug       f 
th    .es..phageal  b..ugie  is  us.d,  talking  shouhl  be  enc..urag.Ml   an.l  the 
spirati..,,  ?h..ul.l  IH.  watche.1  when  the  tube  -^-^'^-'^f;^;:'^^;;^ 
\.  n.,ur.-.l  in.     The  writer  saw  a  case  of  ana-sthesia  of  the  i.harynx 
an.'l  .'piglottis  in  which  raw  oysten*  weiv  partaken.     An  oyster  entered 
,h,.  larx^x.  .-i".!  although  but  a  few  minutes  elapscUH-foro  ^^^-'^^^^ 
p.,^,.    life  -    ^  -tinct:  all  efforts  t.  resuscitate  fai  e.l.     In  .simple 
c'.Lse^  the  f  '.'..i.  •  urront  and  strychnine  given  internally  will  beneht. 
Hyper**  -^«  .  of  the  Pharynx.    Excessive    sensibility    of    the 
nharv^ix  maN    e  due  to  the  inhibit!..!.  ..f .  xcessively  not  f.-ods.  chew- 
ing ,,f  t..baeco,  excessive  use  of  alcohol,  nasal  obstruction  causing 


1044 


Sd.Si:  AM)  Til  no  AT. 


iiinutli-lm-iitliinj.'.  coiigcstioii,  the  result  uf  venous  stasis.  It  ()rpurs 
ill  valvular  I'lirt  disease,  in  hysteria,  ami  in  nieiiinfiitis.  It  is  asso- 
ciated witli  Main  radiatiiij:  to  both  ears,  nausea,  and  vomitinfj. 


Tl 


le  ]i.:ili  1>  - 
Uaritv 


ipK'tnnes  verv  severe 


uiteriMittent,  and  inav  assume 


a  MHO 


tidiaii  or  tertian.     Kxcept  when  due  to  loeai 


the  regular! 

irritants,  '''.eri'  is  no  <'onjiestion  present. 

It  is  very  iniportant  that  the  cause  should  he  carefully  soujiht,  and 
it  should  he  (litTereiitiated  from  rheumatism  and  syphilis.  A  rheu- 
matic history  will  aid  materially  for  the  former  condition:  hut  a 
specific  hist(>ry  is  not  so  readily  obtained,  not  so  much  because  of 
untruthfulness  on  the  part  of  ih<'  patient,  but  because  pharynjreal 
inliltrations  are  aTuoiif;  the  very  late  evidences  of  the  disease,  and 
often  the  |)atient  is  entirely  un;iware  of  the  i)resence  of  sy|)liilis. 
This  is  ('specially  the  case  in  late  hereditary  syi)hiiis,  seen  now  and 
th-n.  The  author  was  recently  called  upon  to  treat  a  laily  who  had 
been  under  the  care  of  a  collea^jue  for  nervous  sore-throat,  and  all 
the  anodynes  <:iven  had  no  elTect.  .V  very  careful  pharynfjeal  exani- 
i'lation  siiowed  two  bands  on  either  side  of  the  jjosterior  pharyngeal 
wall,  well  hidden  by  the  anteri<  r  pillars.  These  bamls  were  putty 
and  of  a  dark-red  color— there  v  is  no  destruction  of  tissue — they 
^ieemed  to  present  the  picture  of  fruminatous  inliltrations  and  large 
doses  of  iodide  and  mercurial  inunctions  cured  her  in  a  week.  It 
was  subsequently  ascertaine.i  that  a  sister  and  a  brother  of  the  patient 
had  evidences  of  here<litary  sy])hilis. 

Where  hypera-sthesia  is  intermittent  (luinine  administered  internally 
is  of  value.  The  cause  asci'rtained,  recovery  follows  its  removal. 
It  is  especially  (wential  that  cocaine  .should  not  be  use.l  here.  Its 
cfTect  is  too  eva""scent,  and  it  is  withal  too  dangerous  a  drug  to  use. 
Paresthesia  ot  the  Pharynx.  .\  perverted  sensation  of  the 
jiharynx  is  rare,  per  sr.  It  occurs  in  the  climacteric  jieriod.  in  hysteria, 
and  liyiMichoiidria,  following  the  use  of  cocaine,  menthol,  and  chloral, 
and  subsequent  to  the  swallowing  of  fori'ign  bodies.  There  is  com- 
lilaint  of  tlie  jiresence  of  a  thread,  a  hair,  or  foreign  body,  or  a  sen- 
sation of  sticking  and  burning.  These  affections  occurring  largely 
in  the  neurotic,  their  fears  become  greatly  magnified  and  their  imagina- 
tions lead  them  to  expect  th<'  worst,  .\lnio-t  the  hrst  (|uestion  is 
whether  they  have  cancer  or  tuberculosis.  Sometimes  the  affe<'tion 
appears  very  suddenly,  jierhaps  even  during  deghititi.m.  and  th('n  a 
foreign  bodv  is  at  once  si,,'poseil  by  them  to  have  lodged.  I'atient 
.vearcii  fails  to  reveal  any  foreign  l»idy.  A  rheumatic  history  is 
negati%ed. 

The  prognosis  is  good,  except,  perhaps,  in  the  ])urely  hysterical. 
In  these  suggestion  hiis  l)een  of  value.  A  case  occurred  in  one  of 
our  clinics-  the  iiatient  insisted  that  an  orange-pit  had  lodged  a 
f.>rtnight  previous  to  his  visit  He  stated  that  he  had  seen  several 
])hysicians  who  could  not  find  it,  and  he  knew  it  was  there,  because 
he  felt  it.  A  most  exhaustive  examination  under  cocaine  aiuesthesia 
failed  to  find  it,  and  he  was  asked  to  come  the  next  day  for  a  further 


yEUROSES  OF  THE  SoSE  ASD  THIIOAT. 


1045 


;:;:;:;;;j;:,i"'"'n::a  Ji>;''::."i^» , .-.-"i. "™"  <••  "■"■"■■ 

Motor  Disturbances. 

i.inLr!,,      >■   i.. "k.  or  l.l„wmc  .,..1  a  lisht  I.T„n,.-«  n.,|«.»-il.l.-. 

,,„„„„„„,,  liko  0,,™,...    U-.;,      .      ■"':,;;  ,'^„.  ';„.■  ri„.  to  i,.l-n.r 
i„  il„,„.  wh<i  tear  l'>'lf"l''"\'VV\";fl'        ;f«aloroauso»viol...it 

rir^,"a,"3^'«--""'^**-"-'' -'■'- 

Clonic  spasm  occurs  occasionally.    *^™ .',  'Ti'^v^x  in  a  woman, 

;;;!;;;!„r,rotrflr',;f';i:':..rl.'ne  »»>,  ,ha,  ..o,„a,i„„ ., 


.  jo„m.lof  Lan-ngul  •  "bU.ul.,  .ndOU.1.,  M»rch,1901. 


«  ijirjrngoKCDpe.  June  1898. 


■«■ 


■STSBIff 


1046 


NOSE  A.\D  THROAT. 


to  tlif  cause  is  idle.  Lamhcrt  I.jk  k  rcpuitiMl  tlic  case  <if  a  fciiialf, 
aped  nineteen  years,  who  complained  of  i)lile}tin  in  liei-  liiroat.  llxani- 
inatioii  sliowed  a  rajiid  Iwilcliiiifi  of  the  posterior  pharynjieal  wall, 
whicli  seemed  to  i)e  rapidly  jeiked  to  tjie  left  side  and  tiieii  relaxed. 
The  niovemi-nts  were  rapid  and  unceasitifr,  l'><(  to  the  minute,  and 
not  (juite  regular  in  extent  or  time.  They  resemhied  nystajimus, 
and  were  (juite  ditfereiit  from  choreic  movements.  The  superior  anil 
middle  constrictors  .seei>  d  to  he  alTecteil,  hut  not  the  i)alatal  mus- 
cles. The  affection  remained  constant  for  two  months.  He  w;us 
able  to  find  ei<;lit  cases  in  the  literalure.  lie  helieves  the  afl'ection 
to  1)1'  due  to  fjross  lesions  of  the  central  nervous  system,  cerehellar 
tumors,  etc.,  or  reflex,  and  apparently  due  to  postnasal  catarrh. 
In  his  own  case  treatment  to  le  posterior  nares  was  followed  hy 
cessation  of  the  movements.  .Mcohol,  mercury,  and  lead  are  j»iven 
as  etiohjfjical  factors. 

The  enumer:ition  of  neuroses  of  the  throat  is  not  complete  without 
mention  of — 

Hysterical  Dysphagia.  This  affection  occurs  more  fre(|uently  in 
women  than  in  men,  and  may  ajipear  in  children.  It  is  l)est  desttrihed 
a.s  a  |)artial  or  complete  inai)ility  to  swallow,  without  known  ])atho- 
lojlical  causes,  or,  by  reflex,  from  so  trivial  a  cause  that  it  iiiust  be 
considered  hyst.'rical  iti  origin. 

There  is  no  pain  in  swallowinp,  a  sound  passes  readily,  and  the 
attack  is  usually  sudden  in  on.set  and  not  contimious.  Solids  are 
often  swallowed  better  than  li(juids. 

The  prognosis  is  jjood  iu*  a  rule. 

The  treatment  consists  in  rest  of  the  parts,  rectal  alimentation, 
if  necessary,  antispasmodics,  and  removal  of  any  exciting  cause. 


NEUKOSES  OF  THE  LARYNX. 

Sensory  Neuroses. 

Hyperesthesia,  excessive  sensibility  of  the  larynx,  occurs  in  bron- 
chial asthma,  hysteria,  neurasthenia,  from  excessive  smoking,  in 
alcohol  habitues,  during  menstruation,  pregnancy,  at  the  climacteric, 
and  sometimes  is  an  early  symptom  of  tuberculosis. 

it  is  evidenced  by  paiti.  visually  unilateral  and  intermittent  in 
character,  sometimes  very  intense.  It  is  very  ])ersistent,  and  the 
tendency  is  toward  recurrence.  It  occurs  in  both  .se.xes  in  early  and 
middle  life.  (Jottstein  ref)orts  a  c;ise  in  which  the  pain  on  talking 
w;us  so  intense  that  i)honophobia  existed. 

Treatment.  Treatment  should  be  constitutional  and  local.  Cocaine 
should  not  !)(■  administered.  The  bromides,  (|uinine,  hot  or  cold 
applications  as  tiiey  are  best  borne  by  the  patient,  sprays  of  the 
suprarenal  extract,  and  menthol  in  li(iuid  Vivseline,  etc. 

Ansesthesia.  Partial  or  complete  loss  of  .sensibility  of  the  larynx 
has  the  same  etiological  factors  as  tiiat  of  the  i)harynx;  both  coexist, 


SEUHOSES  OF  THE  MJilE  AXD  TURO.iT. 


1047 


occurs  at  till'  inciioiiaiisc. 

S;a^:rT^.  r:;;i  ..0.%  ...1.  a...i  ^,...0..  .^^^  ..n-^^y  u~ 

^'"N^iiSa  of  the  larynx  Iw.s  l,<vn  rccnlcl.     It  is  rare.  a.ul  tl.c 
i.KlicS  arc  for  auti-rhcu.uatic  an.l  aut.-ncuralpu.  trcat.ucnt. 

Motor  Neuroses. 

SDasm  n.iv  occur  in  the  a.lult ,  as  it  .l.u's  in  chil.lron.     It  may  attoct 

,„v  oM  0  Tarvn^."ai  nu.sdcs,  an.l  wl.on  the  al.luctors  alone  an 

:    cc    .1  tore  i^  generally  a  paralysis  ..f  the  mhluetors  pn-sent.    Ml  1 

•'"'""!         ,.  i,„.,..i  i,v  the  entrance  of  foo(    into  the  larynx,  nihala- 

•!  1  IrC    hav>  an  esp,.cial  tendency  to  attack,  which  pen.Talh 

:ur  .      ee    te  second  uul  s..enth  years  of  life.     It  may  also  occin^ 

,   1, .    ew  V   .    n      \-ariot  an.l  H.ulour'  m.-ntion  stru lor  m  newl,...n 

\     t.     St-i    n"  roc..rds  two  cius<'s  of  congenital  stnd..r.    Strshel- 

,L•^nrel;"  three  cases.      \  ariot  wa.s  enahle.l  to  perf..rm  an 

hitzk.     pres.  nth  y"T<^  J^'*'  ,     ,     j  ^..^stant  stri.lulous  breathing. 

;.v;ii!Sy  t- ;..  ,;,;•  .x-nic »,».....  ,1,,.  ewi<.t.i»  -h,*  >,»  .„.. 

t.'tanus.  d<>ntition,  larp  <nui  i.u  digestive  d  sturbance.*, 

in  the  mucous  membrane  of  the  air  passages,  uip..  um  f,,rtt,,>r 

.  1.    pvcessive  crying   lymphoi.l  hvpertrophi.'s,  etc.,  are  furth  r 
'■  nf  this  VfTec^l  n     Cer  ain  ehildren  have  predisposition  t.j 

S;;:;:L  tt;.HSSten.lencies.  while  age   sex.  g^^^^ 
unsanitary  surroun.lings  n.ay  be  causal  factors^   ^^^'^  ^^I'f ^^^     ,, 
cas.-  of  a  chil.l  in  whom  the  spa-sm  wivs  due  to  a  thromoosu 
l,.n(litu<linal  sinus.  ^      ,.         ^ts  a 


I  Presse  Miillcale,  Novenitwr  7,  1900. 
>  Mwl.  .>bvs.,  Augunl,  VMM. 
»  Canada  lAUCet.  July,  1901. 


s  Klinlorh.,  No.  is.  OM- 

*  Hcyinanirs  Hamlbuch  der  Laryn.,  I,  7,  lit97. 


...     ..:.:-Lk.JJi.    .Ill-ili 


1048 


NOSK  ASD  THROW. 


t"  a  child  witli  i)!ii)illoin!if!i.  (i;iii};ti<)fiu'r'  fdiiiid  til  ca^cs  of  inaikcil 
tftaiiy  recorded  in  10")  <'ases,  and  lie  cniirlndes  that  tlie  association 
of  siKu^m  and  tetany  is  tlie  rule.  liaRiii-ki-  mentions  enlargement 
of  tile  tliymus  as  an  etiological  factor. 

Ill  mild  cases  tiiere  is,  without  pre-existeiice  of  laryngeal  symptoms, 
a  sudden  attack  of  loiignlrawn  ins])iration  distinctly  heard  in  the 
room:  after  a  few  such  inspir.ations  there  is  complete  subsidence. 
In  severer  c;i.ses  tin'  attacks  always  ap|M'ar  suddenly;  respirations 
liecomc  more  and  more  severe;  there  is  a  g.aspiiig  for  breath:  an 
anxious  expression,  and  even  cyanosis,  with  evident  sutTering.  Tlie 
head  is  ba'hed  in  perspiration,  eyeballs  turned  up,  and  ahe  nasi  widely 
distended.  In  -itill  -ieverer  c;i.ses  there  is  tonic  spasm  of  the  extremi- 
ties, loss  of  consciousness,  and  cardiac  weakness,  death  following 
either  from  such  weakness  or  from  sutTocation. 

The  attack  usually  exhausts  itself;  there  is  a  loiig-ilrawn  inspira- 
tion with  a  crowing  sound,  .a  longer  jieriod  of  rest,  followed  by  less 
noisy  and  olistructive  inspirations,  the  color  returns,  the  piils('  be- 
comes stronger,  .•nid  the  attack  is  over  for  the  time  being.  In  some 
instances  there  is  no  recurrence,  but  usually  there  are  recurrences. 

The  suddenness  of  onset,  absence  of  temperature,  aii<l  the  result 
of  i)acteriol;)gical  examination  make  the  <litTereiitial  diagnosis  fro  n 
dijihtheria  not  so  dillicult.  From  a  catarrhal  laryngitis  or  a  foreign 
body  in  the  larynx  the  diagnosis  is  not  so  ea.sy.  In  one  case  the 
writei''  records  that  of  a  child  in  whom  tracheotomy  reveale(l  a  foreign 
body  on  a  lino  with  the  true  vocal  cords,  which  w;i,s  only  suspecte(l 
before  operation. 

I'nless  the  attack  is  due  to  direct  cerebral  irritation,  the  prognosis 
is  generally  good.  .M.  .MacKenzie  claims  that  the  greater  the  interval 
betwe(>n  attacks,  the  better  the  prognosis.  Death  occurs  either  from 
asphyxia,  from  sufTocation,  cardiac  <'xliaustion,  or  cerebral  compres- 
sion may  occur  from  transudation  between  the  cerebral  membranes 
and  in  the  ventricles. 

Treatment.  Piioi'UVi.Acric.  Rest,  bromide  of  |)otassiuni  internally, 
regulating  the  diet,  small  <|uantities  of  food  at  a  time.  The  roouis 
should  be  well  ventilated,  the  child  ke])t  out-of-doors  in  clear  weather, 
and  adenoids  or  tonsils,  if  present,  should  be  removed. 

For  the  attack  Holt  advises  the  following: 


chlDral  hyiln. 

■i.O 

Kalli  lirom  . 

3.0 

Ammon.  lirom., 

2.0 

\i\.  I'iniiHiiiiim., 

fiJ.o-M. 

Sip.    Tt'a'jpoonful  every  tweiity  minnte*  If  not  relieved. 

This  dose  for  a  child  of  seven  years. 
F'rerichs  gives: 


sig- 


Ert.  hellHd.,  0.27 

I.I':  .tmmon.  ftnlut.,  'l:ift 

\'\.  ilist.,  l;i.o- 

Ten  to  twenty  drops  every  three  lumrs  for  the  ftttnelc. 


'  Miini  henermiHt.  WiK'lieii-rh..  .Vo.  11.  IMKi. 

'  New  V.irit  l=:yeHii<l  Knr  Itiliniiiiry  Re|«Prt»,  1-W. 


»  Internat.  CliniM,  April,  1899. 


XEUIioSLS  OF  THE  SUSK  A  SO  THROAT. 


Iiilialatioiis   of   steal 
,.|iil>l>'yftl  iliiriiifi  till'  attiU 
tinii 


tkiiift 


liii 


ciiictu's,   siiiapisnis    an 


1<»4!> 
all 


k.     liotli  Scvcstrf'  anil  Hi<'hanlifrc-  iin'ii 


larviiKcal  spiisins  rciuiriiiK  traclic-toiuv  i>ri 


iitiibatioii.    Hanitiski' 


tfiiiallv  with  lininiidcs  ur  iiius 
\'\n\v  hv  no  lilt 


i)f  rare  occiir- 


"ivcs  piiosplionis  ill- 

;.,^r:;Tiirri^:^^-ti-"i"  i:^;;.;^..:  ...yn... ..... 

V  i.    n-...rai  in  ori,in.\..  iu  hysU-ria,  chorea,  an.    'j;'';^^^^. 

:  for.ii  there  is  some  irritation  ot  the  l.ranehes  ol  the  red.rn.it 

V  Sh  an  exeess  of  irritation  to  the  -Mu-tor  ,n^<^. 
Tetanus,  hv.lrophol.ia,  an.l  tal.es  are  etmlopeal  lact.  is.     It  n.a> 

.,,,  „!T^;,  Sex  t  •<....  various  orpuis,  the  intestinal  traet,  .ntra.ia>  1 

i  .  J'  -u.  I  the  s.-xual  apparatus.     Brose'   reports  two  eas.-s,  one 

; tt-'ealvlnoiia  of  the     .ler  en.l  of  'l^"  .-^pl^^-;  -U-M  ... 

^Uiieh  sul.se.iu.-ntlv    .l.Avl..i.e.l    tul.er.-..losis       The    ''''^'\^\''\     {' 

;    „„  „„„    ,f  tui..'reular  family   hist.,.,     wl...   poss..ss.-.    a  1..^  .!> 

:,i,.  temp.Tai.ient  an.l  wl...  ha.l  .•.■p.-at..,!  .la.ly  an.l  n.flhtly  a    a ek. 

hrvnseal  spasn.  of  sh.,rt  .lurati.-n.     Th.Te  wen-  no  '"''•"^'■>=' 

I  mih.  th.'  pharynx,  larvnx.  ..r  pulmo..ary  ajj.n.tus       N.n  • 

'j-rn..;ir'i:t;:T;;ii;i;^ 

';  .  .f  a  female' wh..s..  g!..tti.-  spas,.,  seen....    to  he  ^^^^'    ^^J^^ 

1  ♦      :.i:.;  •      Mpr.mlie"  reeor.ls  a  case  ..I  larvnceal  spasm  tiuiing 

r:  inhS^  io..'I;  eS.e"  .;;;•  t..  a  co.i.pensaU.ry  -nit-l  stci-.i. 

Vn    1    n,av  be     plmnatory.  .U'uh.titory.    -r   respiratory      J  he 

,,;.  .'k      su  Men  in  o  is.'t  an.l  sh.iilar  to  th..se  .KTurruiR  .n  ch.Ulr  n, 

1        , .  1 .   .'  .  .lo  not   iK.w.'ver  accompany  the  attack  in  a.lults. 

^' Ti;:-li;;;;:it';: 'hiv  m:;nmi  'tHe  .ar>W.;sc..pe.    The  prognosis, 

''^i:^^''^z:':^^:::^'^^       to  have  ..e 

,^T^  his  i.r..ath.  a...l  t..  hreatlu-  rapi.lly  -t i^  ^  :-;^,;;- ^ 
Mnrit-  Schn.i.lt  a.lvis.s  pr.-ssure  ..n  the  tip  of  the  noM  wl.il.  tiio 
'nS;  i;.v!!!h'-s  i'ci.lv.     Chl..n.f..rn.  inhalati...is  or  tracheotomy  or 

''oi;:;;:o£';ie'La;^:'''™s-mav  occur  in.lepon.le..tly.  hut  it  is 
..STL-Jde.!  .^•h..n.a  elsevv^here  O.uuli'  I-f-  J  -  <;-' 
1  if,,rm  movments,  h.-infl  ..ppos.'-l  to  that  of  chorea  of  the  larynx. 
,1  ;;;uarmanif..sts  it.elf  by  a  constant  barking  noise,  harassing  to 
ti.c  ir.tie'iit  an.l  to  those  about  him. 

T  i  m  nt:  Tlu>  treatm.mt  is  tl...  san-^  :>.s  applies  to  chorea  e.se- 
vvlH-re:  rest,  arsenic,  etc.     The  progn....s  h  geiL-rally  P"«;l- 

Phonatory  Spasm.  An  i,.co-or.li..ati..n  .>f  the  n.uscles  of  the  la  >  nx 
,.l.;SSling.  due  to  a  .nore  or  less  complete  closure  of  the  glottis, 

,^,M,.„.,le.H.p.uu,,Mar.H,>.^.  =  „.j^.  M«..  Fc...ar.,  ,^.  •  I— 

.  J,„ir.ml  American  Medio*.  AMocmtlon.  June  J2, 190.. 
s  Jouma.  iJiryn.,  Khin.,  an.l  Oto...  April,  1901. 
>  New  York  Me.llcal  Record.  February  S.  1900. 


'  Arch.  f.  Lar..  1900,  Bd,  x.  p.  82- 


1050 


KOSK  ASD  TUROAT. 


J'xista  cither  alono  ()r  with  fuiictii)ii:il  iii.-tpinitDry  spasm  (if  the  glottis. 
HcHex  caiisfs  must  Ih-  smigiit  for  ami  rcmcilicd. 

Stammering.  Few  maladifH  to  wiiicii  ticsh  is  hfir  cause  (|uitc  a> 
much  uiil\apiiiu:'s.s  jis  docs  the  stamiucrcr's  iiiaiiihty  to  express  jii.- 
thought.  Froiu  time  immemorial  noted  men  iiavc  Ix'cii  thus  alfiictcil 
whose  "iiervKU^  dread  and  sensitive  sliame  freeze  the  curn-nt  of  llieii 
speech;  they  stand  impotent  of  words,  travailing  with  unhorii 
thoughts." 

For  some  unknown  rciuson  their  treatment  has  hitherto  lieen  prin- 
cipally left  to  the  charlatan,  who,  hy  some  secri't  method,  tries  to 
cure  every  case  on  a  similar  plan,  and  ignominiously  fails.  'I"he  treat- 
ment is  logically  that  which  the  laryngologist  only  can  indicate. 

Some  writers  have  Ijiid  stress  on  the  great  ditTerence  existing  hc- 
tw(  Ml  stuttering  and  stammering.  It  seems  simplest  to  view  stut- 
tering its  the  prodrome  of  stammering,  ;is  indicated  by  Makuen.' 
Among  recent  writers,  Pluschowski'  says  that  most  defects  of  speech, 
and  especially  stianniering,  belong  to  the  curable  neuroses.  Ilolger 
Mygind'  says  that  stammering  nuist  appear  as  thi'  exjiressioii  of  a 
neurosis  which  is  etiologically  n-lated  to  the  .so-called  neuropathies 
of  degeneration,  to  which  diseases  like  epilep.sy,  hysteria,  neuras- 
thenia, chorea,  and  insanity  belong.  This  relation  is  the  stronger, 
as  many  of  the  latter  di.seases  are  found  in  the  family  history  of 
stammerers.  The  latter,  too,  have  .some  of  the  stigmata  of  tlie  former, 
Staiiunering  occurs  at  certain  ages,  in  males  from  two  to  four  years 
of  :ige,  and  has  this  in  common  with  hereditary  neuropathies,  that  the 
occasional  cau.ses  are  far  behind  the  remote.  This  is  not  true  in  every 
case,  for  many  stannnerers  have  no  hereditary  |)redis|H)sition. 

Stanmiering  is  tlie  inco-ordination  of  the  three  mechanism.s  of 
speech:  the  respiratory,  the  vocal,  and  the  oral.  In  the  medulla 
oblongata  is  located  the  centre  which  presides  over  the  co-ordination 
of  the  movement  concerned— the  basal  phonic  centre — and  the  faulty 
mechatiism  of  one  results  in  a  faulty  action  of  all.  This  co-ordination 
in  the  normal  voice  producti-in  h;us  been  likened  by  Wyllie*  to  the 
pleasing  tones  produced  on  the  violin  with  the  bow-hand  acting  in 
pn  ])er  unison  with  the  fingers  of  the  other  hand  along  the  strings. 
K'lTidworth^  used  the  accordion  tis  his  simile. 

In  a  report  ( ii  stannnering  from  the  standpoint  of  military  duty, 
Chervin  ,>tM»'s  that  about  KKM)  :ire  yearly  declared  unfit  fcr  duty 
in  France  Ix'cause  of  this  alTection. 

Makuen'  in  a  study  of  200  ciuses  found  17  p<'r  cent,  due  to  in- 
voluntary i!!iitation  of  others,  1.5  per  cent,  due  to  fright,  8  per 
cent,  due  to  an  injury,  and  0  |M'r  cent,  to  having  l)een  ill-used  at 
home. 

Fully  95  per  cent,  are  males.     It  has  never  l)oen  explained  why 


I  i'lilladeli  lim  Mediral  Journnl.  Miirch  TO  llOl.  '  Rum.  Arch.  Patol.,  vol.  vl.,  1S98. 

»   (-.•h.f,  Ijir  and  llhliiiil,  U.I.  v,;i  ,  1-ojtt.  «  The  Ifisonlers  cif  Speech,  1X94. 

'  .si  ittcrinK:  linw  to  Cure  n.  «  Bulletin  Mill ,  September  ■.»,  1H98. 

'  Th.'rapeutu  '  iiiz'  tie.  .Seplemher  .  .     -  C  IMiilaileiphia  Molical  Jourual,  February  i,  1901. 


.\EUi.u.ii:s  OF  THE  vosf  .i.vy>  iiiHo.ir. 


1051 


I 


;  ^,    :         T        n'  nhliu^  urchin.  k.-,.t  in  a  .tat.-  ..f  terror,  slum.. 

.'  .V  '.■  anxiHv  fro.M  tlu-  very  .un.tal -xiMTtan-y  a...l  t.ar   s... 
i:;l.;;;s  aconfirnuHl  .ta.u.u.-n.r.  wh.-n  p-ntl-  -n-asun.  woui-l  l.ax. 

"";;Iv'oi;!;tru..ti.,n  to  n-spiration  m  th-  ,...«■  or  i„  tlu-  pharynx  sl.oul. I 
..n!     :  ;.;[  .on,u..-ti.-  'ut,  an,l  nu..-i..s  -'.."rn^  surp.-a!  ..  tn.. 
-houM  i..-  can-a  for.     Th.-  factor  <T..at.nK  thj;    "-<  '^  >•«•*"" 

-;':tl,!:;!;:;:"i"  ;is;:':;  >«"■  ™i"'":  ■  ;-^ 'v 

!!:;.a      w'th  p.n,l,.  n>ca.sun.s.  following  the*-  U.ve.,  cures  niay  1h' 

''•'iiiSiii'VSoi'l^'k;;^'  -  -t-  laryngoa  ana  laryngeal 
..pU.T*rs  of  Stal  oc-curronc.  l.ut  1>>-  no  n. cans  a  nm;  .-.js. . 
;i.;;.,.l  mla  CoHet^  r,.c..ra  ■->:i  cases,  while  Chazalon.'  1-ayolle,   ana  th. 

'••^:l,l;S;;;];;:^:;;^i:^rge"  ..una  is  auo  to  asthma.  Tmy; 
.mil    M    3     oun.l   oxces.sive  snioking  rcs,M.asil)lo    ana  I'.TCop.ea 
\l'l^  o    f     lue  to  excessive  smoking,  the  others  to  smoking 
';;;,'1m>      ro^.v">    th.   a,usal  n.ucosa.     .\aier-  re.H.rte.l  a  ca.se  .lue 
t."  l.l!;nga;..a  \m.la.     Hypertrophy  ..f  the  lingual  toml  .nay  act  as 

='  ^;:r:.S  r;^ia";:r:^--l  in  .nales  between  the 

'^  The  ■vttacrb..gins  with  a  tickling  ir.    he  throat,  causing  cough,  the 
fac     bi..m.>s  c.fngest...l,  an.l  the  pat..-nt   fa  Is  -TT^'Z^Z 

..    .  _  J     .1..  fr\m      iau4 


«  Ann.  «l<i«  M»la<l.  de  fOr..  IfM. 
•  I.yiin  MM.,  1S9«. 


1  Spe«-ch  and  Its  l)f  fwts,  18«. 

"  ThMe  de  I.yon.  1>W«. 

i  I^nv«n«i  MiVlieale.  Augml  18, 1«».  o  i,  iqnn 

.  Anna,.  d»  Malad.  de  rorea^  e.  '^-^'■■^;'  "'^""^M^.auchr.  f.  Ohr«.h..  No.  9.  .«9. 

1  Journal  Larj-n..  Rhln..  and  Otol.,  April,  ijui 

•  Normandle  Medical.  February  1, 1K99. 

<"  New  York  Medical  Journal,  February  12,  V^V- 


ln.-)2 


AVWA'  AM'  llHilt.lT. 


ri'iiu-iiilM'riiijr  tin  <"Ujjh  ■■iily,  but  imi  'hi-  lossof  consridiisncHH.  Wliilo 
the  attack  siiniilan-  an  f|iiii'|(tic  .li.i'k,  tlii-n'  arc  few,  if  any,  iiui!«- 
ciilar  spacms,  tlic  tongue  i.s  rmt  hit  ten,  tlicrc  is  no  snlisc<|ucnt  naiisi*:}, 
no  involuntary  uiin:;tioii,  imr  .I'fccMtioii,  ami  no  licadachc.  Laryiiffcjil 
vcrtifjo  (M'cuiv^  in  advanccil  y.  .r-    arnl  is  a'«MV'  of  short  (lunition. 

riic  prognosU  is  froiMJ.  i'lu  lr««tmAnt.  '  •■•  ixMJictl  in  tlu>  t*(>ii:'«'h 
for  aiiil  removal    'f  tlii'  caii-e 

Larvitgeai  Paralysis,  Hypokinesis.  Any  injuiy  to  a  part  .>f  the 
inoti  i  I  tact  of  the  larynx  occasions  |i;iralysis.  Tliis  may  Iw  functional 
or  organii',  o'l-sidei!  or  hiiatem'  complete  or  incoin|ilet(',  afl'cctinfi 
either  phonator\'  or  respiratory  liuctions,  or  both. 

To  properly  .-lopreciate  the  conditions  here  existing,  it  will  1h'  Ixirne 
in  mind  that  the  external  or  small  hr.-mch  of  the  superior  laryngeal 
ner\e  .alone  contains  motor  filaments,  and  these  supply  the  crico- 
thyroid nniscle  only,  the  other  hranehes  of  the  sii|M'rior  laryngeal 
ni'rvi'  iM'Uig  exclusively  eoniposed  of  sensory  lilaments  which  supply 
the  mucous  membrane.  The  crico-tliyroid  receives  motor  impulses 
also  from  *he  (iharyngeal  branch  of  the  pneuniogastric.  TIjc  other 
internal  laryngeal  adductors,  abductors,  un<|  teiisor-s  ;ire  supplied  by 
the  inferior  or  recurrent  laryngeal  nerye.  The  vagus,  niiuiing  from 
the  jugular  fonimen  with  the  bloodvessels,  dips  into  the  thoracic 
cavity  and  gives  o'V  tiiC  recurrent  laryngeal,  which  winds  around  the 
arch  of  the  aorta  on  the  left,  and  tlu  Mibcl.ayian  artery  on  the  right 
and  returns  to  the  larynx.    ^I'late  X.\  vll.) 

Regarding  the  ?uanner  in  which  [laiaiysis  actually  opcurs,  Semoii 
presented,  in  ISSl,  the  theory  that  in  all  progressive  paralyses  in 
organic  disorders  the  abductors  ire  the  first  afTected.  In  all  func- 
tional disorders  the  adductors  iie  ;iifecte(l  practically  alone.  This 
occurred  with  such  regularity  that  it  miounted  to  a  law,  This  view 
\v;is  combated  by  many,  notably  by  Kraii.se,  and  more  recently  by 
Clrossman.  Mjuiy  have  since  recanted  from  their  oppcxsition.  As 
each  opponent  presented  his  own  views  contrary  to  those  of  S<'rn()n, 
he  promptly  chall<'nged  each  and  every  one,  stuniily  defending  his 
own  views.  The  general  consensus  of  opinio!)  trwlay  is  in  support 
of  Semoii. 


DK-SiumiON  (iK  PLATE  XXXII. 
ILLUSTRATIONS  FOR  LARYNGEAL  PARALYSIS.    (iCHNirjull.) 

Fio.  I.— Pttralywi--*  of  twth  t:»ynvar>*t«?noffJ  nrnsclen  Utttemi) 

Flo.  *-'.— Pitmlywis  of  the  ar>-tenoi'l  mu.si:)e  (tranj^vewiw). 

Flu.  :t.— l'«™i>Msi)l  hi)ih  iliyro-iiiyteniihk-i  Intenil  ami  iif  ll.e  trRnKTrnie. 

Fiii.  4.-  I..ei>iii|ilf  e  repiim'iii  [MmlyKis  instil  >|ik->li.  n'niirHt.iiy  position.  (Paralysis  of  thecrlMv 
aryteiuililiin  i-wlliin  «n.l  of  the  thym-arytsnoideiB  Internum  on  tlie  riKht  side.) 

Fl'i.  ■'>— Thi'Niiiie  ill  (ihoimtloii. 

Flo. ''.-  INiralysis  of  ail  aildiictora  of  hynterical  ortKln. 

"■■-.  "  — T..!»!  i...rn'y-':-..f  !!ir  :■-  ■■•fvMi.  riKhi  sHni.  T"::-  ris-"  "-ral  r.-ni  is  !ixc<i  .n  ir.e  \.*MhM 
ralli-'  "cailaverif."  In  this  lijfiiiv  tho  left  normal  v.kkI  lord  1«  ^vn  I'xtenillng  over  Ihi  median 
line  to'vani  the  panilyail  rij-ht  cotd  an.l  the  whole  in  the  fiosltion  <■'  iihoiiaiioii 

Fio.  S.-.-Iueoiin.lete  tveiirreiit  i«raly«li  of  hcHh  «id<».  (Pamiyils  of  both  the  ericoHirytenoldel 
poatlci ;  puaiUci  of  reniiiratlou.) 


HLATK   XXX  I  i 


i^      -i^...--:.    U.JJ'W 


i 


.\Kntosi:s  OF  TJiE  yosh:  .i.v/>  throat. 


1053 


Till-  term  "  cadiivcrii'  "  jxisilh.ii  used  todcsiftiiatc  the  tixctl  cord, 
i-  really  a  iiiLsiioiiuT,  Fein'  having  found  ten  different  positions  in 

the  caiiaver.  ,  ,     • 

( )ne  of  the  most  fre<iuent  of  tlit  eentnil  Ciivuses  of  laryngeal  paralysis 
is  tabes  dorsalis.  Touelie=  in  a  stmly  of  40  tahetie  patients  found 
12  witii  laryngeal  erises.  Other  causes  are  syringoniyelia,  multiple 
xlerosis,  cerehellar  and  bulbar  lesions,  and  syphilis.  Cases  have 
|.,rn  recorded  in  recent  years  due  to  foreign  body  in  the  larvnx, 
l)icnehocele,  cancer  of  the  (esoi)hagus,  after  measles,  mediastinal 
liimors,  influenza,  aneurism  of  the  aorta,  typhoid  fever,  li'ad  poison, 
pressure  of  enlarp'd  glands,  mental  shock,  primary  laryngeal  tuber- 
culosis, and  overuse  of  the  voice  and  of  the  telephone.  Ofttinies  the 
l.iryngeal  lesion  is  the  first  evidence  of  an  aneurism  or  beginninn  tabes, 
and  fre(|uently  the  cause  is  unknown.  <  )f  the  infectious  diseases  diph- 
Ihcria  isthe  niost  frequent  cause.  Lead, copiMT.antimony, phosphorus, 
•  iisenic,  atropine,  cocaine,  or  morphine  may  be  factois  in  the  causation. 
Recurrent  Laryngeal  i'aralysis.  Hoth  nerves  may  be  affected, 
.lithough  it  is  verv  uncommon.  The  vocal  cord  a.ssumes  the  rigid 
position  for  v.liich"the  term  "cadaveric"  has  been  api.lied  In  uni- 
lateral |)aralvsis  aj)h(jnia  is  first  present,  but  the  normal  cord  .soon 
makes  ji  large  excursion  to  its  maimed  fellow,  and  plionat ion  becomes 
possible.  Dvspncra  is  not  pre.-ent,  except  when  bilateral  abductor 
jiaralysis  exists.  No  amount  of  forced  inspiration  will  mike  the 
l)aiarvzed  part  move,  and  it  is  this  fixation  that  is  depended  ui)()n 
for  diagnosis.  The  narrow  chink  that  is  left  in  this  form  of  affection 
is  always  the  same,  while  in  hysteria  the  opening  is  larger. 

Unilateral  abductor  paralysis  occurs  fre(iuently  without  dyspn-ra 
or  dysphonia.  Its  presence  is  an  indication  fo**  a  careful  search  for 
the  cause. 

In  bilateral  abductor  paralysis  the  voice  is  jircsent,  but  the  grave 
symptom  is  (Ivspiuea.  Paralysis  of  both  i)osterior  crico-aryten(>id 
niuscles,  if  complete,  j)laces  the  patient  in  innnediate  diJiiger  of  d'  ath 
by  suffocation.  Wright''  believes  that  the  sudden  deaths  in  cc.-ebral 
aJM.plexv  might  be  exi)lained  by  the  existence  of  this  form  of  paralpis. 
Laryr.goscopic  examination  shows  the  cords  to  bo  almost  entirely 
approximated,  a  small  slit  fully  existing  between  them. 

Tracheotomv  is  fre<|uently  necessary,  and  some  laryngologists  con- 
.sider  this  the  onlv  Drocedure.  Semon  would  leave  it  to  the  i)atient 
to  decide  to  risk  tlie  danger  of  suffocation,  or  to  wear  a  tracheotomy 
tube.  N.  L.  Wilson'  suggests  intubation.  Joachim."  after  trache- 
otomy. iMTformed  a  thvrotomv  and  removed  both  vocal  C(  rds.  with 
restoration  of  function.  J.  S'olis  (\)lien"  says  that  if  tracheotomy 
be  refused  by  the  patient  he  should  be  urged  to  always  carry  a  tra- 
cheotomv tiibe  with  him  to  show  his  pliv>:"ian  if  the  emergency 
arises;  by  this  means  lift-  has  bec-n  saved  in  two  or  three  instances. 

1  Witn.  Kiln.  Wchn  ,  V  .«>,  So  24.  «  f"""'  Me.1..  August,  l-<99,  No.  W. 

'  Amerii«n  Text-book  of  Diseases  of  the  Eye,  E»r.  Noee.  ami  Throat. 

<  Lsryngoscope,  September,  1900.  ''  ■''K'-  '  ™'' 


1().J4 


XOSi:  ASD  THROAT. 


H 


Injections  of  hiclilorido  of  incrcurv  liavc  ln>fii  Viiliiahlc  wlion  due  to 
syphilis,  (i.  dcroiizi'  Ixlicvcs  tliat  if  tlif  rcciincnt  laryiiKral  nerve 
coiiM  he  resected,  if  there  is  no  Ik.jm.  of  restoration  of'tlie  function 
of  tiie  posterior  crico-aryteiioid  muscle,  that  the  danger  of  sutTocation 
aould  be  avert(  d. 

Paralysis  of  the  Adductors  of  the  Vocal  Cords  (Orico-arsrtennidei 
laterales).  Milateral  paralysis  has  its  its  chief  etiolojjical  factor 
liVstrMia.  It  is  sudden  in  its  onset,  without  symptoms  of  constitu- 
tional disturbances,  save  those  of  hysteria,  its  main  symptom  beinji 
aphonia,  more  or  less  complete.  l.arynKo.M'o])ic  examination  .shows 
til.'  cords  far  apart  a.s  in  force<i  inspiration  and  apparently  iuuno- 
\  able.  ( )ccasion;dIy  luit  one  side  is  atTected.  and  a  few  such  ca.ses  are 
recorded.  While  hysteria  is  the  main  element,  reflex  cau.M's  may  exist. 
The  ajihonia  comes  without  warping  and  remains  persistent  at  times. 

Semoi!  believes  that  the  large 't  percentage  of  ca.ses  of  hvstericil 
aphonia  may  be  cured  at  one  Mliing,  one  of  the  electrodes  being 
|)laced  on  the  interarytenoid  foMs.  usin^  die  faradic  current.  The 
application  should  be  energetic  and  lasting  ;ind  the  sitting  contimied 
until  till-  voice  has  returned.  Sugg"stion  iias  been  f(  Mowed  by  good 
results.  The  writer  saw  a  cure  result  from  an  application  of  a  cotton 
swab  in  a  ca.se  of  over  six  months'  duration.  In  another  instance  a 
young  girl  Wiis  brought  to  me  with  the  history  of  sudden  lo.-<s  of  voice 
following  an  accidental  fall.  She  travelled  .several  miles  to  come  to 
my  odice.  :uid  w;is  well  in  every  other  way.  Tiiere  wjis  so  much 
pha.yngeid  irritation  that  it  wa.s  deemed  best  to  spray  her  pharynx 
with  cocaiiw.  .\s  she  saw  the  sjTay  apparatus  approach  and  |)oiiit 
!;t  her.  she  gave  a  startled  look  'iiid  said  in  a  loud  voice,  "Oh!  my  ( iod. 
What's  that?"  She  was  cured  Wh.  ti  faradization  is  employed,  it 
sliMuld  not  lie  u.-ed  too  strmg,  nor  should  we  toy  with  it. 

Paralygig  of  the  central  abductor,  the  arytenoideus  nniscle,  occurs 
alone  at  times.  Kxccpt  for  a  triangular  space  po.steriorlv,  the  cords 
are  in  appo.sition  in  their  entire  length  The  ciiief  symptom  is  aphonia 
and  the  cause  hyste-ia. 

Paralysis  of  the  superior  laryngeal  nerve,  causing  panilvsis  of  the 
extern.il  tensor,  tlie  crico-thyroideus,  and  the  internal  teii.sor,  the 
thyro-arytenoideus  iiiternus.  is  of  ran'  occurrence.  It  mav  be  cau.^ed 
by  traumatism  or  diphtheria,  a. id  n.iy  be  a.ssociated  with  pari'.ly.<is 
of  the  n'turrent  branch,  when  it  becomes  a  very  dangero-is  affection. 
Total  ana-stl-.esia  of  the  larynx  mav  be  occa.sioned,  and  then  there 
is  need  for  great  care  as  to  the  food  administered. 

Paralysis  of  the  thyro-arytenoidei  muscles  is  of  frequent  oocur- 
reri<  <■,  .\ny  infliuiiinatory  process  or  overu.si"  of  the  voice  may  occa- 
sifi!.  it.  Hoarseness  ami  aphoni.a  to  a  mild  degree  e.xist.  The  laryn- 
gnscojiic  examination  shows  an  elliptical  opening. 

The  prognosis  i-;  good.  Hest.  iron  to  the  laryn.x,  and  soothing 
applications  result  in  complete  recovery. 

I  Kirorma  MertlOJi,  Palermo,  .July  6,  1899. 


m 


CHAPTER    XXIV. 

KXTKRNAL  DKFOHMITIES  OF  THE  NOSE;  CLEFT 
PALATE. 


Bv  F.  K.  HOPKINS,  M.I). 

In-  trcatiiiR  tho  suhjcct  oi  (Icfoniiily  of  the  ix-so  a  i)r(>fap(>  nii^lil 
well  he  written  \'\»m  'i„rrnilio,i.  s(^  larp-  a  pcrcciitap"  of  .l.-forimtirs 
i<  (••iii-*c.l  l)V  (!isi)lac(Mn(>iit  or  fractuiv  winch  failed  to  reeeive  proper 
..ttentioi.  at  the  time  of  the  a.-eidetit.  This  ne<jiiKeiiee  may  l)e  (Itie 
t,,  lack  of  ;.!>  .reciation  of  tlie  daiiiafie  done.  Tiie  swollen  eotuhtion 
„r  th<-  nose  sometimes  renders  it  ditlieult  to  .ietermine  the  amount 
of  disnlaeement  or  the  iiltimat."  interfen-nce  with  re.si.iratu.n:  inore- 
,,v.r  the  faet  that  an  injurv  to  the  nose  does  not  usually  imperil 
lit,.  „or  seriously  impair  the  individual's  .•armiiR  capaeity  alnmst 
unconsciously  Ics'sens  the  importance  attached  to  its  treatnu'nt.  The 
Mccident,  howeyer,  for  seyeral  reasons  .lemaiu is  most  careful  atten- 
tion and  that  early.  Circulation  in  the  nose  is  most  actiye,  and  alter 
dispiacement  from  fracture  tlu'  fragments  quickly  and  tirmly  umte 
ill  their  yicious  position,  h-aviiif;  i)ermanent  deformity.  The  nos<.  is 
.o  prominent  a  feature,  and  its  symmetry  so  laijte  a  factor  m  a  p  'asiiig 
^cial  expn>ssion,  that  in  ca.se  of  deforn.ity  the  patient  is  subject  to 

."  decree  of  constant  : tification  which,  apart  from  its  suhjectiye 

side,  amounts  ...  a  taiiRihle  handicap  in  the  struggle  for  exi.st.Mice. 
This  mental  suffering  is  more  acute,  perhaps,  iii  women  and  children, 
•ind  often  is  not  amenal.le  to  any  relief  from  philosophy,  as  the  yictim 
.'ivitly  exaggerates  the  effect  of  e\-en  slight  yariations  from  symmetry. 
N.,t  onlv  is  it  important  to  correct  the  external  injury  for  \vhat  may 
l„.  called  co.sinotic  effect,  but  tho  interior  of  the  no.-e  must  r.Teiye 
..ttention  at  the  same  time      The  .lisplacement  of  the  septum  causes 
■ui  occlusion  of  one  or  both  fossa-,  with  c(.nse<(uent  interference  with 
nasal  respiration.     The  proper  reposition  of  the  septum  aids  in  ,se- 
.uring  symmetry  and  stability  for  the  injured  organ,  as  w  1  as  restores 
„„rmal  respiration.     !•  ther  aiuesthesia    hould  be  resorted  to  if  there 
i-;  the  least  doubt  as  to  whether  the  parts  are  properly  replace.l,  and, 
if  the  case  is  at  all  .serious,  the  use  of  an  aiuvsthetic  might  well  be 
recommended  a.s  a  routine  practice.     Deformrties  of  th.'  nose  are 
■ini.'naiile  to  satisfactory  correction  if  seen  early.     Iracture  (.1  the 
nasal  bon.'s  is  often  but  a  displacement  along  the  lines  ot  articulation 
with  each  other  an.l  with  the  nasal  process  of  the  superior  maxillary 
bone     The  ca.se  of  a  friend,  Dr.  B.,  who  sustained  a  "fracture     ls 
here  in  point,  furnishiiiR  a  typical  case  of  displacement,  and  showing 


1056 


aoaa'  a.w  throat. 


with  wliat  case  it  iiiav  hv  corrccti'd.  Tin-  doctor  is  an  enthusiastic 
h;i-si<fi-l)ali  plavcr.  aiid  wiiiic  iilayiri-;  nrcivcd  a  iiravy  blow  upon 
tiic  dorsinn  of  "the  nose,  displacinj;  it  bodily  to  tiit'  rijiht.  The  acci- 
dent was  attended  by  severe  jiain  and  pidfuse  l)iee.liMj;.  In  aiioiil 
an  iiour  rejiosition  was  ctVected  by  a  confrere,  tlie  parts  returninn  to 
position  with  an  andii>le  click.  Two  hours  after  the  accident  he  came 
to  me  to  be  assured  that  the  deformity  w:is  reduced  tir  to  have  it 
corrected.  Huth  externally  and  intranasally  tiie  partN  were  in  |)erfect 
position.  No  retention  apparatus  was  rc(|uired.  and  tlie  results  are 
entirely  satisfactory.  The  eise  of  maintainiiifi  the  parts  in  position 
was  inferentially  l)roup:lit  out,  in  the  discussion  o>i  fraclines  of  the 
r.  se,  by  the  .\nierican  Laryn^'olofiica!  .\ssociation  at  its  nieetiu};  held 
in  vVashiufiton  in  HMK).  the  paper  w.is  read  l)y  Dr.  Di"  Hlois,'  and 
in  di.^cussion  it  ap|)eared  th:it  nearly  every  speaker  had  a  method  of 
retention  dilt'erin-;  from  all  otiiers,  yet  all  secured  jjood  results.  This 
is  one  side  of  the  sui),jei't,  ami  is  encourafriufr,  especially  >ince  the 
majority  of  cases  of  deformity  of  the  nose  are  due  to  displacement 
or  iraciure.  If  the  general  pr.-ictitiouer  were  imi>ressed  with  the 
importance  of  irivinjr  e.iriy  and  sulficient  attention  to  ca.ses  of  injury 
to  the  nose,  ami  undeist<ind  th.ai  j^ooil  results  may  be  obtained  by 
the  excrci.se  of  a  little  intiviiuitv  and  i)alience,  there  would  U'  fewer 
unsij;htlv  noses. 

Treatment  of  Recent  Fractures.  Dr.  Wrijrht'  has  recently  ftiveii  ;i 
hifrliiy  interestinji  revi<'w  of  ancient  medicine,  from  which  we  learn 
that  Hi])pocrates'  knowledge  of  the  treatment  of  fractures  of  the 
nose  is  well  worth  reviewins:  by  the  modern  rhinolop.st.  He  insists 
tijion  the  importance  of  thomufih  replacement  of  the  fragments  .-ioon 
after  thi'  injury,  and  complains  that  me.ny  |)atients  are  unwillinj;  to 
endure  the  pain  necessary  to  a  correct  reposition.  We  have  the 
advantaj;<'  of  general  aiiastliesia.  and  its  use  is  to  be  recdnunended. 
I  liave  been  more  inclined  to  advise  this  since  a  recent  experience 
with  a  medical  man  who  sustained  a  coinjiound  fracture  of  th<'  nose. 
He  demanded  that  ether  Im'  jriveii,  and  the  greater  control  of  tlie 
siluation  which  was  thus  secureil  w;is  highly  satisfactory,  and  no 
<l(iubt  contriliuted  largely  to  the  good  result  attained.  The  parts 
are  resloreil  to  position  liy  combined  internal  and  external  mani|iu- 
lation.  The  finger,  a  h'.rge  probe,  tlie  handle  of  a  cotton-carrier 
serves  well,  or  a  pair  of  .Vdams  fnrceps  with  hmg  blades  mav  Ik  used 
within  the  nose,  .aided  by  the  fingers  externally.  When  the  frag- 
ments .'ire  rejilaced  the  jiarts  are  easily  retaineil  in  position  iiy  means 
of  an  external  appliance,  nr  intranasal  splints,  or  a  combination  of 
both.  Sometimes  after  perfect  ri'jiositinn  no  retentive  ajiparatus 
whatever  i-^  necess.ary.  Iiwleed,  Swain.'  Clark.*  and  othif<  treat 
most  cases  witlKiut  any  form  of  splints.     This   ea.«e   of    retention  is 


1  'rransaotinns  of  tho  AmiTii-nn  l.ar.viiRcr!iigtc»l  A«!«Ki»Uoii.  IWX),  y.  12, 

2  |jiryiij5.i!i('.,pe.  IWI.  v.il.  xi.  y.  HH. 

>  Triiisaclliiiw ')r  Ihf  Aiiu-rii'an  LaryiigolDuicul  A«*>oiiili.iii.  I'.KN),  p  VI. 


<  Ibid. 


EXTEIISAL  DEFORMITIES  oE  THE  SOSE. 


1057 


.!,„.  to  tho  fact  that  th<<  iH.iu-s  an-  n..t  .lisphu-.-.l  by  nmscula    actio  . 
-n,.  .nusclcs  atta.-lu-a  to  tl.o  nasal   bom's  a.v    t..o    f.-ble    tr  aff.'ct 
1  !ir  I,.lac,..ncnt.  a  .nark.-.l   contrast   to  con.l.t.ons  pr-'vailinR    n 
.„.,ur.>s  ..f  the  oxtrenutics.     Son,.,  n.o.hhrat.on  of  tl.c  Asch  l.ol bw 
vulcanite  tube,  ius  Meyers  or   Me  Kernons    answers   well,  or  Kyo  s 
.  !  a    spli..t  n,av  iK.-use.l.     Tlu-  ri.ler  splint  .lev.se.l  by  Lo  an.    .« 
„  ingenious  ami   us..ful   appliance.    The  a.-companynrg   cut    (1-ir 
:  ".^  n.pr.-s..nts  an   a.laptation    of   this   i.lea.     A   tnangular-shape.l 
piece  of  vulcanit..,  with  the  un.ler 
surfa.'.'  groov.'fl,  an.l  havinji  an 
eve   in   the   unt.'ri.-f  .'xtreinity, 
tin-oufih  which    is  passe.l  a  silk 
thr.-a.l,  is  i)lac.'.l  in  the  upix'r  part 
„f  the  nasal  fossa-,  an.l  McKer- 
ii,,n's  nuulitication  .)f   the  Asch 
tube  is  inserte.1  beneath  it.     The 
riil.T  splint  is  then  drawn   for- 
ward bv  means  of  th.'  silk  thr.'ad. 
As  it  is  .Iniwn  forward  the  dor- 
sum of  the  nose  is  el.'vated,  and 
when  this  is   brought    into   the 
light    line    the  thread    is    ti.'d 
i.cross  the  front  of  the  tube,  m 


Rider  »pUiit  above,  vulouiile  tube  splint  below. 


whi;^;  g;K;;;rhave  b.-en  cut  to  receive  it.  Tins  mak..s  a  firm 
!u  rt  ^l..ws  of  p.o.1  .Irainage,  and  p.-nnits  n^u^al  resp.ratum  t 
:'  ;  V  splhit  is  prop.>rly  ma.l.>,  t'-MM-Uan.-.-  .s  vv..rn  wi  h  httle 
dis.-omfort  an.l  can  rea.lilv  be  rcM  ,ov.-.l  for  d.-ans  ng.  h  an  external 
;  is  uil  (Vs<'lb,.rr;-  n'con.'n.'n.ls  that  it  b.- maoe  of  phuster- 
.  uiit  is  »••"  l'^  ,  ,,^\.....\.^  .1,1.  f„ssa'  witli  anti.s.-i)tic  gauze,  using 
;   i  ^", ;  i  ;;  n    I's  L;  '  t.     .-x  eLl  spun,  Shurley=  a.lvises  gutta- 

;;,.'"   u^^s  n.etal.  tin.  cop,.r.  or  aluminum  for  the  same 
;",;..     He  shows  a  n.-atly  moul.led  splint  .,f  s.uall  sue,  h.-ld  in  ph. 

,     ..Ih.'siv.-  plas,..r  arouiul  th Iges  only.     In  had  cas.-s  it  will  b. 

L'       rv  forVl  .■  pati.M,l  to  w..ars..m,-  part  of  the  retentive  appliance, 

1,;  i^  te    a    ..    .•x..-rnal,  for  a  ,..-rio.l  .-f  fro",  tw.,  to  hve  .,r  six 

i.     The  intranasal  splint  should  not  b.-  re.nov.l  nn.l.-r  for^>- 

:;^\.Z.  aft..r  which  i  is  taken  .u.t  at  '■"■ -f '  ^T;^,;;;    ;. 

needs  uf  each  ca.se.  for  st.-rilizing  and  t..  penmt  of  cbaiiMn^  tlu  lusal 

'"SE  brief  consi.l.Ta,ion  of  fractures  of  the  nose  is  P<'"nane  t..  'he 
sul.iec,  of  ,n.at.i..-nt  ot  deluinnty  of  th..  n..s.>.  sm.-..  •-"^<;  "f/  '"^  ^^ 
riples  of  treatment  are  similar,  but  .■hi.'fly.  p..rhaps,  as  a  i.l.-a  for 

,  T™n««oU.„,, ,..  "•;;^- :,::>^^r ""  'TI:";;™:™:.!:  .i^«r,er.y,  >««,  vol. ..  p.  «. 
•  iJiseasesof  Nose  aim  inroat,  IW"'.  P-  <'-^ 


1058 


XOSK  AXn  THROAT. 


greater  care  in  cases  of  recent  fracture — a  jirophylaxis  against  de- 
fortnity.  Prevention  is  i)etter  tlian  cure.  Deformities  of  the  nose 
requiring  |)la.st<c  surgery  for  their  correction  belong  ratiier  to  the 
general  surgeon.  Uhinologists  are,  however,  treating  every  other 
ileforniity  of  this  organ,  and  jjroperly,  as  intran;usal  conditions  as 
well  as  the  external  form  require  attention.  Of  cla.s.sifications  of 
these  deformities,  that  of  Roe  is  the  best.  This  author  has  written 
extensively  upon  the  subject,  and  hius  made  all  other  workers  his 
debtors,  not  only  by  his  surgical  achievements,  but  by  his  pertinent 
suggestions.  His  classification  is  as  follows:  "From  a  surgical  |M)int 
of  view,  nasal  deformities  may  pn)|H?rly  be  divided  into  the  deform- 
ities which  affect  the  bony  portion  of  the  no.se,  and  the  deformities 
whicli  affect  the  cartilaginous  jxirtion.  Deformities  of  the  bony  por- 
tion may  be  subdivideil  into  vertical,  that  is,  those  which  distort  the 
dorsal  profile,  in  which  the  dorsal  line  is  too  convex  or  too  concave; 
and  lateral,  that  is,  those  which,  when  viewed  from  the  front,  present 
unusual  deviation  from  the  normal  contour,  whereby  the  bony  portion 
may  be  either  spatulated  or  <lcflected.  Deformities  of  the  cartilag- 
inous ixirtion  may  be  subdivided  into  those  which  affect  the  tip  of 
the  no.se,  whether  excessive  or  defective  in  the  amount  of  tissue,  or 
distorted  from  its  normal  direction,  and  tho.se  which  affect  the  wings 
of  the  nose,  which  may  be  either  collapsed  or  abnormally  expanded." 
Convex  vertical  deformity  or  exaggerated  Roman  nose  is,  with  rare 
exceptions,  congenital.  Concave  vertical  deformity  is  a  lowering  or 
depression  of  the  bridge  of  the  nose.  This  is  usually  the  result  of 
violence  from  b..iws  or  falls,  the  deformity  remaining  as  an  evidence 
of  imijrojjcr  or  no  treatment  of  a  dislocation  or  fracture.  It  may 
be  due  to  a  lack  of  development  of  this  part  of  the  nose.  It  may 
also  be  due  to  loss  of  the  supporting  framework  of  the  no.se  by  diseiLse. 
Syphilitic  destruction  is  the  most  common  cause  of  this  lo.ss  of  ti.<sue. 
A  de|)ression  of  the  cartilaginous  portion  .sometimes  follows  abscess 
of  the  .septum.  The  concave  deformity  may  be  exaggerated  by 
excessive  development  of  the  end  of  the  nose,  or  there  may  be  jippar- 
ent  depression  when  the  nasal  bones  and  triangular  cartilage  are 
normal,  in  which  case  concavity  is  entirely  due  to  abnormal  develop- 
ment of  the  end  of  the  nose.  The  broadened  nose  is  usually  a.^.so- 
ciated  with  the  concave  deformity,  the  na.«al  bones  bulging  outward. 
This  and  the  lateral  deformity  conunonly  result  from  neglected  frac- 
ture. Collapse  of  the  ahe  of  the  no.se  may  be  due  to  failure  in  devel- 
opment. The  ahe  are  sometimes  especially  narrow  in  subjects  who 
have  been  mouth-breathers  from  infancy.  They  may  also  be  held 
down  by  cicatricial  contraction  following  injin'ies  or  specific  ulcera- 
tion. Kx])ansion  or  sjin-ading  of  the  ahe  is  usually  of  congenital 
origin.  A  wide  dilatation  is  sometimes  caused  by  intrana.sal  growths, 
as  myxomata.  I  have  seen  one  ea.^e  where  a  considerable  degree  of 
this  expansion  .seemed  to  be  due  to  mu.*cular  effort.  The  na.sal  foss;e 
were  narrowed  by  thickening  and  deformity  following  abscess  of  the 
sej)tum.     In  the  conscious  or  unconscious  effort  to  secure  more  air 


EXTEHSAL  DEEORMITIEU  OF  THE  SOSE. 


1U5» 


11...  (lilatorrs  nsisi  iK-oino  markedly  .loveloiH^d,  expanding  the  al:^ 
Tl,.'  resultant  inerea.se  in  the  width  of  the  nose  exaggerated  the  de- 
fonnitv  due  to  the  iibseess.  . 

should  not  be  in.pUcd  from  the  acceptance  of  this  eliis«'f>cat  on 
,1,     every  ca.e  of  deformity  falls  clearly  m  one  or  another  of  the 
va  eti.>s  named,  or  that  a  single  operation  mil  correct    ne  ent  re 
iJfor  nity.     Individual  ca.ses  present  all  sorts  of  combmatmns,  and 
I u'h  must  1«  studied  by  it.self .     Sonie  due  to  mjury  simply  n>.,u.re  a 
r  turn  to  former  fM.sition  an.l  contour,  others  rc.iuire  a  reduc-tu.n,  iis 
e    "agg.>rate,l  Roman  nose;  ..thers  still,  as  the  sa.l.lle-baek,  nmst 
he  tilled  in.    Taking  up,  in  order,  the  principal  classes  of  .l.'form.ty, 
convex  vertical  deformity  ha.s  been  treated  by  Roe  with  resu  s  tlmt 
h"iv,>  nothing  to  be  .lesired.     H.>  operates  subcutane.nis  y  but  us  de- 
^^Itlon  of  t^e  teehniMue  is  not  suftieiently  clear ^  «-  f !    -;  'j;;'^:; 
and  carried  out  the  following  iugemoas  metho.l,  we  1  dcM-nbed  in  lus 
^oJt  of  a  ca.se:  "The  patient  was  etheriml  and  placed  in  the  Rose 
o  Uion      A  irnir  of  short  curved  sci.ssors,  with  the  convexity  upper- 
ot   was  introduce.1  into  the   left    na.sal  vestibule.     One  blade  was 
aU^t?  penetrate    the   triangular  cartilage   at    its    anterior   ex- 
tmnitv  immediately  iK-neath  the  integument,  and  a  cut  wa-s  made 
■il.,ng  the  su|.erior  margin  of  both  cartilaginous  and  bony  sep  i,  ter- 
ming at  the  junction  of  the  perpendicular  plae  of  the  ethm.nd 
'        lu  cribriform  plate.     The  superior  margin  of  the  septum  ^^^s 
us    eparated  from  the  integun.ent  and  from  the  "'^>;.;'l  1-";;%'^ 
^,  incision,  the  outline  of  which  wa.s  essentially  paralle    with  the 
L^^^^^  of  the  bridge  of  the  nos,-.    The  extrem.t.es  of  this 

:    fXr  inc    on  were  next  connected  by  a  straight  cut  made  through 
treptun.  with  straight  scissors,  an.l  the  portion  of  the  septum 
lu  1  Hi  betw,.en  the  tw,.  incisions  was  removed  with  f'"cops.     A 
sep    m  wth  a  straight  superior  outline  was  thus  produced.     The 
•xt   tep  consisted  in  depressing  the  bony  bridge  of  the  nose  so  tJiat 
Sould  rest  upon  the  now  straight  septum      A  small  nasal  saw  ^.^ 
„         ee<l  ^vith  the  teeth  uppermost  int..  th.-  l.'ft  nasal  passage   and 
tt        cula  i..n  of  the  nasal  ind  maxillary  bones  sawn  through  from 
ow  m  ward.     A  similar  saw-cut  was  ma.le  tlm.ugh  the  correspom  - 
;  ar  i  -ulation  on  the  right  si.le      The  nasal  bones  were  thus    eft 
arti.-ulating  onlv  with  the  frontal  bone  ami  with  each  .n  ut.     A  few 
,,    .    ritivc'lv  g.'ntle  taps  up.)ii  the  nasal  bones  sufhc.-.l  to  br<>ak  the 
X     i^^^^^  and'  .lepress  them,  still  firmly  u".tc.l  with  each 

tl.er  until  thev  came  into  contact  with  the  upper  margin  of  he 
se  urn  Wit  the  ,lepr.-ssi.,n  of  the  nasal  bones  the  brulge  of  the 
isumed  a  straight  line  from  tip  to  f..rehea.l.  but  a  rulge  at 
:  s=  m."ime  appear^:!  on  either  si.le,  forme. ll>y  the  --'"^-y '-!- 
.,l.„..r  the  line  ..f  the  nasal  articulat..)n.  As  determ.ne.l  l.>  n.  pre- 
V  tlv  in  experiments  .>n  the  cadaver,  two  or  three  li^ht  blows 
wllh  a  p^otectlnl  mallet  upon  this  ri.lge  fracture.l  the  maxillary  bone, 

I  BMloa  Me(llc»l  ami  Surgical  Journal,  February  i,  18S». 


lr.dlM 


KHJO 


XOSK  AM)  TlHiUAT. 


wliirli  is  luTc  vory  tliin,  alim);  a  line  situated  about  1  cm.  outsido 
tiic  lutsai  articulation  and  parallel  t<>  it,  with  the  result  of  depressing 
the  ridjie  and  produeing  a  pct'eetly  smooth  an<l  even  eutaneous  sur- 
face. The  op<'ration  occupied  alwiut  forty  minutes  and  was  attended 
hy  comparatively  .slight  hemorrhage.  An  external  .splint  Wif  applied 
to  hold  the  nasal  hones  and  the  fragments  of  maxillary  hone  in  projxT 
position.  The  recovery  from  the  <)}KTati()n  Wius  uneventful,  being 
without  headache  or  elevation  of  temperature.  There  wa.s  a  slight 
nasal  discharge  for  about  ten  days,  which  then  ccjused.  The  bones 
were  firmly  established  in  their  new  |)osition  in  five  weeks.  Inspec- 
tion four  months  after  the  operation  showed  a  slight  superior  outline 
of  the  nose,  smooth  lateral  walls,  and  a  perfectly  normal  skin.  The 
ti))  of  the  nose  was  not  deciirved.  but  the  ui)per  li|)  covered  the  in- 
cisors better  than  before  the  operation.  Kxaminaiion  of  the  interior 
of  the  nose  showed  a  straight  septum,  while  the  turbinate  •■  presented 
no  discoverable  change  from  their  appearance  previou.s  to  the  o|K"ra- 
tion.  N.-i.sal  respiration  and  olfaction  were  normal.  No  abnormal 
subjective  na.sal  .sym|)toms  were  present. 

"In  recapitulation,  the  essential  features  of  the  preceding  operation 
may  be  said  to  consist  in  the  excision  of  the  redundant  portion  of 
the  se|>tum,  the  separation  of  the  nasal  bones  from  their  maxillary 
articulation,  depression  of  the  bony  ridge  to  approximate  the  newly 
foriTied  superior  .sept.al  margin,  and,  finally,  fractuie  and  depression 
of  the  lateral  maxillary  ridges,  the  whole  operation  being  ])erformed 
intranasally  and  without  woumliiig  the  skin." 

Concave  Vertical  Deformity.  Some  cases  of  concave  vertical  de- 
formity can  be  corrected  to  a  presentable  d(>gree  by  nfracturing 
the  nasal  bones,  the  cartilaginous  and  bony  septum,  and  when  the 
|)arts  are  sulliciently  pliable,  moulding  them  into  |)osition  and  holding 
them  by  retentive  appar.-itus,  as  in  a  case  reporteil  by  Harris.'  De- 
scription of  this  method  will  follow.  This  s;iildle-back  deformity  has 
been  corrected  also  by  (illiiig  in  the  depressed  portion  with  tissue 
taken  from  the  sei)tum,  the  patient  .sometimes  conveniently  carrying 
upon  the  septum  a  large  spur  which  can  be  transplanted  to  the  de- 
pressed dorsum.  Roe  and  (ioodale-  have  reported  such  cases  with 
photographs  showing  excellent  results.  I'mler  ether  the  spur  is  sawed 
from  Ix'low  U|)ward:  but  the  nuicous  membr;ui<'  ujion  the  upper  side 
is  left  intact.  With  a  knife  introduced  into  the  nostril,  the  skii  is 
separated  from  the  nasal  bones  and  cartilages,  thus  forming  a  cavity 
to  icceive  the  sjtur,  which  is  idlled  upward,  still  adherent  to  the 
mucous  membrane.  The  l.-itter  must  be  dissected  u])  along  the  .sep- 
tmn  to  allow  of  the  excm-sion  of  the  spur  to  its  new  jiosition,  but  not 
separated  from  the  septum,  that  the  nutrition  of  the  |iart  may  be 
maintained.  Thi'  trans])lante(l  cartilage  and  bone  may  be  retained 
in  |)lace  by  an  external  s]ilint.     Where  it  can  be  done,  this  would 


1  I.«rvni;ii«ri)jn\  Mnri-h,  IS'f.t.  vol    vl.  p,  Jl't. 

»  Anii«lsi)f  OMlnify,  Ijtr>'iiK'>l<<i;y.  mill  laiiMiiliiKy,  NoviMiiliiT.  IWH). 


i:xrt:H.\.ii.  htcFoHMiriJai  or  niJi  mohe. 


lOtil 


sccin  ii  wiwT  iiri>cc( 
>|iliiit,  iis  lias  Im'cii  ( 


lurr  thiiii  tlic  intnxlucti.m  of  ii  iiicti-l  or  r.-lluloitl 


liiiic  hv  ^Vcir, 


Musiks,'  and  oti.iis.     The  traiis- 


|i|;illtf(l    tissiK 


is  saiil  til  iM'Cdini'  iiuiti 


firiiilv  lix'tl  i'>  ''■-'  IMwiti*"!- 


It  certainly  is  far  l.-s>  likely  to  Ix-ci.nie  disi 


lisplaced  than  a  metal  suiiport, 


1,1  it  would  be  nuu'li  ni«>ie  eoi 


ifortal'lv  tolerated  l»y  the  putienl 


Ihis  marks  a  distinct  advance  over 


the  introduction  of  a  foreign 


liodv. 


liepression  of  the  nose  over 
ntraction  followiiif;  septal  al 


the  triangular  cartilage  and  due  to 
hut   when   no  perforation  has 


occurri'i 


1,  1 


las 


The  dorsum  o 


'been  .rvercoi'ne  l.y  d.-vating  a  sr.  turn  of  th.-  caitilag. 
hus  raised  at  thee\penseof  h  pertoiat.nn 


if   the  nose  is  t 


\  the  septum,     (loodale  d.-scrii.es  the  operation  m  a  re] 


•ted 


case  as 


lows:  "Th    operation  <'oiisi 


ted  essentiailv  in  cutting  out  a  <\v.i\d- 


niiigiilar  piece  of  septal  cartilage  an 
until   thi'  external   depression   wa? 


si'prarcn 


111  extract  an  incision  was  iiiaili 


I  lifting  it  upward  sulicutaM-ouslv 
filled  out.     liider  cocaine  aiui 
hnir"!i  the  triangular  car- 


tilage about  1  cm.  in 


front  of  its  articulation  with  the  perpendicii 


ar 


plate  oi  the  ethmoid  and  paralh 


I  to  it,  e.xtending  from  the  skin  al'ovo 


to  tl 


le  vol 


iier  heh)W.     A  second  incision  l>ar 


illel  to  the  first  was  then 


mai 


le  through  the  cartilage,  about 


1  cm.  behind  the  tip  of  the  nose 


The  inferior  extremities  ( 


f  the  incisions  were  ik 


xt  connected  by  a 


third  running  parallel  to  the  upper  bon 


ler  of  the  vomer.     A  flaj)  of 


cartilage  war^ 


thus  produced  adherent  oiilx 


Iv  above  to  the  mucous  mem- 


l.r 


me 


and    fiiscia   corresponding 


sliding  the  fla|)  U] 


iward  and  forwan 


(lei)r''sse( 


1  area  was  lifted  uji.  ai 


foi-ation  of  the  sei>t;im  w 
The  antericr  am 


ling  to    the   external   depression.     On 
ml  in  its  own  plane  the  skin  of  the 
„1  simultaneously  a  rectangular  per- 
tcd  at  the  lower  border  of  the  Hal 


I  posterior  ends  of  the  flap  were  s 


[ill 


Ul   CO 


ntact  with 


tl)( 


lorme 


sei)tum,  .•ilthough  at   a 


loiiit  higher  u]) 


than  that   which  they 


Iv  touched.     After  be 


iii.r  elevated  to  produce  a  nearly  straight 


superior  outline  of  ♦ 


iie'nose.  tlu'  transi)orti'd  llap  was  h.-l<l  in  posit 


l.\   gold-plaied  pins  ttin 


.t   through  it  and  the  adjacent  septum 


ion 
on 


■M'il    Sllll 


all- 


in  an    iiitero-pi 


stevior  direction. 


ifter  three  weeks  the  par's  wer 


slight, 
iHicieiitlv  firm  to  i>ermit  remova 


The  reaction  was 


,(■  the  pins.     The  bridge  wa 
from  the  iterforatioii." 


:  tirm  and  the  jiatient  had  no  discomfort 


tl 


N  i    Ctid  F  iSe.     I.  ease  of  deformity  due  t,.  neglected  frac- 
.n   fher    is  usuallv  n.    loss  of  substance,  and  the  object  m  view  is 
„  :  ,:  iini  of  the  pans  to  aormal  position,  and  their  -ten  u...  unnl 
„„i,„  ,,as  taken  pla.v.     The  md.cations  are  ^""I> «'  '»    '  f.  .^ 

.M.o.rentlv   formidable  problem  sometime;-  i.resented  by  a  ba.l  <li 
i     ;    V    -T    •     -•  is  relnarkably  tolerant  of  manipulation,  and  umon 
.'efra.  ture  will  take  plac^  as  reu.lih   as  alter  the  ong.na    ^i-)- 
•    n  f  a  tTseptic  prec  u.tions  be  ..bserved  no  s.-vere  reaction  is 


=  U,„l.>u  M..li<al  ami  Surgical  J.mriml,  im.  vol.  cixx.i.  p.  562. 


, 


HBl 


lU»i2 


MtSt:  AM>  TllKoii: 


V 


.1  l«l 


'      ! 


li 


!    ^ 


b<',  ami  -If  nM>al  Ih'Iii-!*  iirc  »<»  hi  'cfracHircil,  and  to  siich  a  dcpnc 
tliat  tlif  iHisf  i;<  iiiatlr  pliaiili'.  it  is  tl:cii  ti)  In-  iiioiililt-d  into  i-nrrccl 
position,  and  iiy  inlraiiasal  splii  ts  or  a  ponil>inatioii  of  intranxsal 
and  external  splints  so  n  tainerl  until  firmly  united  in  its  new  pitsition. 
The  Adams  foreepH  wilii  lon^  lilades  is  a  suital>le  instrument  for 
refracturinji  llie  'septum.  The  same  instrument  witii  mie  Made 
covered  willi  ruliher  tuhinjj  to  pruteet  tlie  -kin  is  u-'  d  to  grasp  the 
nasal  hones  and  refraetwre  them,  or,  if  necr^sai*,  .;  piece  of  steel 
covered  with  ruhher  luhinff  can  Ih-  placed  against  the  n!u*al  l>oiie 
or  nasal  process  of  the  suiM-rior  maxilijiry  l>one  and  struck  a  sharp 
l)lo\v  to  effect  its  fracture.  As  internal  .-upport  Mie  rider  splint, 
already  referred  to,  will  do  good  .service,  elevating  ihe  depres.sed 
dorsum  of  the  nose  to  its  proper  height,  or  the  .-uperior  and  middle 
meatus  may  Im-  packed  with  antiseptic  jrnize  mid  an  Asch  s|>lint 
slipi)ed  in  underneath  to  allow  of  nasal  respiration.  If  this  chiss  of 
deformity  is  acounpanied  hy  depression  over  the  triangular  cartilage 
it  will  he  necessary  to  make  incisions  through  the  cartilage,  as  (h-scrilied 
it)  (loodale's  <  ise,  in  order  to  secure  ixrmanent  elevation  of  this 
section  of  the  dorsum  of  the  nose.  If  this  is  not  done  the  .se<'tioii 
over  the  cartilage  will  return  to  its  former  level  on  removal  of  the 
internal  s|ilints. 

For  the  deformity  of  collapsed  or  widely-dilated  ahe  the  cartilages 
are  to  he  incised  .suhcutaneously  with  a  narrow  knife  sufficiently  to 
render  them  pliahh".  In  the  after-treatment  of  collapse  of  ahe  a  tube 
is  to  he  worn  to  give  pro|M'r  shape  to  the  nostrils.  This  mav  well 
be  of  vulc.'inite.  After  widely-dil.ated  rhe  are  rendered  pliable  an 
external  furm,  as  a  plaster-of-1'aris  cast,  is  to  be  worn,  supplemented, 
if  need  i)e,  by  an  intranasal  vulcanite  tube,  as  recommended  by  Roe 
in  such  procedures. 

Artiflcial  Support.  When  the  supporting  framework  of  the  nose 
ha-  l>frn  distroyd,  as  in  ca.ses  of  syphilis,  and  the  sinking  in  and 
cdiili.ii  liin  of  the  .-oil  parts  have  "riven  an  u>r!v  deformity,  attempt 
has  been  ma<le  to  sni)ply  the  defect  |,y  introduciiit;  a  metallic  frame- 
work for  supjiort  If  the  loss  of  substance  has  not  been  great  and 
the  reviilii'i<r  deformity  correspondingly  !e<s.  a  simple  plate  of  metal 
slightly  moulded  ,.r  a  suitably  formed  piece  ol  celluloiil  has  been 
made  to  sustain  the  skin  along  the  dorsum  of  tlie  no.se,  thus  main- 
taining its  contour.  This  metalli<-  or  celluloid  form  is  best  intro- 
duced snliciiianeiiiisiy  or  from  within  the  no.se,  ;dthough  instances  are 
i:tt  wauling  in  whicli  exti'rnal  Icnigitudinal  incision  has  been  made,' 
the  skin  dissected  up  on  either  side,  the  plate  pl.iced  in  the  cavity, 
and  the  wound  in  the  skin  dosed  .above  it.  (I.iod  results  are  claime(l 
for  the  Last  method,  ailhough  my  own  observation  would  lead  me  to 
believe  th:.t  these  f.avorable  reports  must  have  Iwen  made  soon  after 
operation.  If  such  support  is  to  lie  used  it  is  (piite  unnice.-:^ary  t;) 
add  an  um-ightly  -ear  to  ,i  p.re.sent  d'^formity.     The  su|)poriing  nm- 

'  I'rlrc  Brcmn,    Iiisiiists  of  the  Nose  ninl  Thmal,  liKK),  p.  4,'iO. 


h:XTKR\M.  DKhtHtMITIKS  OF  THK  SOSK. 


lutia 


,..rinl  shoul.1  iH.  plucMl  s,.»H-„tnneou.ly  ..r  by  .n.-ans  of  inn.ioi,.s  wifhin 
\.n..nK  ..|..>rat..rs  who  l.uv.-  us.-.l  iIu.h  in.-tl....l  n-lluloK 
.vcr  any  "Hkt  muKTial  l.(Tau>*i'  it  is  well  t<.l«'rut»>«l 
first    to  ciiiploy  pflluloid   f'>r  this 


thi'     IK'SC 

lia>  |in'fiT('iicf  < 
li\   tilt    lissiu 
|iuriHis( 
I-  t'asi 


•s.     H     1'.  Weir  was 
I'lalimiiii  lias  l><i'i>    "f" 


(I    in    a    null 


ili«T  of  Misi's;  liiit  it 


Iv  .hsphuTil.  ami  must    th.'i.   !.<•   removal:  or  it  cuts  its  way 


through  tlic  cu.l  of  th.'  nose-  l)y  mere  force  . 
,i!,.  of  tlic  fact  lliat  miincrous  |KTforatioii 


if  ;;ravity.  and  this  in 

luivc  Im'cii  ina<U'  in  th«' 

the  union  of  tissue  throufjli  lli(>so 


>l:i 


It  is  a  fact,  however,  tlmt 


FlU.  KKl. 


|)hiti',  witli  tlie  1  xpectation  tluit 

..oeninKs  would  litlp  to  retain  it  in  |  -  ,    ,    ,    , 

..len  svhen  this  supporting  substance  has  t  u.s  ehuled  the  ..p«Ta  or, 
,|„.  „„se  has  be.-n  left  in  b.>tt.T  form  than  iMfore  operation.  Kniglit 
Weir  and  Monies  sp.-ak  of  this.  The  l.resence  of  the  foreign  body 
provokes  inflaniniat..rv  infiltration,  aiul  this  uicrea.«e  of  t.ss.ie  renmirw 
u  hell,  till  ill  the  f-nni-r  depression.  Where  the  amount  of  depression 
is  n..t  ereat  (u.odwillie  has  succei'ded  in  securing  a  ronsiderabie  ele- 
vation bv  drawing  heavy  animal  ligature  under  the  skiii  and  allowing 
i,  ,o  remain.  Doiu-  a.septically.  littl.-  reaction  ..Hows.  This  he  de- 
<,.rilM'.l  in  a  paper  which  i  think  has  not  yet  been  published,  read 
recentlv  before  the  New  York  Academy  of  Medicine. 

The  use  of  a  metallic  framework  to  sup|...rt  the  nose  after  <'Xtensive 
l„ss  of  bone  and  cartilage  was  first  sug^'esfd  by  M.  Letievant  Tlie 
.^,;,i,i,iai  l.ridg.'  wa.s  ma<le  ..f  aluminum  and  his  case  report e.l  in 

S7S  On  his  a.lvice  M.  Claude  Martin,  who  had  don.-  much  in  the 
w,v  of  ...rrecting  .l.'foriniti.'s  about  the  fac,  made  a  bridge  of  p  at- 
i.niin  This  on.'  in  f..rin  and  material  pr.imis.'d  hriner  support  than 
the  ."arlier  effort.  Dr.  H.  F.  Weir  introduced 
til.'  meth.xl  into  this  country  in  IS'.Ci,  an.l  in 

bmuarv,   ISOti.  ha.l    oporat.'d   up<m    10  ca.ses. 

l)r    Knight,  Nich(.ls,  and  others  have  rep<.rted 

(■•ises  correete.1  bv  this  form  of  su))i.ort  or  some 

n,odilicati<.n  <.f  it.    I  have  ha.l  a  limit.'d  experi- 
ence with  this  cla.ss  of  cases.     Th.'  first  patient, 

a  woman,  thirtv  vears  <.f  age,  came  un.ler  my 

,"ire  early  in  1S<»i.     The  .l.'f..rniity  of  her  nose 

was  ilue't..  exteii.sive  destruction  of  the  cartil- 

•i.Miious  and  b..nv  septum.    There  was  n..t  only 

sad.ll.'-back  .l.'f..rmitv,  but  th.'  ti).  ..f  the  nose 

was  .'levated  an.l  the  ala>  much  r.-tract.'d.    She 

wis  eag.'r  f.tr  anv  operati.m  which  pr.)mised 

to  imi.rove  h.T  .•ipi.earaiice.    The  Martin  bndg.' 

is  .'M.eiisive  and  its  arms  too  narrow  to  sustam  . 

,,,,,. ,;.„..l  ;,1:.-      I  th.'i-efore  .levis.'d    the  bridge  shown  in  !■  .i:.   .)•«»• 

It  i<  cut  from  a  single  .sh.'.'t  ..f  platinum.  on.'-Hftieth  ..f  an  in.'  i  thick, 

and  111.',.  m..ul.le.l  t,.  fit  th.'  iiulivi.lual  cas...     The  gr.'at.'r  breadth 

.  Tmi.wrtionsnf  ihi-  Amerlran  l..,ryi,Kol.H:lcal  Al-wctatlon,  1R96,  p.  150. 
t  La  Pnilhi^se  tmme<li»te,  Part*,  Iw/J,  p.  -'«' 


riatinui;!  XtMff' 


MICROCOPY    RESOIUTION   TEST   CHART 

lANSI  and  ISO  TEST  CHART  No    2i 


1.0 


I.I 


JflllM  ilM 

I--  1^     112.2 
^    li£     12.0 


1.8 


1.6 


_S     APPLIED  IfVl^GE     Inc 


:'-•:    t..:tst    M-i-    Mr«t 
■'6)    *82  -  0300   -  Phone 


1U64 


yoSK  AM)  r  II  HO  AT. 


of  the  l)0(ly  allows  of  it  hciiif;  iiiouhlctl  over  the  nasal  iMtiics,  which 
prevents  lateral  displaceinent.     The  shape  lessens  the  pn>l)ui)ility  of 


)f  the  thin  skin  (   'er  the  ilorsiini  of  the 


•  Ithel) 


erosion  ol  the  tinn  sKni  (  'er  tiie  dorsum  oi  ine  nose,  and  ine  t)roa(ler 
arms  support  the  ahe  with  less  danjier  of  destructive  erosion.  Per- 
forations reduce  weiijht  somewhat  and  permit  the  union  of  tissue 
throufih  the  openin<rs.  Thi'  arms  are  li'ft  lonj;er  than  will  he  reiiuired, 
and  at  the  time  of  the  operation  are  to  he  cut  of  suitalile  leiiftth. 
The  ends  of  the  arms  are  pointed  and  placed  in  holes  drilh-d  in  the 
superior  maxilla,  'i'lie  hridj;e  is  thus  tirmly  fixed  in  position.  It 
should  l)e  said  that  the  supjiortiiiR  arms  oujiht  to  stand  more  nearly 
at  rijiht  angles  to  the  hody  than  is  indicated  iii  tlie  cut,  that  the  lower 
edfres  at  tlie  ends  mav  not  come  so  near  the  ji'"Jli^'"-l"'*'!'l  f"l'l-  I" 
the  case  referred  to,  HoUfri''s  operation  was  jn'rhirmed  and  the  bridge 
placed  in  posilioii.  In  this  operation  the  soft  parts,  inchKling  the 
external  nose,  are  detached  hy  an  incision  along  the  gingivo-h.hial  fold 
and  a  dissection  upward  close  to  the  hone,  exposing  the  nares  and 
separating  the  skin  from  the  nas:il  hones.  Tlie  bridge  is  then  ailjusted 
and  the  parts  replaced.  The  proper  moulding  ;ind  adjustment  of 
the  metal  support  and  the  division  of  cicatrici.-il  tissue  gives  a  com- 
plete restor.ation  of  external  form.  The  deformity  and  vnrbi  results 
are  well  shown  in  I'igs.  540  and  541.     If  a   metal   s'lpport    is   to  lie 


Flu.  WO. 


Flo.  i>U. 


Kici.  .'vlii.— ('iii)cnve  viTllcHi  'efonnit.v.  ('iillii|>8e,  iiii'l  I'.iiiimciioii  i>f  Hlftr  ciirtllage!i,  irom  speclttc 
di.«)fHi*e. 
Khi.  .'(11. — CorrtH'tt'd  hy  iisiMtf  iinMiiii(.Ml  Murlin  hri'lKe. 


employed  Dr.  Knight's  dictum  should  he  carefully  ohserved :  "(1)  In 
syphihtic  cases  the  patient  must  have  had  a  thorough  course  of 
treatment,  ;ind  a  sullicient  period  must  have  elapsed  since  the 
disappearance  of  active  symptoi'is— not  less  than  three  years;  (2)  the 


rLEFT  PALATE. 


im'o 


,li<>ii'rti(.ii  of  the  sof'  juirts  must  be  so  cxtcnsivo  as  to  ohviiitc  tlio 
p„-sil)ilitv  of  tension  at  anv  point,  and  csiu'cially  over  tlic  l)n(lf;c  of 
tlic  nose"  wh.Tc  til.'  upper  end  of  tiie  l)iate  is  to  r(>st.  Tlie  metal 
hri.lp-  must  be  so  moulded  and  smoothed  down  at  Us  odj;es  as  to 
preclude  the  ilanjjer  of  frietiou  an.l  pressure  upon  the  solt  i)arts, 
iiid  the  ends  of  the  sup|)ortinf;  arms  must  be  deeply  buried  m  the 
maxilla,  as  otherwise  thev  are  liable  to  be  drapRed  out  of  i)osUion." 

\  word  as  to  this  method  of  treatment  may  well  be  m  order.  Ihe 
ultimate  results  of  the  u.se  of  the  .Martin  bridge  are  often  disapiiomt- 
iii<'  notwithstanding  the  gratification  at  first  (>xi)erienc<'d  bv  l)oth 
pUient  and  surgeon.  The  operation  neces.sary  for  placmg  th(>  bridge 
is  easily  performed,  and  recovery  is  ])romi)t.  The  objections  are 
those  arising  from  jilacing  an  unyielding  foreign  body  withm  living 
li-;sues  subjected  to  some  degree  of  motion.  In  si)ite  of  all  precau- 
tions some  i)art  of  the  form,  either  one  of  the  supporting  arms  or 
tlie  body  ov.M-  the  nasal  bones,  will  sooiu-r  or  later  cause  erosion  cjf 
tiie  overlving  skin.  The  .structure  itself  has  become  bodily  disi)laced. 
Th(>  interior  niav  iill  witli  granulation  tissue,  so  that  nasal  respiration 
is  cut  off  (Cicatricial  tissue  mav  cause  une.iual  contraction,  so  that 
the  soft  parts  are  imlled  to  one  side,  sliding  over  the  Iramework. 
Indeed  the  final  outcom(>  of  the  bridged  nose  is  such  as  to  dampen 
the  (>ntlnisiasm  which  arisc-s  over  the  immediate  results  of  the  opera- 
t  i„ii  The  wearing  of  an  artificial  nos.>  of  celluloid  is  to  be  commomled, 
lather  than  the  metal  support  with  all  its  uncertainties. 

CLEFT  PALATE. 

Cleft  palate  as  here  considered  is  due  to  a  failure  of  develop- 
ment in  earlv  f(etal  hfe.  The  perforations  ..f  the  hard  or  sott 
p;,h,te  which  occur  as  a  result  of  si)ecitic  dis(>ase  may  sometimes 
be  ivpaiivd  bv  plastic  oi)erations:  but  this  i)liase  of  tlie  subject  is 
not  to  be  touched  ui)on.  Various  theories  are  a<lvance(  to  account 
f,„-  nature's  failure  to  complete  th'>  work  which  she  liad  begun.  1  he 
interposivion  of  the  tongue  of  the  embryo  between  the  two  approacn- 
in-'  halves  ..f  the  j.alate  is  one  of  the  offered  explanations.  Dr. 
Hn.ntlr  in  his  inten'sting  pai.er  r<>fers  to  the  results  of  observations 
on  lions  in  the  zoological  gard<-ns  of  London.  They  were  te.l  f.u;  a 
time  upon  flesh  containing  bones  too  laig<-  for  mastication.  Die 
voung  born  while  this  m.-tho<l  of  feeding  was  inirsued  had  clett  pal- 
ates The  lions  wee  then  fed  uix.n  smaller  animals  whose  bones  they 
,.,,uid  break  easilv.  and  the  young  born  afterward  had  jierfectly 
f,„.„„.,l  palates.  This  observation  has  been  rei.eate<l  at  the  '  zoo 
in  I)ui)hn  and  in  Philadelphia.  Some  authorities  claim  that  the 
want  of  a  meat  diet  and  a  .leficiency  of  the  phosphates  of  lime  in 


1  N'cw  York  Mi.-.!!.'*'  '••nrr.al   lOiil,  -ri!.  !%xlv.  p.  241. 
•  Ab8.  LaryiiguKope,  1899,  vol.  »l.  p.  308. 


I 

If; 


I'' 


10G6 


A'OSE  AXD  TlinOAT. 


tho  fiMxl  of  the  mothor  act  a.s  a  causo.  The  published  statistics  show 
tliat  tilt'  English  surgcdiis  have  pcrformccl  many  more  operations 
for  cleft  palate  than  have  Americans.  May  the  factor  of  a  more 
generous  diet  among  the  poorer  jM-ople  here  partly  aeco  for  this? 
Heredity  has  been  assigned  as  a  cause  by  some  authors  'Ihe  cause, 
whatever  it  be,  is  a  matter  of  small  moinent  to  the  jiraciical  surgeon! 
"It  is  a  condition,  noi  a  theory,"  which  confronts  him.  The  cleft 
between  the  two  halves  of  the  palate  varies  from  the  slightest  degree 
iis  the  bifid  uvula,  to  a  complete  cleft  of  the  soft  palate,  and  even  of 
the  hard  palate  forward  to  and  through  the  alveolar  process.  This 
cleft  is  in  the  median  line  until  the  incisive  or  intermaxillary  bone 
is  reached.  This  small  porti'  n  containing  the  incisor  teeth  is,  in 
young  bones,  marked  off  from  the  maxilla  on  each  sid(>  by  distinct 
suture  lines.  If  the  deformity  under  consideration  extends  through 
the  alveolar  i)roc(-.ss  the  cl<"ft  deviates  from  the  meihan  line  on  reaching 
th(>  maxillary  bone;  and  if  the  cleft  be  double,  jis  it  sometimes  is 
anteriorly,  this  bone  is  entirely  .separated  from  the  maxilla  ami  hangs 
froin  the  end  of  the  septum.  The  o|)eration  for  closure  of  cleft  palate 
has  been  (lone  for  ■'  century,  and,  as  might  be  expected  in  a  liroblein 
of  such  difhcult\  las  engaged  the  attention  of  the  ablest  surgeons 
1  lie  accumulated  rxperience  during  this  long  period  of  numbers  of 
workers  has  resulted  in  an  improvement  in  techni(iue  which  gives 
the  operator  of  to-day  a  great  advantage,  and  yet  unsucc(-sful  efforts 
are  not  infretjuent,  so  trying  are  the  conditions  presented  by  this 
deformity.  ^ 

Thechanges  contributing  most  notably  to  a  successful  issue  were 
hrst,  1-ergus.son  s  division  of  the  palatal  muscles  to  reduce  the  tension 
upon  the  sutures,  and,  second,  the  introduction  of  general  anaesthesia 
One  IS  possessed  with  profound  admiration  for  the  skill  and  patience 
of  tli(>  surgeon  of  early  days  who,  without  ana-sthesia,  either  local  or 
genera  ,  and  without  the  aid  of  sterilization  or  antiseptics,  yet  under- 
took this  difhcult  op.>rati..n  and  carried  it  through  to  a  successful 

li!! ;.    ri\v""      '"';;„ ''-^''f  T'^^'"'  *•"••''  i'"P>-<.vement  in  point  of 
time,  and  Warrens  h  ling  of  the  fissure  in  the  hard  ,,alat-  by  means 
of  The  niucoperiost..a    flap  the  fourth  of  the  major  improvements 
In  spite  of  every  aid  gained  from  the  accumulated  experience  the 
operation  is  often  a  partial  or  total  failure,  either  from  undue  t(>nsion 
direct  upon  the  sutures,  or  in.m  functional  activity;  or  failure  is 
orihe   mtil.nt     '"''''''""  "'  '""''  °^  '■«'="P<''-'»tive  powers  on  the  part 
The  history  of  staphylorrhaphy  is  interesting  for  several  reasons 
and  111  none  more  than  in  the  change  which  has  taken  place  in  the 
oi.inion  legarding  the  ,,roper  ag.-  at  which  the  operation  shoul.l  be 
performed,     rii..  older  wnters.  lacking  the  advantage  of  ana'.sd.esia 
and    ooking  rather  to  goo,    surgical   results  than  j.erfect   function,' 
adMM.,!  a  late  operation      It  was  necessary  at  that  period  to  rel^ 
u.  .OUT  instances  u|.u„  |h,.  assistance  which  tl...  patient  could  volun- 
tarily render,  even  if  it  were  not  other  than  the  j.assive  aid  of  not 


CLEFT  PALATE. 


1067 


(iffcring  rosistance.  Ono  oarly  autlior'  states:  "As  the  success  of  the 
opiTation  (U'IK'ikLs  in  a  great  measure  upon  the  patient  remaining 
pcrfeetlv  trantjuil  and  steady  during  the  necessary  procedures,  winch 
are  of  a  tedious  and  protract«'(l  character,  upon  his  jissistmg  the 
surgeon  by  opening  his  moutli  and  not  struggling  on  the  introd'-.ction 
(if  tlie  instruments^  and  after  the  ojjeration  upon  his  making  as  little 
movement  as  possible  in  speech  or  deglutition  for  some  days,  it  is 
usually  considered  expedient  not  to  interfere  with  this  malformation 
until  "the  patient  has  attained  the  age  to  understand  the  necessity 
of  remaining  quiet  and  to  be  able  to  control  his  movements." 

The  operation  is  a  difficult  one,  and  when  one  thinks  of  the  jmblem 
presented  of  freshening  the  edges  of  the  cleft  and  inserting  sutures 
ill  the  small  mouth  of  a  struggling  child,  at  an  age  in  which  *.he  tissues 
are  easily  lacerateil,  he  is  ready  to  approve  for  the  earlier  surgeons 
of  the  plan  of  operating  when  it  can  be  done  at  the  patient's  reipiest 
and  with  his  assistr.nce.    Tlie  use  of  amesthesia  has  changed  this, 
and  the  reasons  for  operating  early  are  unquestionable,  first,  because 
of  the  more  perfect  establishment  of  the  function  of  the  palate.     At 
an  early  age  this  assures  the  nutrition  of  the  child.     In  coinplete 
cleft  of  hard  and  soft  palate  swallowing  is  a  matter  of  such  difficulty 
tliat  the  child  requires  the  almost  constant  attention  of  a  nurse. 
Consideration  of  the  parent,  too,  should  have    some  weight.    To 
many  a  woman  the  deformity  of  the  child  can  but  arouse  a  feeling 
of  horror.     Next  to  the  functional  aid  in  nutrition  is  that  of  phona- 
tion.     All  authorities  are  agreed  tliat  in  voice  production  the  early 
oi)eration  offers  vastly  better  prospects  of  good  results.     Makuen 
says  both  the  ttmgue  and  the  palate  are  important  in  the  function  of 
speech,  but  the  palate  is  the  more  so.     The  i)urely  vocal  elements 
of  speech,  such  as  the  vowel  sounds,  may  be  articulated  when  the 
palate  is  defective,  but  their  resonance  is  so  impaired  that  they  are 
seari  "Iv  recognizable.     Of  the  consonant  sounds,  only  two,  m  and  n, 
can  be' articulated  intelligii)ly  when  the  palate  is  not  intact,  because 
in  the  jiionunciation  of  the  other  consonants  the  palate  is  necess;iry 
to  prevent  the  pa.ssage  of  air  upward.      Perforation  of  the  palate 
affects  speech  to  a  greater  or  less  degree,  depending  upon  its  position. 
Surgi<'al  measures  for  the  relief  of  cleft  palate  should  be  undei  taken 
as  rarly  as  possible  in  the  formative  speech  period,  and  these  should 
he  suiiplemented  by  instruction  and  practice  in  the  normal  produc- 
tion of  sp(>ech.  •       •    iu 
Hy  no  m(>ans  least  among  the  reasons  for  early  operation  is  the 
influence  upon  regional  development.     Formerly  it  was  considered 
debatable  whether  the  fissure  in  the  hard  and  soft  palate,  when  both 
existed,  should  be  closed  at  the  same  oi)eration,  and  it  has  been 
•is^erti-d  that  if  the  cleft  in  the  .soft  palate  were  closed  early  in  infancy 
the  fissure  in   the   hard  palate  would  gradually  become  narrower 


'  Krii'liwn.    Scli'ii.i'  iMul  An  ot  Surirerv,  \h-.:\  val.  il.  p.  4.'i9. 
t  New  Yiirk  Miilual  lUriiril,  VM,  vol.  U.  I'.  '*■ 


1068 


NOSE  AND  THROAT. 


until,  in  sonic  instnnccs,  this  would  not  require  operation.  If  this 
were  true,  even  to  ii  slifjht  degree,  how  niueh  more  nearly  normal 
would  development  be  when  the  entire  eleft  were  elosed  at  an  early 
period.  Development  within  the  nose  and  uasoj)harvnx  would  also 
be  more  nearly  normal.  In  cleft  i)a!ate  of  the  adiilt  the  inferior 
turbinated  bones  are  sometimes  so  greatly  hyix'rtrophied  a.s  to  extend 
into  the  eleft,  and  removal  is  necessary "bef or (>  operation  for  closure 
of  the  cleft  can  be  undertaken.  Adenoids  are  also  (juite  likely  to 
develop,  and  the  mucous  membrane  of  the  nose  and  nasop'iarynx 
to  be  in  a  highly  inflamed  condition.  The  Eustachian  tm  "and 
middle  ear  become  involved,  with  the  con.sequent  unhappy  train  of 
disturbances  ()f  the  functions  of  the  ear.  All  these  reasons  call  for 
early  operation.  R.  W.  .Murray'  say.s  from  his  experience  in  UK) 
operations  for  harelip  and  cleft  i)alate,  he  is  convinced  that  the 
oi)eration  for  harelij)  should  be  performed  about  the  fourth  week, 
and  that  for  cleft  palate  about  the  twelfth  month,  that  is,  before 
the  child  has  begun  to  talk. 

C;oodwillie=  has  operated  as  early  as  the  twelfth  hour  after  birth. 
Abb((  says  the  earlier  one  operates  the  l)etter,  and  he  has  secured 
good  results  in  one  case  two  days  after  birth.  The  soft  parts  once 
in  prooer  relation  tend  to  mould  the  hard  parts,  and,  as  in  case  of 
harelip,  the  ojieration  ought  to  be  done  early.  B.  F.  Curtis  also 
advises  operation  in  infancy.  Dr.  Brocr'"  does  not  hesitate  to  operate 
upon  a  child  from  three  to  six  months  old,  pro.ided  it  can  have 
projier  care. 

Since  the  operation  is  not  one  of  immediate  urgency,  sufficient 
time  may  be  taken  to  secure  the  best  possible  degree  of  g(>neral  health, 
and  this  is  especially  important  if  the  jialient  is  a  voung  child.  At 
a  later  ])erio(l  a  number  of  local  points  will  re(iuire  attention  in  an 
effort  to  reduce  to  a  minimum  the  obstacles  to  success.  (Y.rious 
teeth  should  be  tilled  or  ilrawn,  and  an  antiseptic  niouth-wa.«h  ii.^ed 
carefully  for  a  period  before  ojjeration.  .\deiioids  should  be  removed, 
as  also  .sjiould  the  f:uicial  tonsils,  and  at  a  date  earlv  enough  to  allow 
of  iierfeel  healing,  before  the  oj)eration  upon  the  palate  is  undertaken. 
The  reai-ons  for  this  are  too  obvious  to  re(|uire  stating.  In  some 
cases  the  inferior  turbinated  bones  are  hvj)ertrophied  to  such  a  degree 
that  they  projee,  into  the  cK-ft.  Theie  should  be  removed  under 
the  rule's  just  iiame<l.  I-lvery  "ffort  should  thus  be  made  to  bring 
the  patient  up  to  a  good  state  of  health,  and  locally  to  reduce  so 
far  as  possible  the  dangers  of  infection,  and  to  remove  sources  of 
pressure,  of  irritation,  and  of  interferenc(>  with  respiration.  Ih- 
teclini(|ue  of  th(>  operation  for  closing  the  cleft  is  (niite  well  agreed 
upon,  and  this  will  be  given  before  mentioning  anv  modification. 
If  the  case  be  one  involving  the  hard  pal.-ite.  or  if  the  patient  is  a 
child,  or  not  eju«ily  managed,  general  amesthesia  should  be  employed. 


>  British  Meiiirfil  .I<;firrial.  ()<Mn'H'r  ].'».  I<ns, 

«  New  York  Medii«l  Kecoril,  IsiKi,  viil.  xlm.  p.  im. 


'  Ibiil.,  vol.  1.  I..  68. 


CLEFT  PALATE. 


1069 


riic  Rose  position— the  head  hanging  over  the  end  of  the  table— is 
the  i)rcferiil)l<'  position.     This  is  (•ornniondi'il  for  the  reason  that  tlie 
l.lood  and  mucus  arc  tiius  h'ss  Hkely  to  enter  the  hirynx.     The  usual 
sterilization  of  hands,  instruments,  and  field  of  operation  is  of  course 
to  be  observed.     The  Smith  mouth-gag  is  introduced,  which  is  self- 
ictaining,  opens  the  patient's  mouth  to  the  widest  extent,  and  at 
tlie  same  time  de|)resses  the  tongue.     The  mouth,  teeth,  buccal 
cavity,  the  nose,   nasopharynx,  and  pharynx  are  to  be  carefully 
sterilized.     The  edges  of  the  cleft  are  to  be  freshened  from  the  tip 
(,!'  the  rudimentary  uvula  to  the  apex  of  the  cleft,  from  behind  forward. 
The  tij)  of  the  rudimentary  uvula  is  seized  with  a  long  pair  of  volsella 
f(ircei)s,  and  the  edge  freshened  with  a  knife  or  sci.«sors  curved  on 
the  flat.     Recent  writers  prefer  the  latter,  stating  that  a  broader  sur- 
face Is  secured,  since  the  cut  may  be  a  bevelled  one.     Care  should  be 
taken  to  preserve  a.s  much  as  possible  of  the  rudimentary  uvula, 
since  it  will  contribute  to  the  more  perfect  function  of  the  palate, 
lileeiling  may  be  controlled  by  pressure  or  by  gauzt  s[)onges  wrung 
from  a  hot  normal  salt  solution.     It  is  fiu'te  possible  that  the  use 
of  adrenalin  wcmld  control  hemorrhage  to  some  degree,  and  nught 
well  be  tried.     If  the  cleft  is  in  the  soft  palate  alone  the  sutures  are 
now  to  be  placed.     If  the  hard  palate  be  involved  the  next  step  will 
he  the  elevation  of  nuicoi)eriosteal  flajis.     Incision  upon  each  side  is 
made  jjarallel  with  and  near  the  alveolar  border,  and  of  a  length 
(Mjual  to  that  of  the  cleft  in  the  hard  i)alate.    This  incision  extends 
through  to  the  bone.     With  periosteal  elevator  this  nuicoperiosteal 
flap  is  raised,  care  being  taken  not  to  wound  the  palatine  arteries 
in  the  i)rocess  of  separation  from  the  underlying  bone.     As  thus 
sei)arated,  this  flap  is  attached  only  anteriorly  and  posterioriy  and 
slides  jxTfectly  freely  over  the  bone  from  which  it  was  detached. 
The  free  blee<ling  is  to  be  controlled  by  [)ressure  or  the  use  of  sponges 
wrung  from  a  hot  solution.     Many  (l(>vices  have  been  proposed  for 
introducing  the  sutures,  which  is  the  most  difficult  part  of  the  o])era- 
tion.     The  needle  in  a  Img  handle,  with  a  half-round  ciu've  at  right 
angles  to  the  shaft  of  the  instnnnent     jives  good  satisfaction.     Some 
<il)erators  use  an  ordinary  small  ha'f-.ound  curved  needle. 

It  is  interesting  to  observe  how  similar  conditions  lead  different 
workers  entirely  in(lei)endent  of  each  other  to  adopt  like  methods. 
\  f,-i,,,„l— a  general  surgeon  of  wide  experience— mentioned  to  me 
ill  discussion  f)f  this  subject  that  he  found  it  convenient  to  pass  the 
sutures  with  a  small  half-rovu)d  curved  needle,  inserting  it  from 
behind  forward.  For  example,  the  suture  would  be  inserted  from 
behind  forward  ui)on  the  left  side,  and  the  nei-dle  drawn  through. 
The  end  of  the  suture  wuild  now  be  threaded  into  another  needle 
and  passed  from  behind  forward  upon  the  right  side.  Aided  by 
forcei)S  and  a  small  nee<lle  holder,  this  was  said  to  be  quite  easily 
done.  This  seemed  an  ingenious  manceuvre,  and  was  original  with 
this  surgeon,  yet  I  found  the  ^ame  ?uggrstioii  in  a  ropy  of  an  old 
work  on  surgery  which  was  consulted  for  hist<jrical  points.     The 


1070 


yoSE  AXD  THROAT. 


nutliod  which  pprmits  of  passiiij;  the  sutures  from  before  !)aek\var(l 
has  ill  its  favor  the  possiljility  of  placing  them  with  better  symmetry 
and  exactness,  since  the  point  of  tiie  needle  enters  the  mucous  mem- 
brane" of  tiie  roof  of  the  mouth  wliere  it  can  be  phiiniy  seen.  This 
phin  may  tx*  carried  out  iis  follows:  a  suture  is  passed  through  one 
side  from  l)efore  backward.  A  needle  with  an  eye  near  the  point, 
the  one  in  the  handle,  already  spoken  of,  is  passed  through  the  oppo- 
site side.  The  loop  which  it  carries  is  held  by  forceps  while  the 
needle  is  withdrawn,  and  the  suture  first  placed  is  pa.ssed  through 
the  loop  which,  on  being  withdrawn,  carries  the  suture  with  it.  Be- 
ginning in  front,  the  sutures  are  placed  about  one-third  of  an  inch 
apart.  The  Miture  material  may  be  of  silk,  silkworm-gut,  or  sil-er 
wire.  Silk  cannot  be  allowed  to  remain  as  long  its  the  othei,y  if 
union  lia-s  not  taken  ()lace  within  six  or  seven  days,  it  is  not 
to  occur.  To  relieve  the  tension  on  the  sutures  incision  is  nov  ,ie 
through  the  soft  palate,  as  first  recommended  by  Fergusson,  miernal 
to  the  haimiiar  process  upon  either  side.  Thii-'  tlivides  wholly  or 
in  |)art  the  fibres  of  the  levator  palati,  ten.sor  palati,  and  palat(v 
pharyngeus.  Tension  may  still  further  be  relieved  by  snijjping  the 
anterior  and  posterior  pillars  with  scis.sors.  After  operation  effort 
is  made  to  keep  the  i)arts  cleansed  with  an  antiseptic  mouth-wash 
or  spray,  boric  acid  serving  well.  Semisolid  food,  as  beef  jelly, 
custards,  etc.,  are  advisable  rather  than  fluids,  since  these  are  more 
easily  swallowed.  So  far  as  possible,  the  patient  should  avoid  func- 
tional u.se  of  the  palate,  since  any  movement  is  prejudicial  to  union. 
Accidents  will  occ  ur  in  sjjite  of  all  j)recautions.  Violent  sneezing  has 
been  known  to  sej)arate  jiarts  which  up  to  that  event  promised  well 
in  the  way  of  firm  union.  Staphylococcic  infection  niav  occur,  with 
a  consequent  failure  of  union  in  at  least  a  part  of  the  wound.  Should 
this  happen,  <)weii'  advises  that  a  "condnry  operation  should  be  jier- 
foriiied  within  a  short  time,  and  nuntions  a  case  in  which,  after  two 
weeks,  the  granulating  edges  were  freshened  an<l  brought  together 
by  sutures  ph'.ced  wide  of  the  cleft.  As  good  results  were  secured 
as  could  have  followed  e(»m|)lete  ])rimary  union.  Owen  urges  this 
prompt  effort  to  overcoiii(>  the  effects  of  se"ptic  infection,  on  the  theory 
that  the  patient  has  accpiired  an  immunity  by  his  attack,  conse- 
quently there  is  the  better  pro.spoct  of  securing  imnuMhate  union. 
The  suturi's  should  be  allowed  to  remain  eight  or  ten  davs,  anil  then 
not  removed  all  at  one  time,  but  here  and  there,  as  seems  best. 

McF\ernon=  has  projiosed  as  a  ])reliminary  to  the  ,)peration  of 
cl()siii,<r  cleft  palate  that  tracheotomy  be  performed,  the  aiuesthetic 
being  administered  through  the  tube;  and  after  the  operation  that 
the  wound  be  packed,  as  in  any  other  operation,  the  patient  being 
nourished  by  the  rectum.  The  f^ollowing  is  a  descrijjtion  of  the  opera- 
tion as  i)erformed  by  hiin  in  so  far  as  it  varies  from  the  usual  techniiiue: 


I  Junrniil  I.nrvii,.  Htiin.,  mid  Otnl.,  isflf,  p,  462. 
s  Nuw  York  Miiiiriil  Juiiriml,  June  10.  1900. 


CLEFT  PALATE. 


1071 


A  liirg«'.  flat,  thick  piece  of  plain  sterilized  gauze,  with  a  string  at- 
tached, is  placed  in  the  lower  part  of  the  pharynx,  covering  ihc 
(.titnmce  of  the  larynx  and  (rsophugus,  thus  shutting  off  all  possibility 
of  foi-'-ign  substances,  such  as  blood,  solutions,  etc.,  from  being  carried 
i..,(i  mo  larynx  or  the  (esophagus.      The  string  passed  through  this 
piece  of  gauze  is  allowed  to  hang  out  of  the  mouth,  with  a  clamp 
attached  to  it,  so  that,  if  necessary,  it  can  be  (}uickly  removed.  There 
should  be  several  of  these  pieces  of  gauze  on  hand  in  case  the  one 
in  jHisition  .should  nee<l  to  be  removed,  as  .sometimes  occurs  when 
it  becomes  saturated  with  blood.     The  oi)eration  is  then  done  in  the 
usual  way,  and,  after  the  oral  cavity  has  been  cleansed  attain  by  the 
normal  salt  solution  and  the  pad  removed  and  replaced  by  a  fresh  one, 
a  thin  strip  of  sterilized  gauze,  about  an  inch  and  a  half  wide,  is  passed 
between  the  under  surface  of  the  repaired  palate  and  posUrior  phar- 
yngeal wall.     Plain  sterilized  gauze  is  then  used  to  pack  the  lateral 
incisions,  and  here  the  i)acking  should  be  quite  firm.    Sterilized  gauze 
is  also  used  over  the  whole  of  the  operative  field,  the    cavity  of  the 
mouth  is  filled  completely  to  the  front  teeth,  and  the  gauze  is  then 
pressed  rather  iirmly  against  the  under  surface  of  the  new  palate. 
Should  vomiting  occur  and  soil  the  dressings  while  the  patient  is 
recovering  from  the  amesthetic,  then  we  nmst  redress.    This  happened 
twice  in  one  of  his  reported  ca.scs,  and  not  at  all  in  the  others.     If 
no  vomiting  has  taken  place  the  packing  should  be  removed  at  the 
end  of  forty-eight  hours,  and  the  parts  gently  sponged  with  either 
a  hot  saline  solution  or  a  weak  solution  of  formalin,  ancl  the  wound 
gently  repacked.     Owing  to  the  salivary  secretions,  which  are  now 
increa.sed  by  the  mechanical  irritation  of  the  dressing,  the  ])acking 
should  be  removed  each  day  and  the  parts  cleansed  as  before.     The 
tracheotomy  tube  is  left  i-  for  about  twelve  days,  during  which  time 
tlie  i)atient  is  nourished  t)y  the  rectum. 

Dr.  McKernon  very  k?  •  llv  r*ated  to  me  that  he  has  now  employed 
this  method  in  14  c-  <-  ^  nmary  union  in  every  case  but  one, 
and  ill  this  the  faihv  '■  was  for  only  a  small  portion  of  the 

wound,  which  was  reui  '  ■  ..eshened,  and  the  ultimate  results  were 
perfect.  Thit  doctor  de:  i  ves  great  credit  for  the  originality  and 
boldness  with  which  h"  has  carried  out  a  plan  which  .seems  from  the 
imrcly  surgical  side  much  more  certain  and  correct  in  its  technique. 
The  method  would  hardly  be  recommended  in  very  young  children, 
for  example,  at  the  age  suggested  for  operation  by  Goodwillie,  Abbe, 
Curtis,  and  others.  In  selected  ca.ses  among  older  children  and  adults, 
however,  a  method  which  tends  to  assure  primary  union  by  keeping 
the  parts  more  nearly  sterile  and  at  rest  has  much  to  commend  it. 


ullU   I 


FLATL-;    XXXIII. 


M.M  ;i.i  .i:.ii   T\  1 1  i  I  Mill    ii^   St  (-mi   T!ii  (iUc|Ii    a   S|>i->  u  hi  in 


THE  EAR. 


CHAPTER    XXV. 

tWMlNATION  OF  THE  KAIl;    DISEASES  OF  THK 

EVrERNAL  EAR;    DISEASES  OF  THE  EXlhR- 

NAL  Al  DITORV   MEAl'US;   ()T()MY(JOh  &; 

FOREIGN  BODIES;    WOl'NDS  OF  I  HE 

MEM15RANA  TYMPANl. 

Hy  F.  K.  HOPKINS.  MD. 

EXAMINATION  OF  THE  EAR. 

Thk  luwssarv  iiistnmunits  for  makiiifi  an  oxiuninatioii  of  tho  <'ar 
aiv  a  linir, .  a  coucave  mirror,  and  a  speculum.     To  secure  satistactory 


Kiu.  Mi 


,.-,..-.,7*^01.,     A,  Helix     H.An.ihdix     e.  Tra«n..     D.   Antitrngus     Hl...>.ule.     F.  roncha. 

K„.  .-..:! -TIK.  .mrlole  and  .he  oartilugi..™,,  part  of  the  external  ""'"''^  ;''„„,,  ^^'J  <,,^,* 
.,  ,  „r,il„Ki„o™  meatus.  K  Inner  ,«.lnte,1  en.i  whieh  n„i,«.  with  .H.s...n,  ,«rt  of  the  «n,mor>  onnal. 
r    KisMiresof  8ant<>rlnl.     (Pol.IT7.EK.> 

result,  with  these  imi.lemenls,  however.  so.u<>  familiarity  m\h  their 
us.'  is  o^lnltial,  togetller  with  a  knowle.ige  of  the  anuto.ny^of  Uie  ear. 


1(»7() 


Tin:  i:ar. 


Tlic  liglit  and  its  fixturos  may  bo  simple  or  (■lal)(>rate,  as  the  taste  or 
tiie  pui'^e  of  the  owner  may  dictate;  direet  simligiit  may  he  uscil 
when  available,  or  one  may  make  use  of  a  eandle.  In  an  office  \\\i 
li^lit  is  (juite  likely  to  l)e  an  Arjjand  s:is-burner,  and  if  one  |)laii~ 
to  do  nose  and  throat  work,  he  will  i)e  provided  with  a  Mackenzie 
condenser  (Fip.  .J4")),  which  he  will  also  use  in  ear  work,  althoufili 
good  authorities  assert  that  no  condensing  lens  is  necessary  for 
exainining  the  I'ar.  In  a  i)rivate  house  satisfactory  illumination 
may  be  had  from  a  kerosene  lani]).  In  case  the  external  meatus  is 
abnormally  wide  and  straight,  it  is  sometimes  possibh'  to  examine 
the  ear  by  direct  sunlight.  The  direct  light  of  an  electric  lani])  suit- 
ably mounted  for  wearing  upon  the  forehead  may  be  .substituted  for 
the  reflected  light  of  the  forehead  mirror.     The  electric  light  serves  a 


Fl(i.  .>I4. 


■'Sfrni-rimilar  CannI*. 
IMilnde. 


A  front  view  nt'  tbt-  orgHii  of  liuariiig  (right  sidcj.    (Gu 


useful  purjKise  in  ether  operations,  since  the  risk  of  igniting  the  ether 
is  thus  avoided.  For  general  work  sunlight  cannot  be  depended  upon, 
and  batteries  are  unei-rtain.  The  foreliea<l  mirror  has  ([uite  super- 
seded the  hand  mirror  for  reflecting  light  into  the  ear,  for  the  very 
good  reason  that  illumination  is  thus  quite  .as  good,  and  both  hands 
are  left  free  for  manipulation  of  instruments.  (Jood  head  mirrors 
are  now  so  re.adily  purchasable  that  no  further  descrijition  is  neces- 
sary than  that  thi'  h"ad-band  should  be  of  iiu^lastic  ribbon,  that  the 
focal  distance  should  be  about  seven  or  eight  inches,  and  that  the 
mirror  be  worn  over  the  eye.  enabling  one  to  look  through  the  per- 
forati"!!  in  tlir  ci'iitvc,  thii^  allowing  iiwpertinn  in  the  focal  line  and 
giving  the  maximimi  degree  of  illumination.  When  the  mirror  is 
worn  in  this  manner  the  eye  is  i)rotected   from  the  direct  rays  of  the 


E^ssesn 


EXAMiyATwy  OF  Tin:  ear. 


107: 


lifllii.     For  continuous  work  before  a  condensing  lens  this  protection 
i<^a  matter  of  considerable  inii)ortance. 

There  is  a  large  variety  of  ear  specula  from  whii :  to  tuake  choice. 
\l(diride  facetiously  rein'arks  that  many  aurists  have  uevoted  their 
Irisure  to  inventing  si)ecula  that  they  might  attach  their  names  to 
liiem.  Satisfactory  work  can  be  done  with  any  one  of  them  it  ni  the 
liands  of  its  m:ust('r.     It  is  i>nly  necessary  to  speak  of  the  essential 


Fig.  :a:> 


Fio.  546. 


Mackenzie's  biill'seye  lens  aiitl  rtflector. 


iDilirect  ilhimiimtiun  of  the  ear. 


(•oiiditi<ms  to  which  all  shouUl  conform.  A  si)eculum  sliouid  not  be 
too  long,  as  this  interferes  with  th(>  manipulation  of  instnmieiits 
tlirough  it.  The  length  should  not  exceed  one  and  three-eighths 
inches.  One  .should  have  at  least  three  difTerenl  sizes.  The  smallest 
(lid  of  the  smallest  size  shoultl  not  be  less  than  one-eightli  (if  an  inch 
in 


.liameter,  and  not  more  than  five-sixteenths  of  an  inch  for  the 


Kin.  .MT 


(inilier  sspeeuluiii. 


Pi)lltzer'E  Miieculum. 


<nuiller  end  of  the  largest  si^e.  The  siieculum  .should  be  of  bright. 
porwlied  metal,  silver  or  nickel,  to  aid  in  reflecting  light,  and  the  walls 
n{  tiu'  instrument  should  be  as  thin  as  possible,  to  increa.-^e  to  the 
utmost  th<'  space  available  for  ilhimination.  For  this  same  rea.«on  the 
(Inihi-r  srnculum  (Fig,  .')47^  i-^  to  be  recommende.l,  as  its  oval  form  in 
.■nws-seetion  corn>-<ponds  to  the  anatomical  .shape  of  the  entrance  to  the 
external  meatus,  thus  admitting  of  the  greatest  possible  illuimnation. 


r 


1078 


TIJK  EAR. 


The  position  of  the  pationt  with  roforonro  to  tlio  lijiht  is  a  matter  nf 
some  iiii])()rtan('c,  since  it  is  desiraMe  to  seeure  op[)ortunity  to  manipu- 
late instruments  without  interfering  unduly  with  iUumination  oi  tiic 
field.  This  is  best  aceomijlished  by  plaeing  the  light  at  the  examiner'^ 
li'ii  and  somewhat  above  the  level  of  the  ear  to  be  examineil.  The 
light  must  not  be  too  far  froi  i  the  observer,  since  this  diminishes 

Fia.  549. 


OOOO 

Boucheron'8  speculum. 

illumination.  The  patient  should  sit  so  that  the  ear  to  be  examined 
is  on  a  level  with  the  examiner's  eye.  The  light  is  directed  into  the 
patient's  ear  by  tilting  the  mirror.  This  adju.stment  of  the  reflecting 
mirror  is  made  by  the  hand,  without  ;my  movement  of  tlie  observer's 
held,  which  is  thus  allowed  to  iissumc  the  most  comfortable  position 
for  examination.     The  speculum,  after  beir  %  warmed,  is  introduced 

Fio.  560. 


Forci'i*  for  removal  of  foreign  bodies  nmi  the  ear. 


into  the  entrance  of  the  auditory  canal  by  a  slight  rotary  movement, 
and  held  in  position  by  the  thuiiib  and  index  finger  of  the  left  hand, 
while  at  the  same  time  the  (>ar  i.-  lifted  u))war(l  and  backward,  to 
straighten  the  canal,  by  the  index  and  middle  Hngers  of  the  same 
hand.  The  speculum  must  be  held  so  that  the  axis  of  its  long  diameter 
is  parallel  with  the  axis  of  the  canal.     To  secure  the  best  illumination, 


m 


mP 


EXAMiyATION  OF  Till     .AR. 


1079 


tlic  largost  sppouluin  which  th<«  canal  will  iulniit  slioul.l  bo  usp<l,  l)ut 
„„  speculum  should  bo  forcibly  iusortod  into  tho  oar.  Indood,  all 
manipulations  about  tho  oar  nuist  bo  froo  from  anythuiR  liko  rouph- 
iicss  or  hoavy-handod  movonionts.  In  ciwo  of  tondornoss  about  tho 
. -ir  examination  at  first  may  woU  be  made  by  gentle  traction  on  the 
•mricle  under  a  good  light.     It  us  cjuite  common  to  find  the  meatus 


Fis.  Ul. 


Cotton-holder. 


obstructed  by  exfoliate*!  epithelium,  cerumen,  purulent  discharge 
bv  hairs,  or  by  otner  foreign  bodies.  Tho  external  auditory  canal 
nmst  he  perfectly  clean  in  order  to  [)ormit  of  that  thorough  in.siK'ction 
which  done  can  load  to  accurate  diagnosis.  The  instruments  used 
for  this  i)urposo  are  tho  blunt  curette,  the  slender  cotton-earrior,  a 
pair  of  light  angular  forceps,  and  tho  sjTingo.    Tho  M'lnt  curette  is 


FlO.  552. 


Buck's  blunt  curette. 

used  much  more  frequently  than  tho  forceps,  while  the  cotton-carrier, 
armod  with  a  small  pledget  of  tightly-wound  cotton,  ls  more  constantly 
in  tho  hands  of  the  otologi.st  than  any  other  instrument.  Tho  synnge 
i<  used  for  the  removal  of  soft  cerumen,  foreign  bodies,  ano  for  the 
romoval  of  pus  when  it  is  present  in  considerable  quantity  or  is  of  a 
stringy   tenacious  character.     Following  the  use  of  the  syringe  the 


Fio.  653. 


Fio.  SM. 


FT..  5,^i,.-Nonnal  drumhe^  (right  e.r).     o.  Porteriorfold.    b.  Short  process,    c.  Anterior  fold. 
''rirS -Normal  drumhead  (left  ear),     d.  Cone  of  light.    ..  I..ng  handle  of  Incu,.   /.  Imbo. 

rol.ITZKK.) 

.■anal  should  be  thoroughly  dried  with  cotton.  Examination  of  the 
oir  should  bo  bv  touch  as  well  as  by  sight.  Tho  impn-ssion  gained 
bv  palpating  an  inflamed  or  thickened  auricle  is  of  groat  aid  in  making 
a"  diagnosis;  ami  an  interpretation  of  tlu-  signi.Vanee  of  tendomos. 
an.l  sVvelling  about  the  auricle  and  over  the  mastoid  can  only  be  made 
out  by  palpation. 


1080  THE  EAR. 


DISEASES  OF  THE  EXTERNAL  EAR. 

Sonio  of  the  iirt'cctions  of  thi'  auriplc  arc  sucli  tis  are  common  to  tin; 
fkin  of  any  part  of  the  bodj',  and  riMjuirc  tho  same  treatment.  Among 
tliese  are  dermatitis,  due  to  injury,  stinps  of  insects,  burns,  and  frost- 
l)ite.  Sudi  as  tiiese,  whether  slij;ht  or  .severe,  and  whether  simple  or 
infected  hy  bacteria,  causinji  erysipehis  or  any  sejjtic  process,  are  to 
be  treated  on  tlie  principles  hiid  down  in  text-i)ooks  on  dermatoiopiy. 

Eczema  is  one  of  tiie  most  connnon  dis(>ases  of  the  e.vtcrna!  ear  ;  nd 
meatus.  It  is  fre(|uentiy  seen  among  the  children  of  the  poor  !is  a 
result  of  nncli'anliness  and  bad  nutrition.  I'  is  more  common  witii 
children  than  adults  in  any  .social  .scale,  beiiiii  with  them  one  of  the 
ex|)ressions  of  a  strumous  diathesis.  In  the  chronic  scaly  form  it 
exists  to  the  tornu^nt  of  many  adults  who  dig  at  the  meatus  with 
pins,  toothpicks,  tij)  of  a  penholder,  or  anythinj;  within  reach  in  the 
etfort  to  gain  relief  from  the  itching.  Serious  injury  is  tiuis  som<'- 
tiines  done  to  the  meatus  or  membrana  tympani,  or,  if  these  i)arts 
are  not  directly  lacerateil  l)y  the  instrument  used,  the  irritation 
resulting  from  the  repeated  tramnatism  ends  in  inflammatory  infil- 
tration and  thickening  of  th'  lining  of  the  meatus  and  an  aggravation 
of  the  original  troubl".  l'>zema  of  the  ear  occurs  either  as  an  acute 
or  a  chronic  disease  The  bony  i)ortion  of  the  canal  is  not  likely  to 
be  involved,  the  drum  membrane  also  is  rarely  affected.  The  disea.<e 
is  usually  located  in  the  cartilaginous  ])ortioii  of  the  meatus  or  upon 
some  part  of  the  auricle,  or  both  meatus  and  auricle  are  involved.  If 
the  auricle  alone  is  affected  it  is  likely  to  be  at  som(>  ])oint  wher(>  the 
skin  is  folded  ujion  itself,  as  in  the  fos.sa  helicis,  and  in  the  angle 
behind  the  ear,  where  the  skin  is  reflected  from  the  ear  upon  the 
mastoid  process,  .\cute  eezema  begins  with  redness  an<l  swelling  of 
the  skin,  which  is  soon  f(  llowed  by  the  api)earance  of  vesicles  filled 
with  serinu.  Thi'se  break,  and  the  exudeil  fluid  in  the  canal  is  some- 
times mistaken  for  discharge  from  the  middle  ear.  The  bursting  of 
the  vesicles  leaves  a  moist  smface.  This  after  a  few  days  becomes 
covered  with  yellow  crusts,  and  exudation  occurs  imderneath. 

Etiology.  Acute  eczema  may  ocr-ir  in  this  locality  primarily  or 
in  connection  with  the  disease  in  otner  parts;  but  the  cau.se,  unless 
it  be  an  external  irritation,  is  not  easily  assigned.  Of  external  irri- 
tations the  most  comtnon  are  a])plications  to  llii'  ear  or  meatus.  In 
some  patients  with  a  sensitive  skin  the  efforts  toward  cleanliness, 
by  the  freiinent  use  of  soap  and  water,  is  sufiicient  to  excite  an  eczema. 
An  acute  or  chronic  discharge  from  the  middle  ear  is  often  sufficiently 
acrid  to  cause  the  disease. 

Sjrmptoms  of  acute  eczema  arr  a  burning  jiain  and  an  intolerablo 
itchiiig  in  the  ;ifTected  part,  with  redness,  swelling,  and  the  f'.>rmati(>n 
of  vesicles.  The  function  of  hearing  is  not  impaired,  unless  the  mc  atus 
Ix'comi's  ocf'luded  from  the  swelling  and  the  accmmilation  of  crust.s 
and  des((U!imated  epithelium.     In  acute  eczema  not  dependent  upon 


B 


n^ 


DISEASES  OF  TllK  EXTKHSAL  EAR. 


1()«1 


•I  pcr-iistPiit  caiiso,  iis  uu  otorihd'U,  u  new  epidrriiiis  tonus  Ix'iicutli 
tlic  fi-iLst  of  exuihition,  an.l,  after  tlu'  latter  Ikls  been  removed,  soon 
■i^smiies  a  natural  appearance.  Freciuently  t'le  disease  eontuiues  for 
sunie  weeks,  an.l  if  the  external  iiritant  be  kept  up  or  the  patient  s 
iiealtli  is  reduced  from  any  cause,  fre.|uent  relapses  occur  and  the 
disea>.  passes  into  the  chronic  form.  In  chronic  eczema  there  are 
dcciK-r  tissue  chan-jes  in  the  skin.  There  is  thick  linj:  of  the  subcu- 
taneous connective  tissue  in  the  more  severe  forms,  and  this  narrows 
the  meatus.  The  auricle  is  enlarjied  and  hardeneil.  In  bad  ca.ses 
tliere  is  a  crust  formation,  underneath  which  a  serous  or  purulent 
fluid  is  exuili'd.  The  more  conm.on  chronic  form  is  characterized 
l.v  the  format!,  -i  of  tine  .scales.  There  is  .some  liyi)er:emia  and  tliick- 
eiiiiifl  of  the  skill  and  a  constant  des.iuamation  of  scah-s.  Tin.,  is 
very  Imiuent  as  an  affection  of  the  cartilapnous  portion  ot  thi- 
meatus.  With  this  sometimes  occur  fissures  at  the  entraiwc  to  the 
nii'atus.  Thi-se  iissures  are  moisteiieil  by  a  A\\i\\X  exudation.  The 
severer  forms  of  <'czema  are  obstinate,  not  yieldiiij;  readily  to  treat- 
eieiit,  and  fre(|ueiitlv  relapsiiif;. 

Diagnosis.    The  characteristic  feature  of  this  disease  is  an  exudation 
.md  crustinji.     The  stafje  of  exudation  m.'iy  have  passed  before  the 

I  atieiit  conies  under  observation:  but  the  history  will  reveal  a  jx-riod 
,,i  ili.scharse,  and  removal  of  crusts  will  show  a  moist  surface  uiider- 

II  nth.  The  chronic  .s(|Uamous  form  may  not  easily  be  differentiated 
from  i)ityriasis  simplex:  but  this  is  a  matter  of  no  ^reat  imi.ortance 
Ml  far  ar:  treatment  is  coiuerned. 

Treatment.     This  is  almost  wliolly  local,  yet  certain  general  condi- 
tions, especiallv  with  children,  .shoulil  receive  attiMition.     Care  of  the 
.reiieral  health,"  the  rejiulatioii  of  <li('t,  limiting;  this  to  simjiie  ea.sny- 
diyiesteil  food,  and  at  rejiular  intervals,  the  use  of  cod-liver  oil.  syrup 
uf\\v'  iodide  of  iron,  and  Fowh-r's  solution  will  be  helpful.     Adults 
niav  re.|uire  similar  care,  especially  with  regard  to  difrcstion,  reiia 
or  cardiac  disea.'^e.  pouty  tendencies,  etc      The  first   care  in   local 
treatment  is  to  remove  all  sources  of  irritation.     If  this  is  the  too 
free  use  of  soap  and  water,  suspension  of  this  and  the  ajiphcation 
of  an  ..leaginous  preparation  will  (juickly  bring  relief.     The  irritation 
may  be  due  to  an  acrid  discharge  from  the  middle  ear.  and  it  this 
can"  be  overcome  the  eczema  will  often  recjuire  but  little  treatment 
lor  its  cure.     In  a  general  wav  it  may  be  said  that  for  acute  eczema 
soothing  applicati(ms  should  be  used,  while  in  the  chronic  formstimu- 
lalion  is  re.|uired.     In  the  early  course  of  acute  eczema,  in  the  period 
of  heat,  redness,  and  swelling,  a  solution  of  subacetate  of  lead  will 
relieve  the  pain.     A  litlli>  later  Hebra's  diachylon  ointment  is  ;.  most 
.sitisfactory  ap])licatioii.     The  ofhcinal  benzoated  zinc  ointment   is 
also  much  "used.     The  treatment  of  chronic  eczema  will  re(iuire  much 
jiatieiice.     There  will  be  periods  of  imimnement  and  relai)se.     ()n 
the  occurrence  of  exaceri)atioiis.  with  redness  and  a.lde.l  irritaiioii, 
the  a.stringent  ointments,  as  those  of  lead  and  zinc,  should  l>e  "^J'd. 
The  diachylon  ointment  is  made  more  easily  applicable  by  dilution 


I 


u 


If 


1082 


THE  EAR. 


with  olive  oil  or  "rold  cream."  As  [)repare(l  it  is  rather  hard  and 
stitT.  When  no  progress  is  being  made,  when  |)ain  and  other  indi- 
cations of  acute  exacerbations  have  long  been  absent,  then  stimu- 
lation must  be  employed.  For  this  purpose  strong  solutions  of  nitrate 
of  silver  have  long  l)een  used.  In  .some  eases  of  an  obstinate  character, 
in  which  the  ear  is  thickened  and  distorted  by  tlie  chronic  proct's.x. 
applications  of  acetum  cantharidis  will  set  up  a  renewed  activity, 
endiufi  in  improvement.  The  usefulness  of  oleaginous  prei)arations 
depends,  no  doubt,  in  good  i)ar\  ujion  their  (pmlity  of  protecting  tiie 
.surface  from  the  air  and  from  wat(>r.  The  injurious  influence  of  the 
latter  in  this  diseiuse  is  understood  even  by  the  laity.  In  order  to 
secure  good  results  from  any  application  the  crusts  must  be  removed; 
this  is  to  be  done  in  a  maimer  as  little  irritating  ius  possible.  The 
crusts  should  be  softened  by  the  use  of  olive  oil  or  Vitseline,  after 
which  they  can  be  quite  readily  .separated.     The  objection  to  the  use 

of  ointment  in  the  auditory  canal,  be- 
f"  ^  cause  of  the  risk  of  obstruction  from 

the  accumulation,  can  be  obviated  l)y 
ia-^tructing  the  patient  to  wipe  out 
the  canal  each  time  before  making  a 
new  ai)plication. 

Herpes  zoster  occasionally  affects 
the  ear,  but  it  asually  occurs  only  in 
connection  with  manifestations  of  the 
diseii.se  in  other  localities.  It  is  at- 
tended by  severe  pain  of  a  neuralgic 
character  and  the  formation  of  ve.si- 
cl(>s  along  the  distribution  of  nerve 
branches.  Pain  may  be  so  severe  as 
to  call  for  the  hypodermic  use  of 
morphine.  After  rupture  of  the  vesi- 
cles, application  of  some  sitnple  oint- 
ment, as  tii.it  of  zinc  oxide,  is  to  be 
made. 

Lupns  also  is  rarely  seen,  except  as 
accompanying  the  same  disease  of  the  face,  and  even  in  this  coimec- 
tion  it  occurs  in  but .")  per  cent.  f)f  thecises.'  Lupus  vulgaris  and  lupus 
exulcerans  are  best  treated  by  the  galvanocautery.  In  the  latter  form 
the  sjjongy  graiuilations  are  first  removed  with  a  shar|>  spoon,  after 
which  the  galvanocautery  is  thoroughly  applied.  This  vigorous 
trentm(>nt  ought  to  be  use<l  early  to  prevent,  so  far  as  possible, 
the  (Icforin'ty  resulting  from  loss  of  tissue  aii'l  cicatricial  contraction. 
These  ca.<es  are  proper  sui)jects  for  tr(>atment  l)y  the  r-ray. 

I'rivuirij  sjiphililic  nffcclion  of  the  auricle  is  to  be  mentioned  only 
as  a  ciirio-^ifv.  I'ulitzer  refers  tn  but  four  such  c.nses.  Secomhiry 
eruptions  may  occur  along  with  the  general  symptoms,  taking  on  the 

I  Journal  of  Laryngology,  Kbinology ,- and  Otology,  1900,  toI.  xv.  p.  451. 


Thickening  and  ilelDrjiu  1  y 
due  (o  chroiiie  ccz^-tiia. 


il  tin*  uiiiiule 
(Baco.n.) 


DISEAHes  OF  THE  EXrEltSAL  EAR. 


lo«:j 


H-nuvinour.,  pustular,  or  p.ipular  f..rin,  whichever  tlie  cutaneous  inuni- 
IVstatiou  happens  to  be.  _  u„,„„ 

\ii(.tlier  of  the  rare  affections  <.f  the  ear  is  cnrnu  humnnum,  a  horm 
Krmvth  sprinKinR  fn.n.  the  outer  border  of  the  helix.     One  svich  cuse 
has  come  luwier  n.v  observation.     It  occurre.l  u,  a  man  ab.mt  sixty- 
tliree  years  of  sige,  an.l  vvjis  situated  on  the  upper  x.rder  of  the  helix. 
The  erowth  stood  nearlv  upright,  although  curve.l  a  little  backwan. 
It  wa!s  of  a  dark  color,  of  horn-like  hanlness,  and  .hstinctly  striated. 
Its  length  was  one-half  of  an  inch,  and  the  greatest  diameter  at  the 
l,a.se  one-lialf  of  an  inch.     The  base  was  exquisitely  sensitive,  as  a 
result  of  the  mechanical  irritation  from  accidental  movement  of  the 
growth  in  brushing  the  hair,  etc.     He  laughingly  told  me  that  he  had 
suffered  much  from  the  well-meant  oHiciousness  of  friends,  who.  ob- 
serving the  growth  in  the  *    iliglit,  mi.stook  it  for  a  bug  or  a  fly,  and 
with  a  quick  movement,  intended  to  dislodge  or  capture  the  bug,  gave 
the  ear  a  blow  which  caused  much  pain,  because  of  the  sensitive  ba.«e 
of  the  neoplasm.     The  growth  was  removed  under  cocaine  anaesthesia, 
an  elliptical  cut  being  made  through  the  skin,  the  base  dissected  out, 
■m\  the  cut  edges  of  the  skin  brought  together  by  a  few  fine  sutures. 
Healing  was  by  first  intention,  and  after  four  years  there  is  no  return 

)f  the  growth.  .  ^  ■ 

Of  benign  tumors  of  the  auricle,  fibroma  is  most  common,  an. 
sebaceous  cyst,   perhaps,  comes  next  in  fre<iuency.     Lipoma  and 
angioma  are'said  to  be  exceedingly  rare. 

MaUmant  disease  of  the  ear  may  be  primary  or  secondary  to  its 
•mnearance  u))on  the  face  or  neck.     According  to  Cnnal,'  who  ex- 
uIEd  the  slatistics  of  the  Glasgow  Ear  Hospital,  in  15,0(K)  cases 
malignant  disease  was  recorded  six  times,  four  epithelioma  and  two 
sarcoma.     Epithelioma  appears  to  be  less  rare  than  sarcoma,  and 
the  former  more  fre(iuently  attacks  the  auric  e,  while  sarcoma  is 
ottener  found  in  the  canal  than  in  the  external  ear.     Conna  s  case 
was  a  spindle-celle<l  sarcoma  of  the  canal.     The  child,  a  girl  of  six 
v.-'irs  .li.Ml  of  recurrence  after  seven  moiuhs.     I  have  .seen  one  similar 
;.asein  a  bov  three  vears  of  age.     The  growth  fille.l  the  external  audi- 
torv  canal  "  From  its  color,  consistence,  and  the  attending  <hscl.arge. 
it  was  a.ssumed  to  be  a  polyp.     It  was  rem.ned  under  ether,  an.l  ..r- 
tuintelv  submitte.l  f.ir  microscoiiic  exannnation,  which  proy.l  it 
,„  he  a  r.,un.l-celle.l  sarco.na.     Rapi.l  recurrence,  with  extensive  m- 
volv.-ment  of  the  surroun.ling  structures,  t.iok  place  an.l  the  child 
died  ab..ut  six  months  later.     In  case  of  malignant  .hsea.se  of  the 
•u.ricle  operative  treatment  shoul.l  be  resorte.l  to  as  soon  as  diagnesis 
is  ,na.le  and  the  entire  auricle  sacrificl  if  nece.s.sary.     Successful 
n-sult  has  been  reporte.l,  even  when  the  parotid  and  cervical  glan.N 
had  to  be  remove.!  because  of  involvement.' 
The  occurrence  of  marke.l  an.l  persistent  pain  in  connection  with 

.  Joum.1  of  LarynROlngy,  Kl,    ..U>Ry.  an.l  Olology.  November,  1899,  p.  606. 
«  Buraett.    Ear,  Now,  Throat,  isa,  vol.  1.  p.  161. 


1084 


riit:  EMI. 


new  prowtliM  in  tlio  ranal  shmiM  cxritc  suspicion  of  miiliRiiancy  ami 
Icail  to  iiiicrosco|(ic  cxaniiiiatioii.  TIh-m-  cases  often  come  under 
observation  loo  late  to  jHTinit  of  operatic"  with  any  iiope  of  suceess- 
ful  issue.  The  loxins  of  ervsipeias,  as  advocated  hy  Coley,  niiniit  !«■ 
tried  in  so  desperate  a  situation. 

Wounds  and  Injuries  of  the  Auricle.  It  is  an  anomaly  that 
wounds  and  injin'ii's  of  tiie  external  ear.  exposed  a.s  it  is,  should  he 
.so  inueh  rarer  than  injuries  to  the  nienibrana  tyrni>ani  hidden  away 
within  a  bony  cavity.  Statistics  show  that  a  serious  injiny  to  the 
external  ear  is  a  rare  accident,  while  a  wound  of  the  drum  membrane 
is  a  relatively  common  occurrence.  I'erhajjs  the  most  fre(|uently 
seen  deformity  of  the  aurich-  due  to  injury  is  tlie  slit  of  the  lobule 
from  the  tearinj;  out  of  an  ear-rinp.  ICven  this  occurs  less  fre(|uently 
than  formerly,  witii  the  jia-ssinj;  of  the  vofiue  for  wearinj;  ear-riufp*. 
When  this  deformity  exists  the  individual  rarely  cares  to  pi  to  the 
trouble  of  havinji  the  te.'ir  closed,  although  a  tritiirit;  plastic  operation 
would  overcome  the  defect.  Injuries  from  blows  or  falls  sometimes 
cause  marked  deformity  due  to  loss  of  substance,  either  from  direct 
laceration  of  the  tissue  or  from  thi-  subse(|uent  inflammation  and 
necrosis.  The  author  has  seen  a  ease  of  the  loss  of  the  upper  half 
of  the  auricle  as  a  result  of  a  fall  from  the  old  styli' "ordinary"  bicycle 
to  the  frozen  ground.  If  an  incised  wound  of  the  auricle  is  seen 
soon  after  the  injury  the  edjres  tihould  be  approximated  and  held 
with  tine  interrupted  sutures,  fieneral  suniical  rules  beinji  followed. 
In  all  operations  abo\it  the  auricle  strict  antiseptic  precautions  are 
of  course  to  be  observed.  If  the  wound  involves  the  cartil.age,  with 
the  intefiument  on  either  side,  it  will  be  well  to  follow  D'-nch's  sug- 
pestion  and  ])lace  the  stitches  posteriorly,  carrying  them  through  the 
cartilage  and  into  the  skin  anteriorly.  The  sutures  arc  thus  jilaced 
subcutaneou-sly  so  far  a.s  the  skin  of  the  ex])osed  j)art  of  the  auricle 
is  concerned.  With  laccn.u'd  wounds  ctTort  must  bo  -nade  to  pre- 
serve as  iiuicli  tissue  as  possible,  to  avoid  subsecju.  :  deformity. 
To  this  end  aid  is  derived  from  t!ie  use  of  cil  I  applications  following 
the  injury,  thus  ])reventing,  so  far  as  may  be,  severe  iiiHanunatory 
reaction.  The  case  ferred  to  in  \\w  Journal  of  Lnriinijoloijii.  Rhinol- 
(Mljl,  (tiul  Oldoijii,  l.v.lii,  p.  270,  offers  en.-ouragement  to  the  idea  of  pro- 
serving  a-s  much  tissue  a.s  po.ssible.  In  this  ca.se  the  ear  Wius  com- 
pletely bitten  off  by  a  \niious  liorsc  and  drojjped  in  the  stable 
yard.  No  ap|)liances  wer.'  at  hand,  so  it  was  simply  clean.sed  with 
warm  water  and  sewed  on  with  ordinary  .sewing  needles  and  thread. 
Unioti,  with  hardly  any  disfiguroment,  took  place.  The  results  of 
contu.sed  wounds  of  the  oar  vary  from  a  .slight  inflammation  to  that 
disorganization  which  may  follow  a  blow  from  a  prize-fighter.  Seen 
early,  before  extravasation  of  blood  has  taken  place,  cold  in  the  form 
of  an  ice-bag  or  a  Loiter  coil  is  to  be  applied.  If  extravasation  of  fluid 
ha.s  occurreil  this  is  to  be  aspirated  and  the  walls  of  the  cavity  helil 
in  contact  by  pressure  of  the  dressings.  The  device  suggested  by 
Dr.  (}.  H.  Hickok  and  referred  to  by  Hm-k  servos  a  good  ])ur{)ose. 


DISEASES  OF  THE  EXTEHS.XL  EAR. 


1086 


riic  rln-ssinRs  arc  held  in  [)lao«'  J)y  strips  of  uood  plaro*!  parallrl  to 
cacli  (itlicr  in  fn.nt  ami  hack  of  tin- oar,  am  I  tin'  proj<-<-tiiiK  ends  aUovc 
arul  Im'Iow  an-  held  togftlHT  by  cljLstic  liands.  It  is  possible  to  adjust 
the  dfKrcc  of  pri'ssiirc  to  a  iiicity,  and  the  ai)plianc('  is  li)iht.  If 
Mippuration  has  occurred  incision  must  lie  made  to  evacuate  the 
pus.  The  interior  of  the  cavity  shoulil  he  scraped  and  packed  with 
antiseptic  Hiiuze.  Pressure  ran  Ix-  maintained  durinR  healinR  l>y  the 
appliance  just  mentioned. 

Frost-bite.  Those  of  m  who,  in  our  boyhood  days,  pursued  %viiit<T 
siM.rts  with  a  zest  too  keen  to  Ih>  disturbed  by  tiiiKlinR  ears  will  recall 
the  apiM'aranc<' of  a  cotnrade's  frost-bitten  ear.  In  the  first  stage, 
when  the  muscular  walls  of  the  bl(M)dvessels  were  paralyzed,  the  ear 

was  of  a  deep-re<l  color,  then  with  greater  degr if  cold  became  the 

waw  white  of  the  really  frozen  ear.  This,  especially  the  white  color, 
was  likely  to  1m>  true  of  a  part  only  of  the  ear,  for  the  condition  was 
.Mire  to  be  discovered  and  treatment  applied  before  the  whole  auricle 


Kio.  .ViS. 


Fl<i.  W>7. 


OihKmatonia  (1^  and  the  rcniliant  deformity  (2).     (niirBHR.) 


was  frozen.  The  treatment,  too,  of  ai)i)lying  snow  while  the  ear  was 
ihawiiiK  out,  and  this  out-of-doors  rather  than  in  a  warm  room,  is 
the  same  iWi  is  recommended  to-tlay.  The  aim  is  to  lestore  the  frozen 
part  gradually  to  its  normal  temperature.  If  the  part  has  remained 
frozen  too  long,  or  the  normal  temjierature  has  been  restored  too 
suddenly,  inflammaticm  results  which  may  end  in  perichondritis  or 
gangrene,  with  loss  of  substance.  Should  this  occur  it  must  be  treated 
on  general  surgical  princif)les. 

Othematoma,  a  transudation  of  blood  beneath  the  i)enchondrmm, 
occurs  ius  a  result  of  injury.     It  may  also  occur  without  any  history 


10S« 


77/ A'  KAIl. 


of  tnturimtisiii,  <-!<|)i>ci:illy  in  the  iiisaiic.  It  him  Immmi  cIiiIiiumI  tliut 
tlu'  alTcctiiiii  is  |xTiiliar  t<-  tlic  iii?'aiii',  that  some  cfn-hral  lesion  is 
r<'s|)(iiisil)lt  lor  tlx'  cliaiiKi*^  whicli  lead  to  tlic  traiisiulation  of  hlooil. 
It  scciMs  nion-  rcasonaltli',  liowcvcr,  to  attril)Ut('  tin'  tissin-  cliaiifst' 
prnhsposiiiK  to  otliainatoina  to  tlu-  (Icliiiity  and  tnalniitrition  of  llx'sr 
patifiits  aii'l  to  tJK'  tiU't  tliat  tlicy  arc  pccuhariy  iial>li'  to  violf-ncf, 
rather  tiiai  to  any  patliolojjical  coiiditi.in  >>f  the  l>rain.  With  the 
nii>re  humane  treatment  of  the  insane  at  present,  eases  of  otha'inatoma 
are  less  freijiient  amoiin  them  tiian  formerly.  If  the  cji-se  l)e  trau- 
matic the  ctTusion  of  lilooti  is  attended  l>y  considcrahle  pain.  The 
swcllinjt  is  usually  in  the  upper  anterior  part  of  the  ear,  and  the  color 
is  a  liluisii  red.  If  the  iLcmatonia  aiiris  is  of  spontaneous  origin  it 
is  attended  i)y  le.ss  pain,  lu-at,  an.!  ♦  •  ii  than  when  due  to  injury. 
The  proKUosis,  in  tin-  ahsenee  of  sei..'u.>  injury  to  the  cartilage,  is 
favorahle.  It  is  less  fa%'oral)le  in  case  nf -■■vere  inllammatory  reaction 
neces-itatinj;  incision  anil  evacuation  of  the  fluid,  and  it  is  'o  he 
l)orne  in  mind  that  ileformity  of  the  ear  may  lesult. 

Treatment.  If  the  tumor  is  recent,  small,  and  painless,  it  should 
not  he  actively  treated.  If  ther"  is  pain  an<l  redness,  the  swelling 
heinj;  of  recent  orijiin,  cold  applications  are  to  Im.'  employed,  as  the 
ice-haf;  or  Leiter  coil.  In  the  presence  of  pus  or  of  a  marked  deftree 
of  tension  incision  should  at  once  he  made,  anil  if  the  accunnilation 
he  considerahle,  the  incision  should  he  free,  the  interior  of  the  cavity 
curetted,  wiished  with  jin  antiseptic  .solution,  and  packed  with  anti- 
septic gauze. 


DISEASES  or  THE  EXTERNAL  AX7DIT0RT  MEATUS. 

Impacted  Cerumen.  .\n  :iccuinulati()n  of  cerumen  is  the  most 
cmnnion  atTectiim  of  the  external  .auditory  canal.  The  glands  which 
secrete  i-erumen  ar(>  found  almost  wholly  in  the  cartilaginous  portion 
of  the  !iuililnry  ciiial,  and  when  the  c;mal  is  entirely  filled  with  ceru- 
men it  is  hecause  the  gradually  accmnulating  mass  ha.s  heen  forced 
into  the  deeper  part  hy  the  etlorts  of  the  patient  to  clear  the  ear. 
.Micro.scopically  examined,  the  ceruminous  glands  are  found  to  he 
like  the  sweat  glands.  The  secretion  is  fluid  and  of  a  light-yellow 
color,  and  on  exposure  to  air  hecomes  inspissated  and  turns  darker. 

Etiology.  The  cau.ses  of  the  accumuiatioti  of  ceruiiieii  within  the 
meatus  are,  first,  an  !if)normal  narrowing  of  the  external  meatus  which 
thus  interfer(>s  with  the  free  external  movement  of  tlie  cennnen; 
second,  an  altered  character  of  the  .sei-retion  which,  heing  thicker 
and  more  tenacious  than  normal,  is  less  readily  extruded;  third, 
increased  (luantity  of  the  secretion  from  hypera'inia  of  the  lining 
memhraiie  of  the  meatus.  This  hypera-mia  is  often  a.s.sociated  with 
n.asopharyngi'al  catarrli  as  a  reflex  phenomenon.  Hypera'inia  of  the 
lining  of  the  meatus  is  fre(iuently  induced  and  mair't.'iincfl  by  the 
habit  of  digging  in  the  ear  with  a  pin.  an  ear  s[)oon,  or  other  foreign 


NLi..iW»T 


^?W 


frnFF^F^F^mp 


im 


lUSE.iSHS  OF  THE  UXIKKSAL  AVUITOHY  VKATCS.      lo87 

ImmIv.  The  paticiitH  own  j-fforlN  to  clear  the  canal  often  reHiilt  in 
fiireinn  the  niiiftt*.  noft  !is  it  in  when  first  secn'ted,  inward  toward  the 
lynipanuni.  A  foreijfn  lnKly  in  the  meatus  to  which  tiie  eerunien 
adiieres  is  sonietinu-s  the  IM-Riiniing  of  an  accunnilatioti.  The  writer 
h,is  twice  in  one  individual  found  a  pledget  of  cotton  in  the  mass  of 
nn<-n  removed.  This  the  patient  liad  inserted  in  the  ear  and 
;otteii.     In  another  case  a  cherry-pit  was  found  at  the  Ixiltoin 


I'crunK 


torn 


ul  the  mass  of  cerum<'   .     This  patient  was  an  adult  who  had  not 
I  he  remotest  idea  how    .•  when  the  pit  wius  put  into  the  ear. 
Symptom!.     The  sympioms  vary  with  the  amount  and  position  of 

til rumen.    It  is  not  unusual  to  find  a  large  .iceuimiiation,  of  which 

the  patient  is  wl-.olly  unconscious.     S)  lotijt  a.-<  there  is  no  pressure 
upon  the  drum  memhraiw'  there  are  no  subjective  sounds,  and  if  there 
i>  even  a  very  small  sjiace  iM'tween  the  cerumen  and  the  wall  of  the 
meatus  hearing  is  not  impaired.     <  )n  the  other  hand,  a  small  «|uanlity 
tiiMV  he  moulded  hy  » tTorts  at  removal  so  as  to  completely  occlude 
ihf  mealus.  and  thus  cau.-^e  deafness.     When  the  meatus  is    iiearly 
tilled  with  cciumen  the  patient  may  have  periods  of  imcertain  and. 
to  iiim.   unaccountahle  deafness,  (iep<'iidin«  upon   the  closure  and 
upeniiiK  of  the  small  pas.sajte  iM'twet'ii  the  canal  wall  and  the  wix. 
The  hrst  heated  term  in  summer  is  liki-ly  to  hrinp  to  one's  oflice  a 
ct>ii.>i(l  rahh'  immher  of  people  whose  hearing  has  become  sudtlenly 
and  .seriou.slv  impaired  by  the  swelling  of  the  plug  of  cerumen  from 
the  moisture  of  perspiration.     As  a  result  of  filliuR  of  the  external 
r:uial  there  may  be  a  feeling  of  confusion,  even  to  the  impairment, 
ill  some  degree!!  of  mental  processes;  this  is  a  reflex  symptom,  and 
is  not  dependent  upon  loss  of  hi'aring.     There  is  also  a  peculiar  reso- 
nance of  on(>s  own  voice—autophony.     If  the  accunuilated  ma.ss  is 
so  situated  as  to  make  pressure  upon  the  tympanum  there  are  sub- 
i-ctiv     sensations  of  sound,  and  there  may  be  vertigo  as  a  result  of 
this  p;-.-ssure  upon  the  ossicular  chain.     The  walls  of  the  meatus  are 
.-oinetimes  much  dilated  in  conse(|uence  of  desiiuamative  inflanmia- 
tioii,  set  up  by  the  pressure  of  cerumen  as  a  foreign  b()dy.     An  occr.- 
sioniil  case  of  chronic  supjuiration  of  the  middl    ear  is  attended  by 
scri((us  symptoms  because  of  the  interference  wnii  draiiiage  inter- 
posed bv  impacted  cerumen.     When  the  <|uantity  of  discharge  is 
small  it  slowlv  dries  in  the  canal  along  with  the  cerumen  into  a  mass 
Ml  <'ement-likf  !  ardness.     If  for  any  rea.son  there  is  an  in'-"ase  in 
the  flow  <  f  pus  it  can  find  no  exit,  and  is  forced  inward  with  risk  of 
riitering  tl.    crani-d  cavity. 

Diagnosis,  lixamination  with  tiie  s[)eculum,  or  sometimes  without 
111.'  aid  of  .:istruments,  shows  the  meatus  filled  with  material,  the 
color  and  c  >.isistetice  of  which  will  depend  upon  the  age  of  the  accu- 
mulation. It  may  f>"  a  soft,  piusty,  yellowish-brown  ma-ss,  or  nearly 
black  and  of  stony  hardnes.s.  ^ 

Prognosis.    Although  the  hearing  is  commonly  ro^tored  upon  ' 
removal  of  the  cerumen,  it  is  yet  wiser  to  give  a  guarded  prognosis, 
as  it  is  impossible  to  estimate  the  degree  of  damage  which  ti     ear 


n^^iBiv 


It  188 


THE  E.m. 


may  liavo  sufTcrod  from  prorcdiiifr  iiiflainmutdry  iirocossos.  Suppura- 
tion may  follow  the  removal  of  inspissated  eerumen  in  those  eases, 
already  referred  to.  where  ehronie  suppm-ation  is  attended  hy  hut 
little  diseharjie.  The  ri  iiioval  of  the  pluj;  does  not  set  uj)  the  sup- 
puration, hut  uncovers  what  has  been  hidden.  This  situation  should 
he  explained  to  the  i>atient.  Where  the  onset  of  deafness  is  sudden, 
as  after  a  piuiifie  hath,  or  after  jjrohmRed  perspiration,  a  favorable 
])ro};nosis  can  safely  he  jjiven. 

Treatment.  In  the  (jreat  majority  of  cases  the  canal  can  he  cleareil 
more  ])rom])tly  and  more  afireeahly  to  hoth  ))atient  and  ])hysician 
by  the  use  of  the  blunt  curette  than  with  the  syrinj^e.  The  necessary 
mani|iulations  may  re(iuire  more  skill  and  delicacy  of  touch  than  are 
calieil  for  in  syrinpinp;,  yet  a  little  careful  |)ractice  ought  to  enable 
one  to  do  this  without  causing  the  i)atient  i)ain.  The  very  exercise 
in  such  nianip\ilations  increases  one's  dexterity  and  gives  him  t'.o 
advantage  of  added  skill  for  more  delicate  work.     Should  familiarity 


Fig.  558. 


Bacuu's  ear  syriiiKe. 


in  the  use  of  instruinents  be  lacking,  or  if  the  wax  is  soft,  tenacious, 
and  adherent  to  the  drum  membrane,  then  the  syringe  and  warm 
water  nmst  be  u.sed.  If  s|>ecial  basins  are  lacking  a  finger-bowl  may 
be  held  under  the  ear  to  relieve  the  outflow  of  water.  This  the  i)atient 
holds  while,  with  his  left  hand,  the  i)hysician  lifts  the  ear  upward 
anil  backward  to  straighten  the  canal,  and  drives  the  wat(>r  into  it 
from  the  syringe  held  in  the  right  haiui.  The  stream  of  water  is  to 
be  directed  along  the  wall  of  the  canal,  |)referably  the  su])erior  or 
posterior,  that  the  fluid  m;.y  be  insinuated  between  the  cerumen 
and  the  canal  wall.  In  this  way  the  wax  will  soon  be  dislodged  by 
the  return  flow  of  water.  If  the  How  of  water  be  directed  against 
the  centre  of  the  ma.ss  the  tendency  will  be  to  force  it  more  deeply 
into  the  canal.  There  are  eases  in  which  it  is  next  to  impossible  to 
use  the  syringe  eft'ectively,  since  the  wax  is  very  liard  and  fills  the 
canal  completely.  Here  it  is  necessary  to  tunnel  a  pa.ssage  through 
the  wax  with  the  l)lunt  curette  worked  carefully  along  the  canal  wall. 
This  can  be  done  without  inflicting  pain  if  the  instrument  is  carried 
in  ilat  and  pressure  i>  e.\crted  only  toward  ihe  wax.  liasing  made 
the  small  passage,  water  can  now  be  forced  into  it  with  good  j)rosppct 


DISEASES  OF  THE  EXTERXAL  AUDITORY  MEATUS.      1089 

,,|  ilisloilpiifi  tlio  appiiimiliition.  After  syriiijiiiifl  the  ciinal  shmiKl  he 
iliiiioiiKlilv  cloaiK-d  aiul  dricl  witli  tin-  cottoii-canicr,  and,  especially 
in  cool  weather,  a  small  pledfjet  of  cotton  inserted,  to  he  removed 
at  nifiht  and  not  replaced.  K.  I..  Mierhof  commends  the  use  (jt 
undihiteil  snl|)lmric  ether,  poured  into  the  external  au(htory  canal. 

n ther  acts  in  a  few  seconds,  partly  dissolviuK  the  cerumen  from 

ii<  attachment  to  the  canal,  so  that  with  the  most  R.'utle  syrmjtnis 
the  |iluf;  is  promptly  removed. 

Circumscribed  Inflammatiop.  This  jiainful  affection  occurs  as  tiie 
ivMilt  of  an  infection,  the  specific  perm,  staphylococcus,  for  example, 
invadinji  a  hair  follicle  or  fjland.  It  is  more  likely  to  develo])  m  a 
(anal  hatlied  in  pus  from  a  chronic  otitis  media,  or  m  one  which  is 
ilic  seat  of  a  chronic  eczema.  The  infection  may  he  conveyed  hy 
the  instrument  which  the  i)atient  uses  to  scratdi  the  ear. 

Symptoms.  The  most  prominent  .symiitom  is  pam.  hut  this  varies 
.'n-niv  in  inteiisitv,  dependiiift  upon  whether  the  furuncle  is  super- 
ricial  or  d<"ep  seated,  or  whether  it  is  located  in  the  cartila-jmous  or 
|„,nv  i)ortion.  It  is  most  painful  when  deep  seate<l  and  m  the  hoiiy 
portion  of  the  canal.  Should  the  swellinji  close  the  canal,  deafness 
and  tinnitus  result.  When  .situated  anteriorly  movements  of  the  jaw 
are  i)ainfiil:  if  posteriorly  the  jiain  on  pressure  and  the  swelhiifr  may 
-iifT^rest  inflanimati(m  of  the  mastoid  process.  The  ear  .^hould  he 
examined  with  tlii'  utmost  p-ntleness,  :i.s  it  is  extjuisitely  .sensitive 
to  touch  when  thus  iiiHamed.  Reflected  lijrlit  without  the  speculum 
will  often  he  suflicient  to  locate  the  furuncle. 

Diagnosis.  This  jiroci'ss  may  easily  he  mistaken  for  diffuse  uiflain- 
inalion  of  the  canal  or,  in  some  cases,  for  mastoiditis.  In  diffuse  in- 
ilammation  the  swelliii;?  is  more  uniform  and  is  concentric:  m  furuncle 
it  is  ioc;iliz(>d.  and  even  with  mor(>  than  one  furuncle  sejjarate  swellings 
can  he  made  out  with  some  one  imint  of  each  which  is  most  sensitive. 
The  pain  on  ])ressiire  over  the  mastoid  is  found  to  he  superficial  rath(>r 
than  deep  .seated,  and  is  greater  on  pressure  toward  the  ear  rather 
tlian  toward  the  mastoid.  Without  treatment,  or  imi)roi)erly  treated. 
(ir  if  the  patient  is  debilitated,  furuncles  are  ai)t  to  recur. 

Treatment.  The  use  of  leeches  has  heeii  advised,  hut  is  of  little 
avail  in  relieving  i)ain.  Hot  applications  are  somewhat  soothing: 
lint  incision  is  the  most  etTective  means  for  relieving  the  i)ain  and 
cutting  short  the  inflammation.       I'.ven  if  done  before  the  formation 

,.|'  pus  the  les.seniiiir  of  tension  and  the  bl ling  following  free  incision 

l.ave  a  most  favorable  infhienc(\  .Vfter  incision  the  ear  should  be 
^  ringed  with  a  warm  antisei)tic  solution,  and  if  there  is  any  tendency 
ti.w.ird  recurrence  or  die  formation  of  granulation  tissue,  alcoholic 
M.hition  of  boric  acid  or  bichloride  of  mercury  should  be  dropped  into 
tl\e  ear.  The  lining  of  the  canal  may  remain  inflamed  and  sensitive 
following  the  eruption  of  furuncles.  Besides  the  annoyance  to  the 
patient,  this  state  leads  the  more  readily  to  the  formation  of  suc- 

1  New  York  Medical  Journal,  August  24.  1901,  p.  351. 
09 


mm 


lOltO 


Tin:  EAR. 


cossivc  series  of  boils.  It  is  tlicrofore  advisahio  to  inako  uso  of  soiiif 
sootliiii);  oiiitniciit  foliowiiifi  tiic  acute  staj^e,  ;us  tiie  (liaciiyloii  diluted 
with  equal  i)aits  of  "eold  ereaiu,"  or,  if  a  little  later  slif^ht  stiiiuilation 
he  indicated,  uiiji.  hydrarfj.  aniiuoniati,  oni'  part  to  two  of  "cold 
cream. "  A  vi;;(»r()us  plan  of  tonic  treatment  is  to  be  employed  if 
the  patient's  jjeneral  health  is  reduced. 

Diffuse  Inflammation.  This  may  occur  as  the  result  of  injuries 
to  the  canal  from  scratching  it  with  pins,  hairjnns,  etc.,  the  presence 
of  foreign  bodies,  or  roufjh  attempts  to  remove  them,  from  the  instil- 
lation of  irritating  fluids,  an  acrid  discharge  from  the  middle  ear,  or 
the  occurrence  of  fungi,  etc. 


Flu    ."iW). 


Bacon's  cuppiiiK  glass. 


Bacin's  >:parilioator. 


The  severity  of  the  symi)toms  varies  with  the  i)art  involved  and 
the  degree  of  inflammation.  The  i)ain  is  more  s(>v(>re  when  the  osseous 
portion  and  drum  are  involved.  The  hearing  is  impaired  mi  propor- 
tinii  to  the  swelling  and  piling  up  of  pus  and  softened  epithelium. 
After  tile  stage  of  serous  exudation  an  examination  of  the  canal  shows 
it  to  he  narrow  and  lined  with  a  whitish,  sodden  membrane  made  up 
of  epiilermis  and  [)us.  and  filled  with  micrococci.  The  n^moval  of 
the  softened  layer  uncovers  the  reddened  swollen  lining  of  the  canal. 
Promptly  treated,  the  process  may  end  within  a  few  days,  (jr  it  may 
go  on  to  the  chronic  form,  to  the  damage  of  the  canal  antl  the  drum 
menihr.'iiie 

Treatment.  In  the  early  stage  with  sev(>re  inflammation  l)l()o(l 
shoulfl   be   abstnicted   either   bv  leeches  or  with    liacon's  artificial 


OTOMYCOSIS. 


nm 


Icirli  iii)plio(l  near  the  trapis.  Irrigations  of  tho  canal  witli  a  hot 
antiseptic  solution  is  also  a(lvisal)lc.  If  there  is  much  swdhns  free 
incision  shoultl  i)e  iiiade.  After  the  subsidence  of  tiie  acute  syin|)- 
tonis  tiie  canal  is  to  he  carefully  cleansed  l)y  syrinsinR  and  dried  with 
llic  cotton-carrier,  and  boric  acid  and  oxide  of  zinc  in  ('(jual  i)art.s 
siiould  be  blown  in.  In  case  of  the  formation  of  granulations,  these 
are  to  be  removed  by  the  curette,  and  an  alcoholic  solution  of 
bichloride  of  mercurv  or  borolyptol  instiUed.  Strong  solutions  of 
nitrate  of  silver  are  often  ap])lied  at  this  stage.  Constitutional  treat- 
ment mav  be  recpiired  if  the  i)ati(>nt  is  much  reduced  in  general 
health. 

OTOMTCOSIS. 

Inflammation  with  or  without  discharge  from  the  external  canal 
mav  be  caus(>d  and  continued  by  the  growth  of  fungi.  The  inllain- 
niation  of  the  canal  excited  by  this  growth  is  termed  otomycosis. 
I'lic  fungus  most  comiii(.:..y  found  in  the  ear  is  asi)ergi!lus,  ot 
wliich  there  are  .several  varieties:   only  two,  however,  are  usually 


Fig.  r*i. 


XtpcrKill""  nistrlcans.     A.   Mjceliuin  oovere.l   with  numemiis  fallen  s|Hiri's.      B.   njpha.     C. 
Si-iraiiKiura  with   rii«  i.ports.      B'.    Hypha.     />.    Kcceplaeiilum.      E.    SieriKmatu  w.th    sixm's. 

I'ril.lTZEB.) 


tnr 

by 

ill 

:il' 

,'1111 

In. 

]m 

,|c( 

re;; 


•t  with,  aspergillus  nigricans  and  aspergillus  favescens,  nigricans 
far  the  most  fre(iuentiy.  The  growth  is  most  likely  to  flourish 
a  canal  which  has  been"  the  seat  of  disea.se  and  contains  exfoli- 
•d  epithelium,  or  into  which  oily  solutions  have  been  instilled 
1  allowed  to  remain.  Cases  are  said  to  be  relatively  frecpient  in 
lia  under  the  combination  of  heat,  dirt,  and  dampness.  The 
'sence  of  this  growth  maintains  a  chronic  otitis  externa  and  may 
,1  t'>  injnrv  of  the  canal  an<l  membrana  tympani.  When  the 
■per  layers  of  the  skin  are  involved  a  considerai)le  degree  of  pain 
ults.  and  in  anv  case  there  is  itching  or  irritation.     Tinr.itus  and 


m 


mm^ 


lori 


THE  EAR. 


i„„,ainn<-i.t  <.f  h-'arinp  attrn.l  the  tilling  of  tlic  canal  aii.l  tl.o  uiHani- 
ination  ..f  tl..'  .Iruiu  incn.l.raiu-.  The  ..crurroncc  <-!  as!..T};illiis  mgr^- 
cvx^  inav  hv  mistakci.  for  cmuiu-n.  This  error  should  he  rec.nnize.l 
o'„  reiMoVal  of  tli<>  mass,  as  its  eonsisteney  is  lu.t  that  ot  eerumeti. 
•uul  the  surface  exix.sed  in  the  meatus  is  foun.l  to  he  ml  an.l  swollen. 
TlK'  niifrosfopic  examination  renders  diaRiiosis  eertam  Ihe  j.roji- 
n,M-<  i-^  Rood.  Treatment  consists  in  tlie  cleansmj;  of  the  canal  and 
tl„.  use  of  antisejitie  solutions.  Solutions  of  l.ichloride  of  niercury 
in  alcohol  have  been  nuich  used  and  caiu.ot  fail  to  he  efficient  it 
„ersiste.l  in.  Considerable  time  is  often  re.iuired.  however,  and  b„ll, 
the  mercurv  and  the  alcohol  eau.se  much  smarting'  in  the  inHanie. 
canal  Dr"  Samuel  TheoboM'  recommends  the  msutllation  ot  e<iual 
parts', .f  boric  acid  and  <.xide  of  zinc  after  thoroufjlily  eleansuift  the 
,aual.  In  a  tvi-ical  case  to  which  he  ref.-rs  it  was  necessary  to  rep.-a 
the  ai.plication  but  once.  This  treatment  .s  adv.se.  1  for  the  utU'ndan 
inliammation  of  the  canal  as  well  as  to  .lestroy  the  tungi.  IheoboUl 
has  employed  this  treatment  for  seventeen  years. 


FOREIGN  BODIES. 

Foreign  bodies  mav  be  foun.l  in  the  external  auditory  canal  of 
b„th  childn-n  and  adults;  but  it  is  the  ear  of  the  chil.l  that  the 
„toloKist  is  most  freciuently  called  ui)on  to  explore  for  ost  tivasures. 
The  raiiffe  of  objects  which  may  be  found  in  a  child  s  ear  has  no 
limit  sav.'  that  of  size.  I.  adults  the  occurrence  is  the  result  of 
accident  or  the  entrance  of  an  animate  object,  as  a  buR  or  a  tly. 
The  eiiK^  of  the  common  house  fly  are  sometimes  deposite<l  m  a 
canal  containiiiR  pus.  The  subseciuent  development  of  the  larva- 
causes  a  condition  both  distressiiiR  and  disgusting.  Short,  stiff  hairs 
occa-^ionallv  fall  into  the  meatus  and  rest  against  the  membrana 
tympani.  and  the  movment  of  the  jaw  in  mastication  causes  friction 
imiduciiifi  annoyiiifr  symi)tonis.  •,<••♦ 

Symptoms  .\  h.reign  bodv  inav  lie  in  the  meatus  for  an  indefinite 
period  and  give  rise  to  no  svmi.toms.  There  is  no  lack  of  record.M 
instances  of  the  tindin-i  <.f  such  b.-dies  which  have  lam  m  the  canal 
for  manv  years.  Oceasi.mallv  the  dislodgement  of  such  an  object, 
which  has  "caused  no  annovance.  brings  it  in  contact  with  a  sensitive 
part  giving  rise  to  severe  svmi)toms.  Some  sub.stances.  such  as 
bcan"^  or  s<'<'ds.  which  swell  on  being  nu.istened,  cause  distres.s  after 
sea-bathing,  for  example,  or  in  case  the  -anal  is  filled  with  pus  from  a 
supt.urativ.'  otitis  media.  ( )n  the  whole,  howe'  (T,  the  worst  symj-toms 
caulked  bv  foreign  bodies  result  from  the  uiskhful  attemi)ts  at  removal 
on  the  i)art  of  frightened  relatives  or  inexperienced  physicians. 

Diagnosis.     If  the  patient  be  sec>n  befoi.-  any  attempts  at  renioval 
have  been  made  diagnosi>  is  ordinarily   a  simple  matter.     \<mr. 

I  Johns  Hopkira  Hospital  Bulletin,  1898,  toI.  ix.  p.  i)l. 


FOREIOS  BODIES  IN  TUE  EAR. 


1093 


lildrcii.  howovcr,  arc  so 


iliicc 


t  was  inserted,  and  are  so 


inietinies  unal>le  to  say  what  kind  of  an 
unnumageable  that  no  satisfactory 


ixaniinatioii  can 


he  made.     In  surh  ciu^e  tlie  i)atient  sliould  Ik-  ether 


1(1  treatment  are  comparatively  snnj 


.ie.     In 


lation 

;;',l,;:r  cases  the  canal  lias  be.-n  s..  injured  by  unsk.iiui  'nx*'"'!'^'^  ";; 
.....novai  that  the  foreign.  J.o.ly  is  conceal.-.lhy  ,lru-d  b  bod  or  by  the 
swollen  walls  of  the  canal,  and  the  diapiiosis  is  i  iHicult 

Zgn^s.    The  canal  is  .[uite  tolerant  of  fore.gii  bodies,  and  the 
„n.Knasis  de,.ends  rather  upon  the  viol.-nce  which  \v^  been  done  to 
e    arts  by  rough  attcnpts  at  removal  than  upon  the  character  o 
.  ,  j,.et  in  tl...  canal.    Should  inH'i"'"'ation  a  n.uly  have  extended 
,,,  ndiacent  ,.arts,  as  the  middle  .-ar  or  mastoid,  this  is  indicated  by 
-viiiDtoms  iM-culiar  to  involvement  of  those  regions.       ,    .      .      . 
■  T;eatment.    The  means  to  be  adoi)ted  for  the  removal  of  a  foreign 
|„„lv  will  depend  upon  its  size,  shaj-e,  and  cliaracter,  and  whether 
,     canal  is  much  Swollen.     If  the  object  is  not  large  the  syringe 
.hould  be  used,  since  it  affords  a  j-rompt  and  painless  method.     If 
i,  1,0  a  s..ed  which  swells  on  being  moistened,  and  is  not  at  once  re- 
iMoved  bv  the  svringe,  instruments  are  to  be  employed     Ihe  blunt 
...>,'     '  e  hook  are  hen>  likely  to  be  most  useful.     If  the  object 
M    such  shape  that  it  can  be  securely  gra.spe.l  by  the  slender  forceps 
hi    i,   t vament  mav  well  be  us.-,l;    but  many  foreign  bodies  are 
nde     ml  hard,  so  that  the  attempt  to  grasp  them  with  the  foiceps 
rcis  them  more  deeply  into  the  canal.    This  instrument,  there- 
re   must  never  be  emph.yed  unless  there  is  positive  assurance  that 
io    g  asp  can  be  ha.l.     When  the  object  is  round    like  a  gUu^ 
l„.n  1   a  pebblo,  ora  fruit-pit,  and  large  enough  to  quite  fill  the  canal 
; .  .'tiig  a  stream  upon  it  from  a  syringe  but  forces  it  further  toward 
.  f  ndus      Bv  searching  carefully  some  point  will  be  found  where 
•ri    a  little Ipace  between  the  object  and  the  canal  wall,  and  the 
1 'ouk  ia^Jied  flat  can  be  pa^ssed  behind  the  body,  when,  by  giving  the 

Fio.  562. 


ff  t^ 


Fiu.  563. 


30C= 


Hooks  for  removal  of  foreign  bodies. 

i,w.n.ment  a  quarter  turn,  the  sharp  p.Mut  wnll  be  in  position  Jo  ,iraw 
the  object  out  The  blunt  curette  may  perhaps  be  more  safel>  used- 
;l:.nv''event  nc-such  manipulation  is  to  '--♦^^^J^^l'-'-Ji;  ^l'  ^ 
,„„.l  illumination.  To  lift  a  sniooth,  round  body  ""' ;^^™7/J 
,...,.  ,.,„.al  the  use  of  a  camel's-hair  pencil  dij-ped  in  cemen  or  th  cK 
hu-  h  s  been  suggested.  The  object  an,  canal  must  b.-  tlioroug..^ 
dried  t  a   the  glSmay  harden  and  sufficient  time  be  allowed  for  the 


.'"  -,.    ,  T  fj 


.  lnna  .A.V.-^*' 


m 
i  f  i 


; 


:   i   ! 
ii\ 

ill 

i!i 

•  J  ; 

!'t: 


i.i 


iin 


^r 


li 


•Mi 


10i)4 


THE   UJi 


cement  or  pliio  to  boromc  lixcd.'  Wlicii  tlic  Iditijin  IxmIv  lias  hocoiin- 
iiniiiictcd  ill  tlic  l)oiiy  portion  of  the  f;inai  and  tlic  cartilafiinoiis  jxir 
tion  is  so  swollen  that  tlie  ohjeet  eainiot  be  removed  by  any  ordinary 
nifans  at  eommand  the  radical  proeediwe  of  disiilacemeiit  forward  of 
lh(  auricle  and  soft  parts  of  tin  meatus  must  be  em|iloyed.  I'lider 
ana'sthesi.:  the  tibrocartilafiinous  canal  with  the  adherent  periosteum 
is  separated  from  the  bone  posteriorly.  A  transverse  incision  is  made 
in  the  canal  as  near  the  drum  memi)rane  as  possible,  and  the  foreign 
body  removed.  Should  the  foreifin  body  be  too  larp-  for  extraction 
through  this  opening',  Deiich  ailvises  that  the  space  be  enlarjied  by 
chiselliiifi  away  a  sullicient  |)ni   ion  of  bone. 


WOUNDS  OF  THE  MEMBRANA  TTMPANI. 

Wounds  of  the  membrana  tympani  commonly  occur  as  a  result 
of  the  direct  jienetration  of  a  forei<:n  body  or  from  the  sudden  con- 
densation of  air  within  the  auditory  canal.  The  membrana  tympani 
mav  be  ruptured  in  fracture  of  the  cranial  bones;  but  it  is  liei.  a 
matter  of  trifling  importance  in  comparison  to  the  lesion  which  it 
accompanies.  The  drum  membrane  may  be  laci'rated  by  any  one 
of  the  numerous  objects  which  |)atients  insert  into  the  meatus  to 
relieve  itchins;  and  irritation.     An  accidental  movement  of  the  ear- 


Sexton's  foreign-body  forceiB.    (Two-thirds  imtiiml  size.) 

spoon,  tooth])ick,  end  of  a  pen-holder,  etc..  may  penetrate  the  mem- 
brane. The  writer  has  seen  one  case  in  which  the  meatus  and  mem- 
brana tymi)ani  were  woimdcd  by  the  entrance  of  the  tiji  of  a  branch 
of  a  tree.  .\  younp  man  en<:ajjed  in  trimminfr  an  ai)lile  tree  made 
an  unsruarded  movement  of  the  head  to  one  side  and  drove  a  small 
jirojecting  blanch  deejily  into  the  meatus.     Another  peculiar  accident 

'  See  I'olitzer.  l<in,  p.  223. 


Il^-Jt- 


M'orSDS  OF  THE  MKMJlBA\.i  TYMPAM. 


lO'Jo 


vva-  sustaincl  bv  a  wniiiiui  wliilo  walking  in  tl.c  (■..untry      Sho  was 
,„,;,„  a  narrow  i.atli  wl.cn  l.i.-yclc  ri.lrrs  canic  u]>  l..-lnn.l  her.     M.e 
.  ,.,,,,,.,1  asi.l.- 1..  atluw  then.  t..  pass,  and  n-cMv...!  a  ponrtratinp  womu 
„f  ll',.  ,„,.n,l.rana  tvn.pani  from  a  small  walking'  stick  winch  one  of 
il,,.  riders  carclcs-!v  carried  projecting:  fn.n.  Ins  handle  bar      Lonp- 
,„„,i„„e,l  sni.pnration  followd  this  ac.'id.^nt.     A  larp'  pcrtorat.on 
,,,  ,i„.  „,e,„hrana  tvn.pani  remains,  and  theheann-  is  n.uch  i.ni.a.re.l 
■n„.  appearance  of  the  wound  will  deixn.l  on  the  f<.rm  an.l  size  ..f 
,1„.  nl'jeet  which  causes  the  injury  and  upon  the  l.-nf:th  to  time  which 
1,.,.  elai.s..d  hefoiv  the  case  comes  under  observation.     H  the  wound 
iJ  .Made  l.v  a  relativ.'lv  laifie  ol.j«'ct  a  considerable  cntusion  rather 
,1,:,„  laceration  follow^  the  injury,  attended  by  sul.sequent  milamma- 
,i.,„  and  sl.M.sihinf:.     All  th.-se  woiiiuls  are  .luite  like  y  to  be  l..llovve.l 
l,v  inllammation  and  supp.irati.m.  perhaps  as  a  result  ot  diirct  mlec 
,i„„  at  the  time  of  the  accid.-nt.     The  symi.toms  atteiul.nR    uch  an 
,,..idei.t  are  sevr.-  pain  an.l  tinnitus,  with  fainting  or  pd.hn.-ss  and 
|n.s  of  hearing.     The  acuteiu-ss  of  the  symptoms  subsides  son...whaf. 
but  the  l.ain  and  tinnitus  again  increase  cm  the  approach  ot  intlam- 
,„ali,m.      bong-continued   snpi.uration   an.l   p.Tnianent    p.'f  .-rati.... 
„tt.-n   ivsult   from   the.se  acci.lcnts.     The  thick.Miing  an.l   a.lh.-s.ons 
which  att.Mi.l  \hv  inilammatory  pr.K-ess  result  in  p..rman."nt  l..ss  ot 
h.aiing.     The  treatment  t..  be    f..llowe.l  in  these  ca.ses  is  that    Dr 
acute  iJiirulent  ilisetuse  of  the  middle  ear. 


Flo.  665. 


Fio   56*. 


FIG.  567. 


F.«.  56...-Rupture  la  the  anterior  inferior  half  of  the  membrane  of  a  lx,>  after  a  ix,x  ou  the  ear. 
"";■; "  V*  inouble  rupture  o.  the  membrane  of  a  woman  thirty  years  „.  age,  caused  by  a  fall  upon 

(■,n.>eil  by  a  large  box  falling  upon  her  ear.    (1'olit/.kk.) 

liuphircol  the  wrmhrmm  ///'"Z'""'  from  c.m.lonsation  ..f  -lir  wit'ain 

,h..  m.-atus  n.av  b.'  .lue  to  bl.-ws  upon  the  ear,  "a  b..x  on  the  ear 

l„.i„jr  the  m..st"  riv.iuent  illustrati.m  ..f  this  torni  of  in,liiry.     A  tal 

,  ,m  t  e  ear  mav  <4iso  the  sam.-  form  of  .lamag...  as  als.>  the  impact 

wnve     hilo  i.athing.     lAl-l.-sions  an.l  th(-  firing  of  heavy  cannon 

;;!.;..  Z  ^ause-ltlns  injury.'    C-rtain  con.liti.ms  .,f  the  n.mbraiia 

.vMH.nni  favor  the  occurn-n.-e  .,f  this  form  ..f  in,iury.  ami  these  are 

,■„'  •  tn.i.hv   calcareous  .leposits,  an.l  cicatricial  formal  ions,     (insure 

;,f  illi  EusUichian  tube.  to.,,  by  preventing  the  reatly  escape  of  air 


109G 


rilK  KAK. 


within  the  middle  oar.  favors  rupture  of  the  nioinbranii  tyinpiini  under 
tlie  conditions  named.  Tiie  syniitoin.'  eaiised  l)y  tliis  aceident  are 
the  s;ensation  its  (tf  a  loud  report,  jjreat  pain,  giddiness,  and  tinnitus. 
The  decree  of  impairment  of  hearinj;  depends  upon  the  (himage  done 
tlie  labyrinth  hy  the  roneussion.  If  this  is  .slicht  the  hearing  will 
prohabiy  he  Imt  little  impaired,  while,  if  considerable,  fiernianent 
deafness  and  tinnitus  follow.  The  mere  tear  in  the  nienibrana  tyni- 
pani  is  not  a  serious  matter,  for  it  soon  heals.  If  the  case  be  examined 
shortly  after  the  acciilent  it  will  be  (piite  pos.sible  to  differentiate 
between  it  and  an  old  i)erforati()n.  The  sh.ii)o  of  the  rujjture  is 
u-sually  oblong,  with  oval  sides  and  pointeil  extremities.  The  edges 
of  the  opening  are  thin,  sharply-defined,  and  show  blood-stains. 
Through  the  opening  the  inner  wall  of  tlie  tymjianic  cavity  is  .seen, 
not  changed  in  color  by  inflammation,  and  thus  differing  from  the 
apiiearanee  in  urdinary  jierforations.  Politzer  says  that  upon  infla- 
tion by  the  \alsalvan  method  air  pas.sed  through  the  ear  much  more 
freely  than  in  the  ca.se  of  orilinary  perforation,  and.  instead  of  the 
liigh-i)itclird  hissing  sound,  there  is  a  free,  deep,  blowing  souiitl  if 
the  accident  has  happened  to  a  normal  ear.  If  the  ca.se  is  not  c(un- 
plicated  bv  concussion  of  the  labyrinth  the  course  followed  is  usually 
favorable.  Only  rarely  does  suppuration  occur,  and  this  is  connnonly 
attributed  to  unwise  and  too  active  efforts  to  .aid  the  healing  process 
by  the  use  of  instillations.  Permanent  openings  are  more  likely  to 
result  from  such  interfiTence  than  if  the  ca.se  be  left  alone.  Treat- 
ment consi.sts  in  non-interference  beyond  simply  sterilizing  the 
external  portion  of  the  meatus  and  protecting  the  tympanic  cavity 
by  the  use  of  stoiilized  cotton  worn  in  the  meatus. 


Hi   : 


17  i 

Hi 


m 


ill 


tin 

ml 


i  I 


CHAPTER    XXVI. 

DISEASES  OF  THE  INTERNAL  EAR  AND  AUDITOUY 
NEUVE;  DEAF  MUTISM. 

Hy  K.  a.  CROCKKTT,  M.I). 

Anatomy  and  Physiology.  Tl.o  intcmul  car  consists  cf  tlic  ccrc- 
1„;,1  |,.,rti.ii.  of  tlH-  au.litorv  iutvc,  its  trunk,  an.l  its  cndn.Ks  n.  the 
lil.vrintli,  the  latter  eonsistinfi  of  the  osseous  liihyruitii,  cnveloi-mR 
til,."  vestilnile  three  semicircular  canals,  and  the  cochlea,  tonclher 
xvith  the  membranous  lahvrinths  contained  witlun  the  former,  the 
-iccule  and  utricle,  memtmmous  semicircular  canals  and  nici  .- 
liranous  part  of  the  cochlea.  The  foratnen  ovale  opens  into  t  e 
vestibule  as  also  do  the  mouths  of  the  three  semicircular  canals, 
hv  two  (IpeninRs,  the  superior  and  posterior  op(>ninR  as  one  Tin- 
vi'stibule  itself   is  an  irregular  cavity  from  4  to  b  mm.  in  its  dit- 

ferent  axes.  ,  .      ,  ..•         r  4V,„ 

The  semicircular  canals  lie  embedded  m  the  petrous  portion  of  the 
temporal  bone,  on  the  upper  surface  of  which  the  superior  project 
a^  the  eminent ia  arcuata.  They  lie  in  three  i)lanes,  superior,  posterior, 
•md  horizontal.  The  exterior  portion  of  tJie  latter  projects  into  the 
inner  wall  of  the  tvmpanic  cavity  behind  the  Fallopian  canal,  bach 
canal  is  dilated  at'its  beginning  into  the  so-called  ampulla. 

The  cochlea  is  a  canal  about  30  mm.  long,  turning  two  and  one-half 
times  around  a  central  axis.  It  communicates  with  the  vestibule  and 
•d-o  bv  means  of  the  fenestra  rotunda,  with  the  tympanum.  It  is 
,.nib'e.lded  in  the  petrous  portion  i,i  the  temporal  bone  between  the 
int.TTial  auditorv  meatus  and  the  carotid  canal,  with  its  base  toward 
tlie  internal  uuiitorv  meatus  and  apex  towanl  the  tympanic  cavity. 
On  a  vertical  .section  of  the  cochlea  we  see  the  modiolus  ()r  central 
canal,  and  on  its  surface  an  osseous  plate-the  lamina  spiralis  ossea 
-  beginning  between  the  fenestra  rotunda  and  the  vestibular  orihce 
of  the  cochlea  and  running  spirally  to  the  cupola,  where  it  ends  in 
the  p..inte<l  hamulus.  Hy  this  ridge  the  canal  of  the  cochlea  is  sub- 
divided into  the  scala  vestibuli,  communicating  with  the  vestibule, 
and  the  scala  tvnii.ani,  communicating  with  the  tympanum  by  the 
fenestra  rotunda.  The  two  scahe  communicate  with  each  other  at 
the  apex  of  the  cochlea  bv  the  helicotrema. 

The  membranous  labvrinth  follows  in  most  part  the  contour  of 
,he  osseous,  just  described.  The  menibranous  vestibule  ,s  sub(liyide,l 
into  the  utricle  an.l  the  saccule.  The  utricle  communicates  w.  h  t he 
semicircular  canals  by  five  openings,  the  saccule  with  the  ductus 

(  1097  ) 


rasra^^H 


«rf 


109« 


TllK  EAR. 


i 


1 1 


i  * 


iii 


cDclilciiiis.  lictwccii  Ixith  and  tin-  lateral  wall  of  tho  vostihulo  is  a 
very  (Miisidi'iahh-  s|»aci'  tilled  with  pcrilynipli.  The  form  of  the 
iiiciiihraiioiis  sciiiicircular  canals  is  exactly  thai  of  the  osseoiw,  and 
they  fill  the  cavity  of  tin-  latter  alxnit  one-third.  They  are  station- 
ary, heinj;  fiistened  to  the  sides  of  thi'  osseous  canals  by  connective 
tissue,  and  the  intervening  space  is  filled  with  ixTilyniph. 

The  most  coniph'x  structure  found  in  the  internal  ear  is  the  ineni- 
hranous  structure  and  termination  of  the  auditory  nerve  in  the 
<'o<'hlea.  Sprinninn  from  the  free  edjie  of  the  lamina  sjiiralis  ossea 
to  the  proji'ctinj;  li^i.-unenium  spirale  of  the  o|)posite  wall  is  the  mem- 
branous s|)iral  lamina.  This  diviiles  the  cuial  of  the  cochlea  into 
the  scala  vestibnli  and  seala  tyinpani,  and  ihi'  former  is  apiin  divided 
by  till'  membrane  of  Ueis.suer,  which  extends  obli(|uely  from  the  lamina 
spiralis  o.s.sea  to  the  external  wall  mto  two  canals.  One  of  these,  the 
cai.alis  cochlearis,  formed  by  the  membraiia  iKtsilaris,  external  wall 
of  the  cochlea,  and  membrane  of  Heissner,  communicates  with  the 
saccule  and  ends  in  a  cul-de-sac  at  the  top  of  tlie  cochlea,  and  contains 
the  elaborate  structure  known  as  the  oifiati  of  ("orti. 

An  exact  understamliti^  of  the  mechanism  by  which  the  sound- 
wave is  transmitted  from  the  middle  ear  to  the  brain  is  impossible 
with  otir  present  knowledge.  The  vast  majority  of  ol)serV(>rs  believe 
that  the  sound-wave  reaches  the  labyrinth  by  way  of  the  lm.se  olate 
of  the  stajM's  rather  than  via  the  round  window.  The  perilymph, 
beinR  an  incom|)ressible  fluid  contained  in  an  unyieliling  medium, 
receives  re])eated  shocks  from  the  piston-like  motion  of  the  stapes' 
ha.se  plate.  These  shocks  are  first  received  by  the  perilymph  of  the 
vestibule,  then  by  that  of  the  scala  vestibnli,  then  by  way  of  Heis.s- 
ner's  membrane  to  the  endolymph  of  the  ductus  cochlearis.  By  the 
vibration  imparted  to  the  lamina  s])iralis  mi-inbranacea  these  shocks 
ar(>  received  by  the  perilymph  of  the  scala  tynipani,  and  the  outward 
and  inward  movement  of  fli<'  membrane  of  the  roimd  window  com- 
pletes the  circle.  Presumably  the  end  organ  of  tlie  auditory  nerve 
is  to  be  found  in  the  cells  of  Corti's  organ,  and  each  cell  vibrates  in 
sympathy  with  a  fixed  t>>iie,  and  no  other. 

As  to  the  semicircular  canals,  the  results  of  Flou;  early  experi- 
ments have  been  acce])ted  by  most  writers  to  prove  that  they  ])oRses.s 
no  part  in  the  perce|)tion  of  sound,  but  are  organs  nf  ecpiilibration. 

The  organ  of  Corti  lies  in  the  zona  arcuata  and  consists  of  an  imier 
and  outer  layer  of  fibres,  the  lower  portic^n  resting  on  the  membrana 
basilaris,  and  the  upper  ends  are  coimected  together.  The  outer 
row  present  on  their  upper  ends  lamelliform  processes  on  which  is 
fastene<l  the  lamina  reticularis.  The  cilia  of  Corti's  cells  project 
through  the  oi)enings  of  the  lamina  reticularis,  the  lower  jiortion  of 
the  cells  res'  g  on  the  menibrana  basilaris,  and  they  are  connected 
with  the  .luditory  nerve  bv  thin  filaments. 

No  exact  part  in  the  perce|>tion  of  sound  has  l)een  ascribed  to  the 
vestibule,  although  some  observers  think  that  the  otoliths  may  act 
as  dampers  in  diminishi.ig  the  force  of  the  sound-wave. 


DISEASES  OF  rUE  L\TE1{.\AL  E.IU. 


lO'JD 


The  rxnrt  cM)iirs<-  of  the  auditory  iktv.-  l)(>foiv  it  enters  tlio  ix-trous 
noition  of  the  teiiii)or!il  hone  is  still  in  disi.iite.  It  iiris.s  in  the 
iixMiulla  oblongata  hetw.-en  the  facial  a-  '  -lossopl.arynneal  nerves, 
and  is  easily  divide.l  into  two  seetions:  i.  .  ..•■r  hraneh  supph'-s  the 
(dchlea,  entt'ring  at  the  modi  >lus,  and  also  sends  a  Itraneh  to  the 
••Micule  and  ampulla  of  the  vertieal  semieireular  eanal.  The  upper 
hianeh  enters  the  vestibule  and  supplies  the  utrieulus  anil  the  amiuillii 
of  the  semieireular  eanal. 

The  blood  supply  of  the  internal  ear  is  derived  from  a  braneli  ()f 
liie  basilar  arterv,"  whieh  enters  the  internal  auditory  meatus  with 
ihe  auditorv  nerve.  The  r.'turn  supply  is  into  the  inferior  j.etrosal 
-inus,  and  there  is  an  ana.-*tomosis  with  the  tympaiiie  vessels  through 
the  external  labyrinthine  wall. 


DISEASES  OF  THE  INTERNAL  EAS. 

These  are  primary  and  seeondary,  and  have  been  oonsidered  as 
forming  a  >mall  proportion  of  the  total  number  of  ear  disea-xes;  but 
it  is  eertain  that  the  more  careful  the  observation  the  greater  the 
number  of  labyrinthine  ca.<es  recorded. 

The  most  connnon  primary  diseases  of  the  internal  ear  are  hemor- 
rhages from  fractures  of  the  temporal  bone,  and  from  the  active 
changes  common  in  nejihritis,  diabetes,  and  syjjhilis,  and  injuries  to 
tiie  auditory  nerve,  either  in  its  course  or  termination,  by  blow.s  on 
the  head,  or  pressure  of  new-growths. 

liv  far  the  most  common  secondary  disease  is  the  invasion  of  the 
vestib-  le  bv  osseous  changes  in  the  neighborhood  of  the  base  i)late 
<if  the  stajies.     Purulent  jjrocesses  in  the  labyrinth  by  extension  of 
a  middle-ear  sui)puratioii  are  a  rare  but  very  serious  complication. 
I'ractures  of  the  petrous  portion  of  the  temporal  bone  may  cau.se 
deafness  by  a  direct  solution  of  continuity  of  some  portion  of  the 
auditory   nerve,   or   from  the  resulting  hemorrhage  ilestroying  the 
nerve  fibres.     Infreiiuently,  severe  head  injuries  may  cause  hemor- 
rhages into  some  jKtrtion  of  the  internal  ear,  without  fracture  of  the 
lemjioral  bone.     The  svmptoms  in  both  these  conditions  are  essen- 
tially the  same.     The  deafness  is  practically  complete  in  the  extreme 
cases,  although,  as  a    rule,  aerial  tone-perception  may  remain  for 
>ome  portion  of  the  scale.     In  the  le.'ss  severe,  a  portion  of  the  musical 
scale  may  be  struck  out,  usually  in  the  high  tones,  the  remainder 
bring  vuiaffected.     With  this  deafness,  which  is  commonly  at  its 
maximum  iminediatelv,  are  a.ssociated  vertig(,,  nausea,  or  vomitmg, 
,111(1  a  loud  and  jHTsistent  tiimitus.     In  severe  cases  the  vertigo  may 
be  so  "xtreme  as  to  prevent  the  patient's  moving  even  from  side  to 
<ide  in  bed,  or  walking  without  .supjjort.  for  one  or  two  weeks,  and  in 
such  cases  the  vomiting  is  very  i)ersistent  and  may  necessitate  rectal 
feeding.     These  severe  -ises  are,  of  course,  ai)t  to  be  confused  with 
tli(>  cerebral  symptoms  ui  head  injuries;  but  the as.sociatiou  of  vertigo, 


IKN) 


Tilt:  KAR 


tiaiwa  or  vomiting,  tinnitus,  an<i  .icafm-ss  in  tlic  aliKcnco  of  dtlur 
ciTfl.ial  sy!iii>tiMn.s  sliouid  niakr  llit'  diaRnosis  df  tin-  average  caw 
p«'rl'ccllv  clt'ar. 

In  such  patit-nts  tlic  prognosis  as  to  tiic  relief  of  symptoms  is  very 
im|M.rtaiit  in  a  medico-lejiai  way.  Tlie  deafness  is  almost  always 
incural)le  and  permanent.  l)ut  non-progressive.  The  yertigo  and 
timiitus.  esi)erially  in  ca-ses  where  only  one  labyrinth  is  involveil, 
often  aimoy  the  patient  more  tlian  the  deafness,  ami  it  is  extremely 
dillicult  tolw  definite  as  to  the  leiijith  of  time  they  will  persist,  exri^jit 
l)V  wat<'hiiip  the  course  of  the  case.  The  vertino  often  remains  for 
n'loMllis,  uraihiallv  .liminishinn  in  inten>ity.  and  the  tinnitus  is  fn- 

(lueiilly  a  matterof  years.     ( )ccasionally  nystapnus  will  1 I>served 

in  laltyrinthine  injuries  and  also  in  operative  interference  with  the 
stapes  base  plate. 

.\  pr.'ciselv  similar  .symptomatology  is  ohservod  in  the  hemorrhages 
from  arterial  deneneration  in  syphiJis,  nei-liritis,  dialx'tes,  and  the 
severe  ana'Uiias.  Where  the  hemorrhage  is  irge  the  deafness  is 
exlieme.  and  the  nausea,  vomiting,  an.l  timiitus  severe.  In  these 
persons  the  attack  is  often  a|M)plectiform:  tiie  vertigo  .seizes  the 
patient  when  he  is  |)urs\iing  his  usual  occupation  or  while  asleep, 
often  he  falls  to  the  ground  without  any  warning,  with  severe  vomit- 
ing lasting  two  or  three  hours.  Such  cases  are  often  wrongly  tliag- 
nosed  as  cereliral  hemorrhage;  l)Ut  in  the  aliseiice  of  any  loss  of 
consciousness  or  of  any  local  jianUysis,  the  group  of  .symptoms  is 
plainlv  aural. 

Whili-  the  severe  cases  are  relatively  rare,  milder  forms  are  common 
in  the  practice  of  every  aurist.  Transient  attacks  of  giddiness  with 
timiitus,  hut  no  nausea,  are  quite  conunon  in  arterial  degeneration, 
and,  as  the  accomiianying  deafness  may  he  in  the  upper  registers 
only,  it  is  frequently  overlooked.  In  si. eh  cases  the  e.ar  comi)lication 
may  be  the  first  symptoms  of  the  general  disorder  and.  of  course, 
any  treatment  imist  be  general  and  not  local. 

this  grou])  of  symptoms  coming  on  in  the  course  of  sy])hilis  is 
much  mori'  common  than  is  supposed,  and  may  be  either  hereditary 
or  acquired.  The  latter  comes  either  in  the  late  secondary  or  ter- 
tiary .stages,  sometimes  ten  or  '-'teen  years  after  the  primary  lesion. 
Such  ca.ses  usually  yield  to  ai)l>-'priate  syphilitic  treatment,  and  also 
show  a  remarkar)le  tem|)orary  ;;iiproveinent  undiT  the  use  of  pilo- 
carpine either  by  nunith,  or  better,  subcutaneously  in  full  do.ses  of 
one-eighth  to  one-<|uarter  grain  once  or  t»vice  a  day.  It  nvist  not 
be  forgotten  that  this  is  only  a  transient  improvement,  and  should 
lie  su|ii'lemented  by  the  regular  treatment  for  the  usual  length  of 
time.  In  these  syphilitic  cases,  especi.ally  in  the  tertiary  lesions,  a 
correct  diagnosis  is  often  not  made  for  a  hmg  time,  and  unless  the 
proper  treatment  is  begun  within  a  week  of  the  onset  of  the  e.ar 
pym]itoms.  imiirovement  in  hearing  must  not  be  ex])ected:  but  the 
use  of  ])ilocarpine  will  relieve  the  vertigo  months  after  the  occurrence 
of  the  attack. 


DlSKA.sKS  i>F  Tilt:  ISTKKSM.  KAH. 


1101 


This  wnii-  uniiip  of  syinptDiiw  in  ofli-n  pnwiit  in  slight  liihyrintliiiir 
,|,pmrati..i»  from  any  ••uumc  Thic  is  particularly  triif  wIhtc  ii 
tliiikfiiiiij;  rxists  alioiit  tin-  stapes  l)as<'  platf  or  tin-  iiifiiiltraiii'  of 
ihr  rouiitl  wini'.ow,  so  that  tlif  nioWilily  of  oiu-  or  tiotii  of  tl;''  r  stnir- 
hUfs  is  atTfctfd.  Where  tliere  is  any  increase  of  pressiu:  in  the 
liihyrinlh  coniiM-nsation  cannot  l)e  made,  as  is  usual,  liy  the  outward 
movement  of  thene  structures,  anil  vertijjo  results.  The  inerea.se  of 
deafness  may  U-  sli^iit,  hut  is  always  perceptible.  Numerous  attack*' 
o|  vertifjo  from  this  cause  are  ohserved  in  the  course  of  fixation  of 
ilic  stapes  in  middle-iar  thiekiMiinj!. 

Suppurative  Processes  in  the  Internal  Ear.  These  processes  arc 
always  secondary  to  middle-ear  suppurations  and  form  a  rare  com- 
plication of  thi.s  disease.  The  ciiurse  of  the  purulent  iiitlammatiou 
is  usually  tlirounh  the  foramen  ovale  or  the  foramen  rotuiula.  and 
ilic  lahyrinlli  alone  may  be  involved:  but  often  tin-  purulent  process 
extends  to  the  middle  cerebral  l'os.sa  throunh  the  internal  auditory 
meatus. 

In  acute  purulent  inva.sions  of  the  labyrinth  the  symptoms  are 
iinmistakabh — the  vertigo  is  very  st'vere,  with  vomiting  lasting 
li.r  hours.  In  two  cases  which  the  writer  has  seen  the  vomitinp  wa.s 
-c,  extreme  as  to  necessitate  rectal  feedinfj  for  two  or  three  days. 
The  de:ifness  is.  of  course,  total  .soon  after  the  onset  of  the  attack. 
If  the  process  extends  through  to  the  cerebral  fossa'  the  symptoms 
,,l  miiiingilis  foHow  those  of  the  labyrinthitis  in  from  twenty-four 
to  fortv-ei<;ht  hours. 

In  invasion  of  the  internal  ear  a.«<  a  result  of  chronic  suppurative 
proce.s.ses,  the  characteristic  symptomatology  is  absent  in  most 
p;iticnts,  and  wo  merely  find  a  deafness  of  a  higher  grade  than  can 
lie  HiM'l'Uted  to  an  uncomplicated  middle-ear  suppuration 

In  removing  secjuestra  from  the  r.nddle  ear  or  mastoid  tlu  oi'erator 
will  occasionally  hud  portions  of  the  labyrinth  in  the  desiroyed  bone. 
;iiid  a  number  of  ca.ses  of  removal  of  the  whole  labyrinth  have  been 
reporte.l.  These  slow  suppurations  are  usually  the  result  of  neglect 
(if  the  preceding  middle-ear  |)rocess,  and  are  obser\-ed  more  fre(|uently 
after  neglected  scarlet  fever  or  diphtheria  or  in  the  course  ()f  tuber- 
(•ulosi>  of  the  temporal  bone:  but  they  may  occur  from  infection  with 
;iiiv  of  the  pathogenic  bacteria. 

In  chronic  caries  and  necrosis  infection  of  the  meninges  is  nuich 
le~<  likely  thai'  in  the  acute  processes,  owing  to  the  thicki'iiing  of 
the  dina  over  the  disea.sed  bone. 

In  any  extensive  caries  of  the  petrous  portion  of  the  temporal  bone 
!!ie  facial  nerve  is  almost  certain  to  be  jiaralyzed,  and  this  may  bo 
the  first  symjUom  leading  us  to  suspect  that  a  simple  acute  middle- 
••.ir  sujipuration  has  become  converted  into  a  more  serious  affair. 
Such  a  jiartdysis  may  bo  partial  or  total,  according  to  the  extent 
"I  till-  iiijurv. 

Involvement  of  the  facial  nerve  must  not  bo  considered  as  diag- 
nostic of  labvrinthitis,  as  tho  nerve  may  bo  involved  in  the  tym- 


■ai^p 


vil  , 


IMr, .'.  Ji<*m 


tM0a^."im'^f:. 


\    .    < 


1102 


Till-:  ICAJi. 


imiiic   portion,  and  espcfially  in   the  luigiihoiliood  of   the  niastoiil 
aiitiiini. 

Ill  llic  al)S('nco  of  symptoms  of  mcninfiitis,  cerebral  abscess,  or 
tiiroinl>osis  of  any  of  the  cranial  sinuses,  the  i)roKnosis  of  caries  (if 
the  lal>yrinlh  under  treatment  may  be  considered  gooil.  The  fatality 
is  much  hij^her  in  the  acute  ca.ses  than  in  the  chronic.  Tiie  prognosis 
as  to  hea:in>;  is  absolutely  bad.  although  a  few  cases  have  been  re- 
jMirted  whi're  some  trace  of  hearing  remained  after  exfoliation  of  the 
cociilea.  The  facial  nerve  will  occasionally  resume  its  functions,  even 
after  v(>ry  extensive  .se(iuestra  have  been  removed. 

The  treatment  of  such  ca.ses  nui.-^t  be  determined  by  the  symi)toms 
of  the  individual  patient.  In  acute  infection  oi  the  internal  ear 
fr<.m  the  mid<lleeur  the  most  radical  surgery  should  be  resorted  to 
in  view  of  the  much  higlier  fatality. 

In  the  more  chronic  ca.-^es,  and  especially  in  young  children,  an 
ex])ectaMt  treatment  by  .syringing  and  ordinary  surgical  cleansing 
may  be  advisable  until  nature  has  establishe<l  a  definite  line  of  tiemar- 
calioii,  as  in  such  ea.-^es  the  risk  of  setting  u])  cerebral  inflammation 
or  of  woumling  the  internal  carotid  artery  at  some  jioint  of  its  course 
through  the  petrous  portion  of  the  temixiral  bone  is  nmch  dimin- 
i.'^hed.  There  can  be  no  question  about  the  inunediate  removal  of 
.sequestra,  no  matter  what  their  .size  and  po.sition.  and  this  will  usually 
be  found  a  simple  matter.  Such  sequestra  are  of  all  sizes  and  shaju's, 
and  involve  either  the  whole  labyrinth  or  any  portion.  Where  no 
septic  or  cerebral  symjitoms  exist  cleansing  the  ear  by  fretiuent 
.syringing  until  dem;ircation  is  established  is  often  the  most  rational 
smgical  procedure. 

Sixteen  cases  of  fatal  hemorrhage  from  the  internal  carotid  artery 
have  been  rejiorted.  In  all  instances  s(mie  portion  of  the  carotid 
canal  w;is  carious,  and  in  all  there  was  a  direct  communication  be- 
tween it  anil  the  tympanic  cavity.  In  each  a  neglected  mid<lle-ear 
suppuration  had  exist(>d  for  a  long  time,  and  the  first  .^^ymjitom  was 
])rofuse  liemorrhage  from  the  external  canal.  In  most  ca.ses  tlie 
bleeding  was  so  severe  as  to  leave  no  doubt  as  to  the  diagnosis,  as 
a  solid  "jet  of  blood  issued  from  the  external  meatus,  and  there  wa.s 
als:>  free  bleeding  into  the  throat  by  means  of  the  Kustachian  tube; 
in  only  a  few  jiatients  a  jiersistent  oozing  gave  the  first  warning  of 
the  later  severe  hemorrhage.  The  possibility  of  this  contingency 
should  suggest  itself  in  the  removal  of  all  large  seciuestra  of  the  ii(>trous 
portion  of  the  tcmi)oral  bone.  The  only  rational  treatment  of  such 
complication  is  the  inune<liate  ligation  of  the  internal  carotid  artery. 

Neuroses.  1.  HsrperaBsthesia.  A  certain  amount  of  hy|)era'sthesia 
is  normal  to  all  person-,  usually  in  the  u|.|ier  register,  as.  for  example, 
the  upper  tones  of  the  (Jalton  whistle,  the  scnitching  of  a  slate-i)encil, 
etc.  This,  of  course,  is  greatly  increased  in  neurasthenia  or  in  con- 
vjilf^eoncp  from  exhausting  illness,  nuiemia.  genera!  nerve  strain,  etc. 
It  is  also  exceedinglv  conution  in  scmie  middle-ear  diseases,  especially 
in  the  early  stages  of  the  fixatioti  of  the  sta]ies.     In  some  instances 


I  lai    U|l 


dlsi:asi:s  of  the  ].\ti:i!.\al  kmi. 


J 103 


the  syinptoin  persists  even  after  the  jiatieiit  lias  In'ooiiie  so  deaf  as 
til  !)(•  unable  to  j)erceive  artieulate  sounds. 

Local  treat'  'eiit  is  naturally  of  iittle  avail,  and  attention  should 
lie  direeted  to  relii-vinji  the  {jeneral  eoiuUtion  of  the  patient  and  to 
nniovinj;  tiie  particular  exciting  cause  of  the  synijjtoni  wiierever 
IKissihie. 

1.  Subjective  Sensations  of  Hearing.  Noises  '-,  t^.,•  ImihI  or  ears 
are,  of  course,  one  of  the  most  common  of  all  the  -yniptoins  r,f  c.  lis- 
ease,  whether  tlie  process  is  one  of  the  extern!  I.  nii'idle,  or  ii  *  rnal 
ear:  hut  we  fre(iuently  also  see  a  purely  funci  -n  >'i  tinnitus,  nd  it 
is  of  tlie  latt<T  only  that  this  section  treats. 

The  sensations  of  sound  may  i)e  directly  leferred  to  one  or  both 
eais,  or  may  be  referred  to  any  portion  of  the  head,  and  may  be  con- 
tinuous or  occur  in  attacks.  When  th(>  patient  has  a  subjective 
tinnitus  it  is  invariably  increased  by  any  cause  which  stimulates  his 
labyrinthine  circulation,  eitlier  by  takinp  of  drugs  like  (|uinine  or 
salicvlic  acid,  by  alcohoi,  by  sleei)lessness  or  nerve  strain,  worry, 
indigestion,  or  many  similar  causes.  A  tinnitus  of  this  description 
occurs  in  a  ])erson  witli  healthy  ears,  and  may  continue  indehnitely. 
The  tinnitus  is  seldom  of  the  severe  variety  seen  in  the  middle  and 
internal-ear  diseases, but  usually  is  a  steady  sizzing  sound,  like  escaping 
steam,  althougii  any  of  the  dilTerent  varieties  may  be  observed.  In 
some  cas(>s  the  sound  starts  immediately  after  a  severe  mental  shock, 
and  continues  for  years.  As  a  ruh',  it  is  heard  only  wiieii  the  person 
is  ([uiet ;  but  in  a  few  in.stances  it  is  augment. ■(!  i)y  surrounding  noises. 
Such  tinnitus  may  last  through  a  i)atient's  whole  life  without  any 
(listin-bance  of  the  hearing  function,  and  is  almost  certain  to  hist  for 
a  number  of  years,  unless  some  definite  physical  cause  is  found  and 
remedied. 

It  should,  however,  be  rememl)ered  that  a  jiersistent  tinnitus  may 
he  the  early  symptom  of  a  middle-ear  disease,  and  esjx'cially  of  a 
primary  fixation  of  the  stapes,  and  may  jjiecede  any  other  symptom 
by  a  liumber  of  months.  It  is  well,  therefore,  to  keep  such  ca.-es 
under  observation  until  this  possibility  has  been  ruled  out. 

The  treatment  of  \mvv  fimctional  timiitus  is  very  unsatisfactory, 
unless  the  particular  cause  can  be  made  out  and  relieved.  .\s  in 
ihe  great  ina.iority  of  cases  a  faulty  mode  of  living  is  the  cau^-e,  and 
■IS  such  is  almost  necessary  to  the  success  of  the  individual  under 
the  conditions  nf  our  modern  civilization,  we  are  forced  to  the  con- 
clusion that  the  timiitus  in  such  instances  must  continue  or  the 
patient's  natural  ambition  '<e  sacrificed.  In  severe  cases  if  may  be 
necessary  temporarily  to  )rt  to  the  use  of  drugs  to  relieve  the 
tinnitus  or  the  insoninia:  i  t,  needless  to  say,  such  treatment  ."should 
be  used  with  great  caution  and  never  continued  for  a  long  jieriod. 
In  a  few  instances  relief  may  be  obtained  by  inflation  of  the  tympanum 
or  bv  some  form  of  aural  massage,  o.-specially  the  tragus  pressure  of 
lloMunel.  This  is  especially  the  case  in  functional  tinnitus  following 
concussion  of  sound,  a.s  in  artillery  practice  or  trap  sliooting.     The 


^^W^K^^^^ 


sei 


wmm^mmmi 


11(»4 


TUi:  HAH. 


II 

H 


author  lias  l)con  unahli-  to  ol)laiii  any  iicrmaiicnt  ticiicfil  ffom  tin 
usr  of  clcctiii'itv  or  vihratiiij;  inassafif  with  iustninu'iits  of  tlic  vihra- 
jihoiic  ivjic  or  i)v  tlic  old  trcatiiiciil  of  couiitcr-irritatioii. 

Ana'iuia  is  a  "coinlitioii  frc(|uciitly  causiii';  functional  tinnitus.  a> 
also  do  insomnia  and  overwork  in  all  the  conditions.  If  the  under- 
Kin-'  cause  is  corrected  at  once  the  synii>loius  may  he  relieved,  hut 
if  the  iK-urosis  heconies  lixed  it  is  much  l<"ss  likely  to  he  remedied. 

.{.  Functional  Paralyses.  Besides  the  orfjanic  paralysis  from  various 
causes  el.s,.wliere  mentioned,  there  is  no  douht  that  functional  par- 
alyses, either  partial  or  total,  e.xist,  and  such,  for  the  lack  of  a  dehnite 
understaiidiiifi  of  the  patholofiy,  are  usually  considered  vasomotor 
or  hvstericat.  . 

From  till'  standpoint  of  the  clinician  the  vasomotor  aih'ctions  .seem 
to  he  .(uite  common  in  neurotic  suhjects.  and  are  usually  characterized 
by  a  transient  vertijio,  nausea  or  vomitin<r.  tinnitus  and  deatne.ss. 
The  deafness  is  often  of  a  very  hijrh  <rrade.  hut  seldom  continues 
l()nf;<'r  than  a  few  hours.  Such  patii-nts  are  liahle  to  repeated  attacks 
froiu  anv  cause  which  mav  increase  the  intralahyriuthiiie  circulation, 
and,  as  "the  attack  is  usu'ally  of  brief  duration,  treatment  is  .seldom 
uece-sarv  at  the  time. 

Hysterical  deafne.-s  is  ([uite  rare,  and  is  usually  comi)arative!y  easy 
of  diagnosis  from  the  occurrence  of  the  chanicteristic  lahyriiithine 
symi>toms  with  general  manifestations  of  hysteria.  Local  aiia'.sthesia 
('f  the  membrana  and  auricle  has  been  reported  in  a  number  of  such 

cases. 

4.  Paracusis  and  Diplacusis,  Inability  to  hear  jntch  correctly  is 
iisuallv  <lue  to  an  abnormal  tension  or  relaxation  of  me  portion  of 
the  middh'-ear  ai>paratus,  but  may  be  from  affections  of  the  auditory 
nerve  either  in  its  course  or  termination  in  the  labyrinth.  Where 
not  of  middle-ear  oriniu  it  is  more  likely  to  be  central  than  labyrinth- 
ine.    I'aracusis  of  Willis  is  always  of  middle-ear  orisjin. 

Diplacusis  also  is  by  the  <;reat  majority  of  writers  considered  of 
middle-ear  ori<:in,  but  it   may  be  central. 

Tumors  in  the  Internal  Ear.  Primary  neoplasms  of  the  lat)ynnth 
are  rare;  but  they  are  not  es|)ecially  unusual  in  the  course  of  the 
auilitory  nerve  before  it  enters  the  internal  auditory  meatus.  The 
new-growth  when  fouml  will  usually  be  an  extension  from  surround- 
in-;  |KUts  anil  the  diafrnosis  easy.  The  usual  symptoms  of  increa.sed 
labyrii-.thine  pressure,  vertigo,  nause;i,  aii-l  tinnitus  are  often  absent, 
ami  onlv  the  -leafness  shows  the  extension  of  the  ilisease  to  the  laby- 
rinthine structure.  The  facial  nerve  is  generally  involved  with,  the 
auditorv,  owing  to  their  intimate  relation. 

The  "malign.int  neoplasms  are  the  most  fre(|uent.  both  ei>itheho- 
niata  ami  sarcomata:  but  the  benign  tumors  aiv  occasionally  seen, 
a  number  of  cases  of  fibroma  and  iingioma  being  on  record.  All  of 
tlii'  hibyrinthi!!''  tmit-ir-.  :ire  inoper'ilive.  but  t!ie  possibility  of  gumma 
siioui.l  make  a  course  of  syphilitic  treatment  always  advisable  before 
the  case  is  regarded  as  hojieless. 


m^mafw^mT^mrvs 


■^w^HiraFWi 


i)i:.ir  MiTisM. 


1H>5 


DISEASES  OF   THE  AUDITORY  NERVE. 


Tliis  nerve  is  ;i|ii':iiently  rather  rarely  involved  in  ititnicTaiiial 
irrnwths,  hut  sueli  cases  are  oeeasionally  seen.  Tlie  diafinosis  is,  as 
a  rule.  (Villieult.  (iwinj;  to  the  ah.senee  ot  .syinptonis.  The  verti^'o, 
ii,iii>ea.  an.l  sinnitus  invariably  .se.'n  in  the  diseases  of  the  lahyiinth 
are  usually  ah  i-nt  where  the  trunk  of  the  ner  nly  is  nivoiyeil, 
and  deafne.ss  is  the  onlv  syMptoni  noticed.  I'urulent  infiltration  into 
Ihe  nerve  is  occasionallv  seen  secondary  to  a  purulent  nienin<ritis, 
hut  the  most  common  lesion  is  atrophy.  This  is  seen  after  pressure 
from  intracranial  neoplasms,  and  has  also  been  reported  as  a  com- 
plication of  disease  of  the  spinal  cord,  jiartiiailarly  tabes.  Degen- 
erative processes  in  the  auililory  nerve  are  also  reported  by  a  mnnber 
of  ob.servers  after  !on;i-coMtiiuied  disease  of  the  labyrinth;  but  this 
is  not  as  common  as  alroiihy  in  the  gan}ili(«nic  layers  of  the  cochlea. 


DEAF  MUTISM 


Deaf  nnitism  may  arise  as  a  secjut 
1   is  either  |)artial  or  tota 


•I  of  many  (iisea.''es  of  the  oar, 


_ I.     In  partial  deaf  mutism  the  whole 

ference  with  the  pa.ssafje  of  the  sound-wave  may  be  in  the  middle 
he    labvrinth    is  always  involved.     In 


ant 

interterence 

e.ir:  but   in   the  total  cases  the    hil)yrintli    is  a 
eonsideriiif;  the  etiolofrv  of  mutism  we  must  remember  that  more    or 
less  disturbance  to  the  sjieech  function   nnist   result   from  extreme 
deafness  at  anv  time  of  life,  l)Ut  that  mutism  only  results  fiom  deaf- 
'less  incurred  "before  the  siieakiiifr  afre.  or  before  the  fifth  or  sixth 
vears,  when  the  child  may  h.rp't  what  woi.is  it  has  already  ac.juired. 
Ill  an  examination  of  some  two  hundred  individuals  m  a  deal  mute 
institution,  recentiv  made  by  the  writer,  it   wa>  found  that   nearly 
.■)()  per  cent    were  deaf  from  some  easily  i.revented  cause,  either  the 
suppurative   diseases   resulting   from   scarlet    fevi-r,    measles,   or  the 
(,ther  child  affections,  or  from  the  adhesive  middl(>-ear  processes  set 
up  in  con.se(iuence  of  the  presence  of  adenoid  vegetations  in  the  phar- 
\  nx.     The  other  oO  per  cent,  were  largely  the  se(|uel  of  an  epidemic 
of  cerebro-spinal  meningitis  which  had  prevailed   in  New   Kngland 
.some  vears  before,  and  a  hnv  cases  were  the  result  of  pneuinococeua 
•uid  other  infections  of  the  auditory  nerve  in  the  course  of  acute 
dis<-ases  in  earlv  life.     In  the  entire  2()()  cai.es  there  were  only  2  in 
which  the  absence  of  an  easily  assignable  cause  made  the  probability 
of  a  direct  inheritance  po.ssibh'.     It  is  the  writer's  belief  that  these 
statistics  are  fairly  rei)r(>sentatiye,  and  that  a  careful  analysis  of  cases 
will  .show  the  process  causative  of  the  deafness  to  be  acciuired  and 
not  hereditary  in  the  vast  ]ireponilerance  of  patients.     Pneumonia  in 
iiita.ncy.  cerebro-spinal  meningitis,  and  adenoid  vegetation  ui  the  naso- 
jiharynx  are  the  three  most  common  causes  of  (leaf  mutism.     Next 
to  these  come  heail  injuries  and  inhcriteti  syphilis. 

70 


mm 


n(»6 


Tin:   .AR. 


if! 

ii  i 

.1 


•  I  if 


B> 


The  diagnosis  of  this  ;iftlioti(in  may  prcsoiit  many  unoxpcctotl  .litti- 
pultics,  particulaiiy  ii;  youiis  !Sul)j(Tts.  liy  far  tlic  larpii'st  mimlxT 
of  cases  will  !)(•  hrmijilit  to  the  auiist  about  two  or  two  ami  oiio-liall 
years  of  ajte,  beeause  they  liave  not  yet  bepun  to  talk.  In  these 
till'  hrst  and  most  important  consideration  is  as  to  whether  the  ease 
is  not  one  of  delayed  development,  and  this  consideration  alone  should 
deter  one  from  making  too  positive  a  diagnosis.  In  older  children 
we  must  be  most  careful  to  eliminate  the  factor  of  iip-readirg  which 
many  a  deaf  cliiM  ac<iuires  instinctively  at  an  early  age,  and  at  which 
they  become  very  proficient. 

In  testing  hearing  at  'iny  age  allowance  must  be  made  for  the 
perception  of  vibration  in  ail  loud  sounds,  and  particularly  in  those 
of  a  low  pitch. 

In  children  of  two  or  three  years  of  age  or  younger  a  (hagnosis  will 
often  be  imi)ossible  at  a  first  visit  where  the  physician  is  a  stranger 
to  the  child;  but  much  may  l)e  learned  by  a  careful  (jbservation  of 
the  patient  in  its  own  home  or  in  .surroundings  familiar  to  it.     At 
these  ages  hearing-tests  can  only  be  made  with  sounds,  and  esi)ecially 
with  sounds  incapable  of  imparting  jierceplible  vibrations  to  sur- 
rounding objects.     .\  whistle  is  one  of  the  best   tests  .;t   this  time, 
or  striking  the  edge  of  a  tumbler  or  finger-bowl   with    n(>tal.     At 
five  years  old  or  over  the  voice  will  be  the  best  test,  and  ye  may  try 
tone-] )ercept ions  by  the  tuning-fork  and  the  (ialton  whistle.      With 
the  voice  vowel  sounds  are  naturally  better  perceived  than  conson- 
ants, and  the  phvsician  should  pronounce  the  vowels  one  after  another 
with  the  lips  fairly  close  to  the  patient,  or,  better,  through  a  con- 
versation tube,  having  the  child  re])ea1   tlie  sounds.      .\,  ll,  and  O 
will  be  found  the  most  readily  heard  of  all.     If  the  vowel  sounds  are 
perceived  the  ca.se  should  then  be  tried  in  the  same  manu'-r  with 
simple  words,  and  in  all  i)atients  old  enough  to  answer  correctly,  an 
exact  measure  of  hearing  should  be  ol)taine<l  !)y  tuning-forks,  and, 
whenever   jio.-isible.    by   some   exact    instrument    likv-    HezohTs   tone 
■series.     It  shoul<l  be  rememlxn'.l  that  the  ca.-<e  may  be  deaf  in()ne 
portion  of  the  scale  and  hear  relatively  well  in  the  other  jjortions. 
As  a  matter  of  clinical  experience,  total  deafness  will  be  found  very 
rare,  as  ]M>rception  of  sound  in  some  portion  of  the  musical  scale  is 
]ires(>nt  in  nearly  all  cases.     Testing  with  tuning-forks  by  bone  con- 
duction will  be  found  impossible  in  all  young  aiul  most  adult  patients, 
owing  to  their  inability  to  discriminate  between  vibration  and  tone 
])erceplion. 

The  exact  definition  of  the  amount  of  deafness  ])resent  in  the  indi- 
vidual p.'itient  is  exceedingly  important,  as  even  a  jxirtion  of  the 
musical  scale  may  be  utilized  in  the  educati.)n  of  the  child. 

High  grailes  of  (h-afness  are  also  caused  by  neglected  suppurative 
middle-ear  diseases  in  childhood,  and  in  such  ca.ses  deaf  mutism  may 
result.  .Appropriate  treatment  in  tliese  ca.ses  ma\  >ieid  iunX]i<ried 
results,  and  the  middle  e.ar  shoulil  always  be  brought  to  as  normal 
a  point  as  possible  before  the  ca.se  is  ;ibandoned  as  hopeless. 


■■U iU. 


■WU'Wff!^ 


raSWB^^ 


pi:af  MrrIs^r. 


1107 


Treatment  is  ofton  of  iiKirc  iiiii)()rtancc  in  tlic  ciirly  stages  "I  dciif 
nuitisiii  thiin  is  ordinarily  supposed.       It  lias  been  the  author's  cxpe- 
lirncc   that   all   casos  of  ccrchro-spinal,  pncuinococcus.  and  mumps 
infections  of  tin-  auditory  nerve  and  iahyrintii  are  incurable  as  far 
as  treatment   <roes.     The  prognosis  in  the  head  injuries,  of  course 
depen<ls  upon  the  severity  of  the  injury  in  the  particular  instance 
under  observation,  and  if  the  damap'  done  is  not  too  great  the  nerve 
may  recover  itself  and  resume  its  functions. 
'Phe  affections  of  the  auditory  nerve  in  consociuence  of  inherited 
)hilis  are  al.si>  very  intractable:  but  if  the  case  is  seen  <'arly  a 
.,i)rough  trial  of  the  usual   remedies  for  syphilis  should  be  made 
before  it  is  abaniloni'<l. 

The  prognosis  of  the  lesions  resulting  from  adenoid  disease  in  the 
ntisopharynx  is  imich  more  hopeful,  and  the  growth  should  always 
he  r(*inoved  in  all  patients  at  whatever  age  they  are  seen.  In  the 
cases  ojK'rated  on  before  three  or  four  years  of  age  a  great  imi)rove- 
laent  mav  be  expected  in  many  instances.  The  author  has  had 
-everal  siicli  ca.-<es  which  obtained  nearly  half  the  normal  hearing, 
.ind  were  al)le  to  attend  the  public  schools  instead  of  s])ecial  insti- 
tutions for  the  e(hication  of  the  deaf. 

Where,  after  a  careful  examination,  the  deafness  is  decided  to  be 
hojieless.'so  far  :is  treatment  is  concerned,  or  where  the  api)ropriate 
treatment  fails  to  .show  any  result,  the  future  education  of  the  child 
'^liotild  be  consi.lered:  but"^  the  child  should  never  be  referred  to  a 
special  institution  for  the  educatiim  of  the  deaf  until  it  is  decided 
that  there  is  not  a  sufficient  amount  of  h(>aring  to  enable  it  to  be 
educated  in  the  ordinary  way,  and  that  it  is  imi>ossible  to  obtain 
such  hearing  bv  treatment.  . 

.\s  JKUs  been  before  mentioned,  many  deaf  mutes  are  instinctive  lip 
readers,  and  in  all  instances  where  treatment  is  of  no  avail  the  imli- 
vidual  shoul.l  be  speciallv  educated  in  this  method,  beginning,  when- 
rv(-r  possible,  at  the  usual  school  age.  In  this  country  this  education 
i~  ensitv  obtained  by  even  tlie  jioorest  children  at  some  one  of  the 
special  institutions  which  are  found  In  ni'arly  every  State. 


i    i 


en  AFTER  xxvir. 


IM'RriJlXT  INFLAMMATION  OF  TIIK  MIDDLE  KAIf 
Hv  IIKNHV  AU.NOI.I)  ALDIIHTON.  M.D. 


In  tnkinj;  up  the  suhjcct  of  punilciit  iiillanmiatioii  nl'  ttic  iiii(kll< 


car  stnictiiics  it  is  prcsiiinci 


lliat  tlic  reader  eiilier  lla^■  already 


ired 


t  Wdrkiiij;  know 


led<;e  of  the  aiiatoriiy  and  pliysiiilo^y  t^  ti 


)rgaii  (if  lieariiifi,  nr  else  lias  at  coiiiiiiaiid  iiKulerii  text-books  treatinj; 


of  anatomy  and   pliysioloj;y,   to   wliieli   li 


II   refer.     Briefly,   the 


middle  ear  'Fig.  "HKS)  hegiiis  at  the  pharyngeal  mouth  of  the  l-lusta- 


View  of  the  middle-ear  cuvitif^  iroin  within.  1.  Mafltoid  antrum.  2.  Posterior  liffHment  of  incus. 
3.  ^usiiensoryli^amentof  hummer  and  incus.  4.  OpenInK  In  the  plica  tmrisvemt  h.  Tendonofthe 
tenwir  tym|iani  muscle,  li.  oixMiinRS  of  cells  around  tympanic  oriliceof  the  Eustachian  tube.  7. 
Isthmus  ol  ti'lic.  8.  I'harj-nifcal  mouth  of  tubt'.  ii.  Superior  posterior  horizontal  cells  of  mantoid 
process  10.  Large  cells  in  tip  of  maiitoid  pnwcss.  i  From  .Siebenmann's  Anatomy  of  the  Midille  Ear 
and  Labyrinth.) 

chiaii  tube  as  a  canal  with  walls  wliieh  are  ir'ternally  partly  oartil- 
aginow.s  and  jiartly  membranous,  and  externally  become  entirely 
osseous  tij)  to  their  entrance  into  the  cayity  of  the  tym])anum  by 
an  aperture  in  the  anterior  wall  (juite  a  little  aboye  the  floor.  The 
cayity  of  the  tympanum  is  completed  externally  by  the  drum  mem- 
braiio  and  the  downward  extension  of  the  superior  wall  of  the  osspous 
external  auditory  canal  (Fig.  5()9),  and  internally  by  the  petrous 
(1108) 


■■■■m 


PVRILE.ST  ISFLAMMAIKIS  of  Till:  Mll'Pl^J-:  /■'■I''-       110!) 

IKiriion  of  tlic  tciiiporal  Ih)Iii'.  I'osti'iioiiy,  at  tlic  superior  aiigli'. 
iinotlicr  l)ony  canal,  tlic  (iililiis  lul  initnnn  (l'i>;.  ")7(»),  coimmiiiicatcs 
with  the  Mia'stoiil  aiitriiiii,  from  which  diverge  in  various  directions, 
mostly  downward  and  hackward,  communicating  cells  between  the 


iiied    tliroufihoiit    In-   mucous 
the  membranes  of  the  drum 

Fig.  STO 


Vltw  of  tymiianiim  from  in  front.  1,  2.  .\tlic-.  3.  Incus.  4.  Suspensory  ligament.  5.  Uammer. 
(.  l'ai<epit>mi»inica  and  wall  of  f.tli.Tn,il  far  iMmal.  7.  Tendon  of  tensor  lymi«ni  muscle,  8. 
-brapnell's  membrane.  '.».  In™.l.>-slni,ediftl  artieuialion.  10.  CmU).  11.  Tympanic  membrane. 
\i.  InUTnal  auditory  canal.  13  Turnolc.Kdilea.  14.  ITomontory  l,",.  Carotid  canal  for  thecarotld 
iirlery.    (From  8|iecimeil  in  the  author's  collection.! 

outer  anil  inner  tallies  of  lli(>  skull.     (Fifl.  "i<>>i.)     These  c.>lls  extiMid 
for  varyinf;  distances  iu  tlilTeiviit  skulls,  even  into  the  adjacent  occip- 
ital  lioiie.     The   tympanic   cavity   is 
iiKMiihraiie,  and   its  walls,  excejit    for 
inenitinine  proper,  the  round  and 
tli(>  oval  window,  and  the  cartilag- 
inous   portion   of    the    Kustachian 
tube,  are  of  bone,  unless,  as  some- 
times  lia])pens.  Nature  Iiad  failed 
to  complete  her  work  and  has  left 
here  or    there    an   aiiertiirc  in   the 
bony    casement     cIosimI    only    by 
tibroiis  membrane.   Sech  apertures, 
or  dehiscences,  sometimes  leave  ex- 
poseil  important  structures,  as,  for 
instance,  the  jufrular  vein,  the  car- 
otid   artery,  the    facial  nerve,  the 
^ijimoid  sinus,  or,  occurring  in  the 
roof  of  the  tympanum  or  mastoid 
antrum,  the  dural  covoriiig  of  the 
intracranial  cont(>nts.  ,  •  i 

Within,  or  jiassing  tlin;ugh  the  tympanic  cavity,  are  the  ossicles 
or  -uial!  bone:  of  the  ear  the  chonla  tyinpiini  nerve,  th.e  tetidons  of 
the  tensor  tvmj  ani  and  sta|)edius  muscles,  and  various  folds  or  bands 
of  mucous  inenibrane.     (Fig.  571.)     Outside  of  the  bony  casing  of 


view  of  irembrane  and  oesidcs  from  within. 
1.  Mcmbrana  vihrans.  i.  Eustachian  tut«.  :t. 
Hammer.  4.  Incus  5.  Antrum  6.  Aditus. 
".  Tensor  tympani  tendon.  8  chordatympani 
nerve  (From  specimen  in  the  author's  col- 
lection.) 


1110 


T1I£  IJAIt. 


Fia.  .'.71. 


llic  iiiitldlc-car  (■••ivitics  lie  tlnw  .-;lnictun's  the  prcsciicf  of  wliicli, 
in  siicli  close  coiitifiuity,  icmlcis  iiiiy  punili'iii  iiitlaiiiiiiiition  of  tlif 
iiiidillr  ear  a  factor  of  the  fircatc.-;!  jiravity.  Swell  are  the  cerehnmi. 
the  eerelielliim.  tile  lateral  and  .sifjiiioid  simi.-<e.-<,  the  liiilli  of  the  jugu- 
lar vein,  and  tiie  carotid  artery.     That  the  existence  of  such  a  purii- 

l<Mit  intlaniniation  of  the  tniddh- 
ear  is  a  matter  of  };rave  impor- 
tance is  shown  1).\  the  fact  that  in- 
vestipition  of  the  mortuary  sta- 
tistics of  one  of  the  larfrest  jjeneral 
liospitals  ha.<  sho«ii  that  one 
death  in  every  1.").S  resulted  from 
theeoniplications  arisirifrfrom  this 
condition. 

Durin}!  the  ten  years  immedi- 
ately preceding;  1!H)1  there  were 
.mis'.)  ear  cases  treated  at  the 
-...Q  Urooklyii  Jive  and  l-iar  Hospital: 
i)7()"),  or  aliout  27  per  cert,  of 
tlie.se  were  atllicted  with  someone 
of  the  ditTerent  purulent  diseases 
of  the  middle  ear:  ;{.'{47.  or  nearly 
Ojiercent.,  had  the  ilisease  in  its 
acute  form:  (Jll.S.  or  nearly  IS  per 
cent.,  had  the  disease  in  itschronii' 
form.  Besides  these  there  were 
142.5  ca.<es,  or  nearly  t  per  cent., 
showinfr  cicatricial  conditions,  evi- 
dently th(>  result  of  a  healed  sui>- 
purative  process.  In  other  words.  al)out  ."{I  |)er  cent,  of  all  ear 
cases  .ipplyinfr  fur  treatment  at  the  Brooklyn  Vac  and  V.iiv  Hospital 
were  sufferers  from  conditions  directly  eonnecteil  with  suppurative 
|)roce,sses  in  the  middli'-iar  cavities. 

.As  miiilit  lojricajly  he  presumed,  purulent  otitis  attains  its  <;i'<'!itest 
pre\alence  in  cliildliood;  hut  no  af;i'  can  elaini  immunity.  The  acute 
processes  are  as  likely  to  in\ade  one  ear  as  the  other.  .\t  the  Brook- 
lyn !",ye;inil  liar  Ilos|)i'.tl  durinjr  the  year  1!)()().  1022  cases  (»f  purulent 
otitis  media  presented  tnemselves.  Of  these  4!tO  were  in  fcTTiales  and 
.").']2  were  in  males.  This  slijilit  diserepariey  nia\'  e.asily  he  accounted 
for  1)\'  the  e\tri  hazards  usually  attend.mt  upon  occupational  and 
playful  pursuits.  Sex.  as  such,  does  not.  therefore,  seem  to  influence 
the  appearance  of  purulent  otitis. 

There  would  seem  to  exist  in  certain  fatnilies  an  hereditary  ten- 
dency to  purulent  middle-ear  disease,  mostly  in  connection  with  tiie 
strumous  .'ind  tuhercular  diatheses,  or  with  various  p.'itliolf)}rical  con- 
ditions of  the  nasopharynireal  tr.act.  n(.lahly  lymphoid  hypertrophy. 
IVe-exi.stinji  affections  of  the  rni<ldle  ear  or  of  the  external  auditory 
meatus  would  also  seem  to  exert  a  predisposinf;  influence. 


View  of  tympuuum  from  behind  and  witbiu. 
1  TeKuicii .  ■-.  Suspensory  liguiueiit  3.  Allie. 
t.  Htimmer  be;iil.  ,'>.  Iuimis  (i.  clionia  tymtiani 
nerve,  7.  Tenilon  of  tcni^r  tynipaiii  mui^ele. 
?*.  Ensiaohian  lube,  tt,  Munnbrhiin,  10  Stajies, 
II,  Teuilon  of  siapedius  muscle,  IL',  ryramld, 
i:i,  Tyni|«iuie  membrane,  iKroni  ^iieeimeu  in 
tbe  aul.lor  J*  eoUeetion.. 


t'lRVLESr  IMLAMM.irioy  OF  Till-:  MIDDLE  EAU.       1111 

rMiiillv  tht'  nii(l(llf-«-:ir  iiifiainiiijition  follows  cluscly  iilK)n  or  is 
,.uinci(i."nt  with  an  i.itiaiMnuitiui.  involving  tl.c  nas..pi.arynncal  cavi- 
li,.<  Such  •■niulitions  (.i)taii.  as  ih.'  result  of  an  acute  curyza,  ol 
t,.,.thin.'  scarlet  fever,  nicitsles,  sn.alli).)X.  diphtheria,  mtluenza 
whou,,intr-c.,ut;l      syphilis,  etc.     ()c.-.asio,.ally  Xh,' ^^  is  m.luce.l 

l.v  a  .Irauiiht  (     c.l.l    lir  i etratii.-l  the  external  auditory  meatus, 

„r  i,v  the  entranc(>  of  c.ld  water  int..  .he  same  canal,  m  swimming  or 
diviiiji.  Injurie-'  to  ti.e  hearing  or-an  may  likewise  he  causative. 
Thus  fractures  ..f  the  temporal  hone,  forcible  entrance  of  water  in 
-urf-l.athin>;,  l.lows  over  the  auricle,  entrance  of  fhud  into  tlie  tym- 
„i,nuin  while  Imthinn.  usinj;  the  nasal  douche,  snulhnj;  of  li-iuids  into 
'the  nose  foicinj;  of  vomit.  .1  matters  into  the  tympatium,  and  hually, 
imratvmpanic  operations,  .\monf:  other  cau.se.-«  we  have  t..  reckon 
with  mumps,  phthisis,  tvphoid  and  typhus  lever.  p!iemnonia  and 
bronchitis,  diabetes,  malarial  diseases  (Harr).  tuberculosis,  erysiiieUus, 
Mild  the  puer|.eial  state  (Hacoii).  local  manifestations  of  acute  articu- 
lar rheumatism  (WoltT),  ai-d  carcinoma  auris. 

The  ivlation  of  scarlet  fever,  mea.sles.    and  (hphtheria  to  purulent 
otitis  media  is  of  such  imi.ortaiice  as  to  warrant  si.ecial  consideration 
..v.-n  in  such  a  bri.-f  article  as  this  must  necessarily  be.     Artluir  H. 
Due!    of  New  York,  because  of  his  connection  with  the  .New  York 
Health   Hoard,  has  iiad  exceptional  opix.rtunities  for  iiivestifiation 
lion.'  this  line,  and  it  is  mainlvfrom  his  article  that  the  followitiR  facts 
iK.v.^been  fjleaiied.     Me  states  that  .a  purulent  mi<ldle-ear  inHamma- 
ti„n  mav  app.^ar  at   anv  tin..'  durii.f,'  the  course  of  these  diseases. 
That  it  occurs  in  about  20  per  cent.  <.f  the  cases  ot  scarlet  lever,  in 
10  p,.r  cent,  of  tli.-  eases  of  di|.'>th.Mia.  and  in  5  per  c'lit.  of  the  ™ 
,,f  m(>a.sles;  while  in  those  cases  in  which  tli.'  two  diseases  scarlet  fever 
;,Md  diphtheria  w<.re  combined,  the  percentage  of  cases  ol  purulent 
..titis  media  mounted  u|.  to  b.^twe.-n  .W  and  W  percent      In  measles. 
,U,.  car  trouble  usuallv  i.ursues  a  mild.'r  cours(>  than  m  the  other  two 
•  li^eases.     In  diphth.-Via  it  is  usually  mon>  .s.'V<Te  than  m  measles, 
but  less  severe  than  in  scarh't  f.>ver.  is  more  likely  to  make  its  appear- 
;n,ce  durin-  th.'  acute  stafie,  and  in  ..ver  ha,    'he  <Mses  is  In  a  eral. 
In  scarlet  fever,  the  discharfre  is  much  nion   likely  to  ai.|)ear  later  in 
the  diseas.-.  about  th.-  s.'cond  ..r  thinl  week,  an.l,  beinR  of  a  much 
<,.v.M-er  tvpe.  is  pr..n<'  to  cans.-  much  destruction  ..f  the  tympanic 
structured.     In  all  ..f  thes.-  dise.as.-s.  m."asl.>s.  scarlet  fever  an.l  diph- 
th.-ria   till-  t.-ndencv  is  toward  the  involv.'inent  .>f  both  .-ars 

The  followiiifi  inicro-orfranisms  hav.>  been  foun.l  m  the  (hscharges 
in  cast's  of  iMirul.'iit  otitis  m.'.lia:  the  strei)tococcus  py.)f;en.>s.  the 
.laphvloc...-cus  pv..>i.'n.'s  albus  an.l  aureus.  Frank.M's  pn.'um..c.,ccus 
.,,  ,liplo.'..ccus.  Fri.Mllan.l.T's  piu-umolmciUus.  th.-  tulxTcle  bacillus. 
an.l  th.-  bacillus  i.yocyaii.'us.  In  the  majority  of  ca.ses  the  infectu.n 
is.  or  soon  b.'comes.  a  mixed  one. 

Be-rinninn  with  a  more  or  le.^s  .activ.  con-estion  of  the  mucous 
,„.-ml.ran.  coatiiift  the  mid-lle-.-ar  cavities.  in.luc.Ml  by  the  various 
ab..ve-menti.med  causes,  there  succ.-e.ls  an  iufiltratu.n  of  the  tissues 


111-2 


THE  EAR. 


with  l)l(i(iil  ciniiiisclcs  and  ruiitul  cells,  prodiiciii);  swdliiin,  :'>"!  '1''^ 
is  rulldwi'ii  Ity  an  cxuilation  from  tin-  free  .surfact's  of  the  niiirdiis  incin- 
liiant'.  .\\  times,  especially  in  inlluenza,  tiipfure  of  tlie  oviT-ilis- 
teiideil  caiiillaries  is  l)niuj;lit  almnt  liy  tlie  intensity  of  the  congestion, 
and  the  escaping  lilood  either  finds  its  way  into  the  tyinp.anuni,  lifts 
the  mucosa,  formin<;  intiatym|)iinic  hulLe,  or  lifts  the  ilermal  layer 
of  the  ilrnm  memhrane  or  external  auditory  canal,  forminj;  hlood- 
lilel)s.  which  protrude  into  the  external  meatus.  These  hulhe  or 
blebs  tend  to  rupture,  leavinj;  behind  a  raw,  unprotected  surface 
prone  to  infection.  The  exudation  from  tiie  mucous  surface  may 
be  serous  or  mnco-serons  and,  the  lumen  of  the  luistachian  tuiiebein^ 
closed  by  swellinfr.  may  collect  in  c<insider;ible  quantity  in  the  tyin- 
pannm.  Heyond  this  the  intlammatory  process  may  not  go.  Or  tlie 
exudate  may  be  from  the  first  more  or  less  purulent  or  may  become  so. 

In  .-iex-ere  cases,  the  !iiiddle-ear  condition  m:iy  brinjr  about  a  similar 
conjiestion  of  the  lal)\  rinth  or  of  the  adjacent  portion  of  the  external 
auditory  meatus. 

.\s  the  swelling;  and  the  i|u»ntity  of  intratynipaiiic  exudate  in- 
creases, the  drum  membnirii-  is  put  undi-r  extreme  tension  until  it 
beconi(>s.so  thinned  and  weakened  that  it  finallyjiives  way,  or,  because 
of  the  intensity  of  the  inflammatory  process,  a  portion  of  the  mem- 
brane sloughs,  so  permittinir  the  escape  of  the  contained  secretion. 
.Most  commonly  this  penetration  takes  place  in  tlie  lower  half  of  the 
drum  membrane  and  is  accom|)anie(;  more  or  less  heniorrhajie, 
l'!xceptioiiaiiy  the  dium  membrant  i  be  so  stroiifily  built  that 
it  is  able  to  resist  the  pressure  arisinji  from  the  swelling  and  tiie  ac- 
cumulated exud.'ition.  When  this  happens,  the  secretion  contained 
within  the  iniildle-ear  c,i\ities  is  forced  to  seek  other  outlets,  either 
througli  the  luistachian  tube,  the  mastoid  cortex,  the  carotid  canal, 
the  lal)yrinth.  or,  finally,  the  inner  table  of  the  skull.  Such  a  condi- 
tion of  things  I, '.)i  a  ins  relati\ely  more  freiiueiitly  in  children:  the  drum 
menibr;ine  heic  offering  greater  resistance  than  the  tissues  which  bind 
together  thestil!  imperfectly  united  bones. 

In  the  majorny  of  cases  of  acute  |iuriilent  inflammation  of  tlie 
middle  e;ir.  the  process,  after  perforation,  naturally  tends  toward 
resolution,  with  lie.aling  of  the  perforated  drum  membrane.  Less 
fre(|uently,  especijilly  when  occurring  in  the  course  <if  the  infectious 
diseases,  the  process  tends  to  become  clironic,  generally  through  the 
establishment  of  an  area  of  localized  caries  at  some  point  in  the  bnny 
wail  or  on  the  o.ssicles.  It  is  rare,  indeed,  tiiat  a  primary  attack  of 
jjuiulent  otitis  media  leads  directly  to  serious  complications  in  the 
way  of  intr.acranial  ilise.ase,  and,  as  Macewen  well  says,  "  When  such 
occurs,  the  invasion  is  generally  .so  ra})id  that  the  intracranial  involve- 
ment occurs  befoH'  o])i)ortunity  is  given  for  radical  intervention." 
The  tissues  still  retain,  usually,  suflicient  vitality  to  successfullv  with- 
stand the  invasion  of  infectixc  material. 

Slionld  tlie  intensity  of  the  inflammatory  process  be  unusually 
severe  or  result  in  a  continuance  into  the  chronic  stage,  then  the 


}'lRri.t:ST  IShhAMMATlUS  OF  Tilt:  MIDDLE  h.Mi.       HI,} 

iiitfKrity  of  various  inlratyiiipaiiic  strMcturcs  may  !<!■  jco|.ur(liz<-<l. 
rims,  tin-  small  Ixnifs,  malh'us.  incus  or  slaius,  may  suffer  a  urcalcr 
,,r  lcs.scr  ilcgrcc  of  caries  (Fig.  Tu2),  or  may  even  have  their  .ittach- 

Fio.  .-.TJ. 


^^/r 


6  7 


^8  9  10  II  12  13 


-€> 


19 


20 


^ 


\  ■'  and  :i   Siinnul  ossicles,  hammer,  incus,  aii.l  sl«i*s.    4  ami  5,  <'ari..us  aiik>M(»cd  Inrus  and 

n„.'lk'US   from  two  cKsi^s  of  pn Ke.1  Mlfporation.    6  iiiM  7,     I'ortioii.  of  lurli  mu.I  han.il,'  of  inal- 

i,.i,.  all  ib,a  «■«-  apparently  left  in  lluw  two  case-,  h  and  0.  1'*  and  r.>,  -M  and  .'1.  Carious  mallei 
tnd'incM.li  Kroni*'.!  a.-,  tlicv  were  renumnl,  1:1  and  1 1.  Carious  hammer,  healthy  incus.  10,  ii.  and 
Ij  1.-,,  Itiand  17.    Carious  incus  and  hummer,  and  in  each  case  a  sequestrum  fnnn  tymi«nic  wall. 

hrom  specimens  in  the  autlior's  collection  ) 


View  of  Irtemal  half  of  middle  ear.  1.  Adlfis.  2.  Stapes.  3  and  9.  Facial  caur^.. 
oval  window  ft  Promcmtory.  6.  (Xdlular  etructure  of  floor  of  tympanum.  7.  t. 
windov.    8.  Stapedius  tendon,    lo.  Horizontal  »einicireular  canal.    U.  Antrum, 


i.  Fossa  nl 
Baa  of  round 


illt 


Tin:  em: 


! 


incuts  tit  till-  iH'ijililMiiiii!;  -itniiliiri's  ilfstmycil  iid  Itr  carried  oiii 
..f  111."  car  l>y  llic  i>iinilciit  .liM-liariJc  ur  !>>  llic  suliiliniis  iw.l  in  ^y\ 
\\\vi\\\il.  (  M'  llic  (.-.sides,  ilic  incus  is  liic  least  resistant  to  pallmloKie.ii 
cliaiijie.  Itccaiisc  III'  the  delicacy  of  it  >  li|iaiiieiits  and  the  incajjreiie-^ 
of  its  vas<'iilar  siii.|iiy,  ()cca>iiinally  the  intlainniatory  process  may 
invadi'  the  l'ailu|iian  canal  (Ti^.  .")7;{i  and  cause  nioie  or  h'ss  iiijin\ 
to  the  facial  nerve,  with  resiiltiiic  paralysis.  This  occurs  with  s|M'cial 
ease  in  those  cases  ill  which  there  exists  a  defect  ill  the  holie  lietween 
theciina!  and  the  tynipaiiiiiii  and  is  also  of  more  fre(|iient  occurrence 
ill  children,  hecause  of  the  natural  lack  of  complete  ossification  ot 
the  parts.  If  the  structures  of  the  laisiactiian  tiilie  are  frravely 
involved,  the  intensity  of  the  infection  may  I'liiiji  altoiit  the  forma- 
tion of  an  ahscess  in  the  walls  of  the  tuhe;  or  the  pus  from  the  tym- 
p.annm  may  dissect  a  way  aloiiir  the  liihe  walls  and  presently  appear 
as  a  jrravitiitioii  abscess  in  the  nasopharynx.  It  is  al.«o  possible  that 
the  purulent  intlammatioii  may  extend  to  tin-  carotid  artery  tliroiinh 
a  series  of  (•oiinectinjr  eelU  lyin<;  between  the  tympanum  and  the 
carotid  canal  (well  shown  in  a  speciini-n  in  tlie  author's  collection - 

liii.  :>u. 


W;a 


I'nibc  itfisat^il  ihrmiuh  chain  of  cells  liehinrt  OHrntlii  cKiiiil  iiiiil  loiumuniculini!  «lili  tin- tympanic 
cavity.  1.  Kxlcriiir  Miiilitnry  inciilili-.  i«i«lori.ir  wall.  -•.  Annnlils  an.l  n-ninunl  nf  ilnini  nrcTnbmne 
.t.  liiiunil  Hinilcm-.  4.  I'nitK-.  :..  Adilus,  c  SUii«».  T. 'IVnaur  lyin(«Mi  niilsc'.c.  »  Canilid  lanal 
;i.  Prnl«-«liii«li.i;  tbrmiKli  Iho  tliili  wall  ..I  carDtiil  canal. 


Tifl.  ",\\  and  opening  into  both,  or  tliroi  ,  .i  dehiscence  in  the  bony 
wall  between  the  carotid  canal  and  the  tyi..panum;  should  this  occur, 
thrombosis  of  the  carotid  artery  may  result,  or  iaial  hemorrhafie  ensue, 
as  in  .Mibe's  case.  The  existence  of  a  similar  defect  in  the  bone 
between  the  tymi)anum  and  the  sii;m()iii  sinus  or  the  bulb  of  the 


i-ini  i.i:.\r  /.>.■;. i.w .v. i//'>a  "/   /'"/•  mii>i>i.i:  i:m:      m:, 

jujriilar  'i\ii.  .'i7.")i  iiiii'  liki-wix'  n-r^iilt  ii>  tin'  diri'd  (•xtcii-*i«iii  of  ilir 
imriilfiit  i.n.cff's  ti.  llic  Vfiii.  In  rarr  niw'r*,  pus  aci-uimilatiii):  al">ul 
llic  aiticulatioii  i>(  tlif  Iuwit  jaw  may  ultitiiati'ly  i-aus<-  fn.sic.ii  of  flir 
rajisulf  (MacfWfii). 

n.i  .•.7.-.. 


a  a. 

IKhlM*nm  m  the  h..iiy  w«ll  between  the  tympsnii-  isvfty  ar  ;  .  -lernal  auditory  oaiial  and  the- 
luKUlar  bull.,  iille.1  !»■  Ilbn,ii«  tliwue     1.  Pmun,,,  .xternal  .-aim    .  i.  Dehlncences  both  ulUe.  of 

annulu-.    X  Ai,i.u:ii»     1.  <-,irutid  canal    ..   -^       -     «.  Mtain-lMi.  timl.m.    7.  F.«ia  of  oval  window 
s    I'mmonum.    »,  fell       Fniiu  a  «ieelni.  i.        lu- anihorN  mllectloni 

iVrtMiii  cliaiiKcs  in  tlic  iiiiu-oiis  iiiciiibranc  soiiictimcs  nrnir  as  a 
ivsiill   nf  iiniloiiiicl  su|>|)matiuii    -iicli  as  (icposit-  nf  lime  salts,  or. 
all  iilccralivi-  procfss  is  troiim  ,,i),  with  tiit-  I'l 

■       '     ■  h  caries  oi  tlic  iinilcrly' 


oil.     ^utii    a.^    (u|"'.^n'    '"     iitii'     .-.».. 

whcri'  all  iilcfi-atiw  process  is  >:oiim  on,  with  tin-  formation  of  graiiu- 
lalioii  tissue     usually  associateii  with  '  *' '""■'■ 


where  all  uiceraii\e  |)ioti»  i,~  ^i.ni^  "n,   ..  •>. r. 

lilion  tissue  usuallv  associated  with  caries  of  the  unilerly'M.j;  hone— 
I  he  formation  of  polvpi  reaililv  follows  It.  'JTS  cases  of  aural  polypi 
uliserveil  at  tlu'  Brooklyn  Kye  and  Kar  Ilosi>ilal,  144  were  in  males 
anil  i:U  in  females,  slmwins;  a  sli-rht  preponderance  in  favor  of  males. 
\s  to  ;i(;e,  ahout  as  inaiiv  were  found  in  patients  over  as  under  twenty 
years  of  age.  We  are,"  therefore,  justitieil  in  tliii.um«  thai  neither 
...r'..  !i,,r  <.'v  hits  mudi  to  do  with  the  icirmatioii  of  iiolyiH.id  ;:P.\vtlis. 


I  riironic  supiiuratioii.  polypi  were  found  in  '_'!.  l'olyi)i  are  not 
.iuavs  sinjiie.  sevi'ial  niav  coexist  in  the  same  ear.  Cases  in  whicii 
ihe  tVmpanic  attic  is  tlie'seat  of  the  dis(>ase.  with  perforation  of  the 
iMcmi.rana  tlaccida.  or  ShrapiK'H's  meml.rane.  fre.iuently  jiroduce  poly- 
poid enlarfieineiits, 

I'resupposinK  tliat  the  inllammatory  process  is  either  intense  or 
nroloiifred,  ll..'  inuco-pcriosieal  pn.feotivp  iininj:  -f  the  ,„;,!a!e-ear 
civities  naturallv  tentls  to  disintegrate,  thus  exposuif:  the  underlying 
I.OIU-  to  the  sam'e  infective  attack.     This,  top'ther  with  the  pressure 


IIIG 


THE  i:ar. 


Flo. 


of  the  acciiiiHilatiii<i  purulent  sccn'tioii,  lniii>;s  :il»>ut  canes  and 
necrosis  of  tlmse  parts  of  tlie  l)ony  cellular  structure  of  least  vitality. 
From  the  nuicous  ineruhraiie  coveriiif;  the  tyinpanuni,  the  intlaniina- 
tion  spreads,  liy  continuity  of  structure.  throu>;li  the  aditus  to  the 
mastoid  antrum,  and  from  thence  into  the  larger  connecting  nm.stoid 
cells,  which  also  are  provided  with  a  nnicons  memhrane.  The  giving 
way  of  these  cell  walls  permits  the  jnirulent  collection  to  hnd  its  way 
into  the  surrounding  cells  which  may  have  no  direct  coimection  with 
the  mastoid  antrum,  and  some  of  which  may  lie  im|irovided  with  a 
nmcous  tiieml)r:uie;or  the  inllammato"-y  jMocess  may  extend  indirectly 
tiirough  llie  veins  or  lymphatics  into  these  isolated  cells  and  result 
in  a  localized  jiurulent  collection  which  does  not  eonununicate  with 
the  mastoitl  antrum;  or,  without  the  formation  of  any  marke<l  col- 
lections of  pus,  the  intensity  of  infection 
Uiay  |)roduce  a  more  or  less  gen<'ral  deiitii 
of  the  hony  cellular  structure,  which  be- 
comes darkly  discolored  and  friable. 
Coincidently  with  the  accunuilation  of 
pus  and  death  of  bone,  nature  attemj)ts 
to  form  a  line  of  demarcation  by  the 
pmlifendion  of  granulation  tissue  from 
the  still  living  tissues.  This  granula- 
tion tissu<'  becoming  exubenuit,  we  have 
cavities  in  the  bone  filled  with  pus,  gran- 
ulation tissue,  and  the  detritus  of  decayed 
bone.  Sometiiiiis  the  inflanunatory  jiro- 
ce.ss  extends,  at  the  same  time,  through 
a  series  of  small  cells  which  occasionally 
conununicjite  with  both  the  tympa.ium 
and  the  mastoid  cells. 

Occasionally  the  accmuulation  of  pus 
in  the  antrum  or  a<ljacent  cells  easily 
linds  its  way  into  the  external  auditory 
canal,  because  the  Ixmy  wall  between  is 
thin,  or  even  at  times  defective  (Fig,  oTtii;  or  i;  may  pas-  along  a 
j)ersistent  mastos(iuamosal  suture  to  the  soft  tissues  covering  the 
parts  back  of  the  auricle.  This  suture  (Fig.  'u~)  has  been  found 
I)resent  by  .Maceweu  in  (17  out  of  4">()  adult  temporal  bones.  Or  the 
pus,  having  gravitated  to  the  cells  in  the  mastoid  tip,  or  having 
formed  there  as  a  localized  collection,  may  penetrate  through  the 
thin  iimer  wall  of  the  tip  into  the  digastric  or  occijiital  grooves— a 
condition  first  noticed  by  Hezold,  of  Munich,  and  conse(|uently 
named  Rezolil's  mastoiditis. 

In  children,  the  juis  contained  in  the  tympanum  has  a  tendency  to 
dissect  off  the  periosteal  lining  of  the  jiosterior  and  superior  external 
nuditnrv  i-.uv.il  walls,  forminsr  a  channel  through  winch  the  pus  escapes 
to  the  soft  parts  lying  behind,  above,  aiid  even  in  front  of  the  auricle. 
But  much  more  frequently,  the  pus  finds  it.i  way,  in  children  as  in  adults. 


ImiitTfect  devcloiiment  of  bony  wiiUs 
of  extiTiittl  auditory  canal.  1.  Tym- 
jianic  inembraiii'.  2.  Anterior  wall  of 
canal  almost  atwent.  R.  Hiatus  in  bony 
wall  under  annulu".  4  Posterior  wall 
of  external  canal,  with  oiwn  cell.",  i'. 
and  an  ojieninK  into  the  nia.itoid  I'ells. 
7.  Apex  of  masinid  process  (From  a 
Bfieeimen  in  tlie  author's  eolleclton.) 


X 


ill 


< 


s  :  ? 


>  U  ' 


li,^ 


rrinLEsr  iM-i.AMMAi'ioy  of  the  m/ddij-:  kxh-     1117 

li,vt  t..  the  mast. ml  aiitn.in,  aii.l  tlicncc,  by  ilic  ,lcstnicti..n  ..f  tho 
l„m.',  ..!•  thnuifih  the  s<iiiiii.U)n.astni.l  lissuiv.  or  l)y  tl'c  vessels  to 
,|„.  outsi.lf  soft  parts.  Hccausc  of  the  structural  peeulianties  of  the 
l„,„e  ill  .■hil.lreii,  thev  are  more  liable  to  liave  necrosis  of  eot.si.lerable 
portions  of  tlie  mastoi,|  j.rocess.  usually  in  the  form  of  a  seiiuestrum 
-urrounded  by  pus  and  jiramilation  tissue. 


Fig.  57' 


A.lult  U"inp.ir..l  bone  will.  !«isl8tent  miuitnKiuamo»al  suture.  1.  PersUtent  mMt.*iuamo«al 
-iiinn-.  2.  TemiHjral  rMKu.  3,  Suprawieiital  n>i«e.  4.  Mb«U>1.1  fossa.  (From  O.  K.irneri.  Die 
KitriKcn  Erkronkungen  des  SchUftnbcius.) 

The  direetion  usuallv  taken  by  this  destruetion  of  t>>e  bony  parts 
i<  toward  tlie  ma.stoi(i  i^ocess:  but,  exceptionally,  it  may  proceed 
inward  and  forward,  so  that,  as  Macewen  says:  "The  whole  of  Mie 
interior  of  the  petrous  bone  may  become,  in  extreme  cases,  hollowed 
Milt,   leaving  a   shell   exfrnally.     The   labyrinth,   bi'inj);  encased   in 

'  sinteRratinfi  i)rocess.     Such  extensive  de- 

a.s  a  tubercular  disintejtration.     Occa- 

are  similarly  affected."     In  other  cases, 

ioic  cells  IvinK  between  the  superior  wall 

,„  ,„,-,,„.-,„.. , ,■  ,..nal  and  the" inner  table  of  the  skull  forniins 

the  floor  of  the  middU"  cerebral  fos.sa;  from  these  cells  it  if  ly  extend 
lo  those  present  in  the  posterior  root  of  the  zygomatic  process;  or, 
In.ni  the  nuistoid  process,  the  destruction  may  involve  the  diploic 
reils  in  the  occipital  bone.  In  fact,  wherever  there  is  diploic  tissue 
in  the  vicinity  of  the  suppurating  middle  ear  there  exists  the  possi- 
bility of  extension  (Plate  XXXIV.),  especially  rapid  and  widespread 
if  tlie  inilammalorv  proces.s  is  tubercular  or  syi.hilitic. 
\'ery  generally  it  may  happen  that  tho  persistent  irritation  of  a 


liarder  bone,  resists  t' 
-t ruction  is  met  \v'  . 
-ionally  lioth  jx'troi 
it  may  spread  into     n 
>f  the  external  autliti.. 


I 

I 

i 

I 

I 


1118 


THE  EAll. 


!i 


cliionic  piinilciit  inflaniiimtion  liiuitcd  to  the  iniincdiate  rpRion  of 
the  tynii)amim  iiidiin's  a  coiulciisinfi  osteitis  of  the  iicij;lil)(iriiip;  Unu\ 
(•si)C('iaily  liiat  of  tlu"  mastoid  process.  This  condeiisatioii  of  the  hone 
has  l)eeii  deiioiiiiiiated  "ehunialion,"  and  it  is  (juite  a  cotmMon  con- 
dition wlierever  the  suppurative  i)rocess  is  of  a  low,  te(Uoiis  ty])*'; 
hut  it  does  not  hy  any  means  necessarily  follow:  for  example,  the 
writer  did  a  radical  o])eration  n|)on  a  young  girl,  aged  nineteen  years, 
who  had  he(>n  a  sufferer  from  chronic  puruh-nt  otitis  media  since  an 
attack  of  scarj-^t  fever  in  infancy,  and  in  whom  there  existed  so  much 
atresia  of  the  external  auditory  canal  that  the  small  ear  ])rol)e  of 
Hart  maim  w!us  inserted  with  difticulty,  pushing 
before  it  a  protruding  valve-like  mass  of  granu- 
lation tissue,  yet  the  mastoid  ])rocess  still  re- 
tained its  original  extremely  pneumatic  forma- 
tion. Nor  does  it  necessarily  follow  that  the 
ossicles  are  carious  in  cases  of  chronic  middle- 
ear  suppuration;  thus,  ihe  writer  has  removed, 
from  a  young  man  who  had  been  a  victim  of 
this  disetise  since  childhood,  the  two  large  ossicles 
in  a  jierfectly  healthy  strte. 

Unfortunately,  howevi  r.  this  so-called  ebur- 
nation  (Fig.  578)  of  the  bone  does  not  always 
rake  iil'ice  at  every  point  in  the  surrounding 
wall:  if  this  were  the  ciise  an  efficient  barrier 
would  lx>  raise<l  to  protect  the  intnicraiiial  con- 
tents. More  often  a  carious  process  is  making 
inroa<ls  at  some  locilized  spot  that  is  destiTieil 
to  HMider  abortive  all  of  nature's  elTorts  to  guard 
her  citadel. 

The  carious  i)rocess  advancing  upon  the  bone 
attacks  most  fre(|uetitly  the  mastoid  process; 
next,  the  roof  of  the  tymi)anum  or  antrum:  next,  the  sigmoid  groove, 
and  least  freipiently  the  i)osterior  wall  of  the  external  auditory 
canal,  or  tiie  floor  of  the  tympanic  cavity  toward  the  carotid  canal, 
or  the  jugular  fos.sa,  or  the  petrous  nortion  of  the  temporal  bone. 

P>om  the  middle-ear  cavities  the  purulent  infection  spreads  to 
the  intracranial  structures  in  various  wa\.-.  It  may  ;  ..ss  along  a 
suture  to  the  dura  mater:  this  especially  in  children,  since  for  obvious 
reasons  the  lines  of  junction  of  the  ossitic  centres  are  here  very  vju*- 
cular.  .Again,  it  may  |)ass  through  the  minute  veins  which  form  com- 
munications between  the  middle  ear  and  the  suiK-rior  petrosal  and 
sigmoid  siiuises;  in  chronic  inflanun.-ition  of  the  middle  ear  these 
veins  become  enlarged  and  are,  therefore,  of  greater  importance. 
Again,  along  the  nerve  sheaths,  either  along  the  facial  or  through 
the  labyrinth  to  the  auditory  nerve  in  t!ie  internal  auditory  meatus. 
Finally,  the  infection  may  spread  through  the  lymphatic  vessels  in- 
ward to  the  skull  contents. 

In  the  majority  of  cases  the  pathway  of  infiH'tion  is  vi.siblc  because 


Mastoid  procew  of  poiii- 
liact  tiMiie,  not  patholfigi- 
cal.  Resemhics  "eburna- 
tioii."  Mastoids  vnry  in 
texture  between  this  and 
the  pneumatio.  (From  a 
s^iecimen  in  the  author's 
collection.! 


fSRO'vnwfBai 


PURULENT  ISFL.IMMATION  OF  THE  MIDDLE  EAR.      \l\% 

,,f  the  discoloration  of  the  l)on(',  its  carious  comlitioii,  or  tlic  pres- 
oiicc  of  u  fistula.  The  hone  is  turned  to  a  dark  grocnish  or  hiackish 
color.  Maccwcu  hclicvcs  that  -the  ri-rht  side  of  the  head  is  iiion- 
(.ftcn  affected  by  intracranial  si'(iuela'  from  otitis  media  than  the 

left."  ,  u-   1  1 

The  dura  abutting  upon  the  infected  bone  becomes  thickened, 
livpera-mic,  <rdi'matous,  and,  when  exi)os('d  by  osseous  erosion,  cov- 
ered with  granulations.  If  the  i.us  from  the  middle  ear.  under  press- 
ure, follows  the  breaking  down  of  '''c  bone,  tlw  dura  is  strijjped  up 
and  a  .so-called  extradural  abscess  is  formed  in  the  resulting  cavity 
between  the  dura  and  the  Ix.ne.  Such  extradural  ab.-*cesses  tend  to 
spread  upward  toward  the  vertex  rather  than  downward  toward  the 
l)a.se,  because  the  dura  is  more  loosely  attached  above.  Tiias  the 
writer  recentlv  had  a  iiatient  who.se  mastoid  jirocess  was  intact;  but 
the  pus  from  the  middle  ear  jjasseil  through  an  erosion  in  the  tegineii, 
dissected  off  the  dura  upw,  rd  to  about  two  inches  above  the  external 
auditorv  canal  and,  at  a  point  one  and  threcMiuarter  inches  above, 
IK'netrated  through  both  tables  of  the  skull,  appearing  externally 
under  the  periosteum.     (Fig.  (Mil'  >  •  •       •  i 

\X  other  times  there  is  produced  a  localized  pachymeningitis,  with- 
out the  loosening  of  the  dura  by  pus.  ami  this  inflammation,  .spread- 
iug  to  the  other  membranes  of  the  brain,  with  the  evolution  of  more 
,.f  less  plastic  material,  may  cement  thom  together  around  a  centra 
.•ore  of  infection  in  direct  connection  with  the  bone  disea.se.  Shomd 
.III  accumulation  of  pus  take  i)lace  in  this  central  core,  between  the 
pia  and  dura  mater,  and  surrounded  ami  |)revpnted  from  dissemi- 
nating by  the  i)lastic  efTusion  uniting  the  brain  enveloi)es,  then  we 
have  what  is  commonly  called  a  subdural  abscess.  In  the  majority 
..f  such  c:i.ses  there  occurs  coincidently,  or  directly  following,  a  super- 
ticial  ence|)halitis,  with  or  without  ulceration. 

If  the  infective  material  gains  an  entrance  into  the  subdural  space 
ihrough  the  dura  mater  before  this  adhesion  of  the  membranes  ha.s 
occurred,  an  acute  leptomeningitis,  either  serous  or  purulent,  will  very 
iiK.bably  be  set  up.     In  the  serous  variety  of  leptomeningitis,  there 
i-   lyiHTa'mia,  followed  by  the  exudation  of  clear  serum,  often  contain- 
:m  Hakes  of  fibrin,  leucocytes,  or  a  few  pus  corimscles.     Such  an  effu- 
-ion  mav  result  either  in  internal  or  external  hydrocephalus.  Macewen 
-iat<«s  tiiat  occasionallv  such  subdural  efTusions  may  be  localized.   In 
I  he  ()urulent  variety  tliere  is,  in  addition  to  the  hypera'inia  and  serum. 
I  marked  exudation  of  leucocvtes,  degenerating  in  places  into  purulent 
loci,  together  with  more  or  less  encc])halitis.     Such  a  leptomeningitis 
tends  to  s]>read  rapidlv  and  widely.     Infection  spreading  along  the 
Mirineural  sheaths  gener.ally  gives  rise  tolei)tomeningitis:  thus  it  may 
,.a.ss  from  the  middle  to  tl'ie  internal  ear  and  from  thence  backward 
iloiig  the  sheath  of  the  facial  and  auditory  nerv(>s,  or  from  th(>  facuu 
ij.wardand  f'TWiird  through,  the  foramen  enclosing  the  great  petro- 
-al  nerve.     In  voiing  children,  purulent  otitis  media  is    ■■)t  to  give 
rise  to  purulent  lei)tomeniiigitis,  the  infecticm  passing  thiough  the 


1120 


TtlK  t:.iH. 


luimi'ii.us  veins  and  ihtvc  slicatlis:  this  is  csiu'cialiy  true  of  the  tuhi-r- 
ciilar  atTcction. 

.\.s  lias  Ix-eii  said,  nu.rc  or  less  cnceplialitis  must  neeespanly  W 
foincident  with  or  follow  dose  upon  a  purulent  leptomeningitis, 
because  "of  the  intimate  relations"  existing  between  the  pia  inater 
and  the  l)rain.  and  "the  maimer  in  which  the  bloodvessels  dip  into 
the  cerebral  sui)stance,  carryin};  aloiif;  with  them  their  investment 
of  the  pia  mater."  Also,  the  purulent  leptomeningitis,  extending 
along  the  pia  mater  wher(>  it  dips  into  the  sulci,  may  bring  about  a 
collection  of  pus  in  these  sulci,  which  may  take  the  form  of  a  localizeil 
^-  ,  ricial  abscess  if  the  line  of  inviusion  is  ch)sed  by  plastic  adhesion 
...  ,.ie  membranes.  A  localized  encephalitis  adjacent  to  this  absee.ss 
usually  results  in  ulceration  of  the  brain  surface,  adding  to  the  size 
and  extent  of  the  abscess.  Sucli  an  abscess,  although  involving  the 
superficies  of  the  brain,  is  not  entitled  to  be  termed  a  brain  abscess, 
it  is  more  proj>crly  an  ulceration. 

FlO.  57». 


1.  Carious  ..penlng  in  tympanic  ro..f.    2.  Thickened  dui»  tamed  b«ck.  but  when  in  position 
coTera  cariouK  opening.    (Bacon.1 

A  true  brain  abscess  is  brought  about  by  the  extension  of  the  infec- 
tion along  th(>  bloodvessels  into  the  brain  -ubstance  proper,  inducing 
(edema  of  the  surrounding  brain  tissue,  with  exudation  of  leucocytes 
and  red  blood  corimscles  in  varying  proportions.  .\s  the  (rdema 
and  swelling  increjise.  degeneration  of  the  nerve  tissue  en.sues,  and 
then  finally  results  an  area  of  purulent  encephalitis;  in  other  words 
an  abscess  "made  uj)  of  pus  and  disintegrated  brain  tissue.  It  some- 
times hatMX'Hi^  tl'sd  the  death  or  necrosis  of  a  considerable  area  of 
cerebral  tissue  results  in  the  presence  of  sloughs  within  the  abscess. 
Such  sloughs  mav  be  caused  by  infective  embolism  or  thronibo.sis 
of  the  main  vessel"  supplying  a  iM)rtion  of  the  brain,  leading  to  ana>mic 
gangrene:  emf)olism  of  "the  main  veins  inducing  gangrene  from  the 


9-n^ 


^^mmmmm 


VVRl'LEyr  IXFLAMMATIOX  OF  rilE  MII>I>I.E  EM!.      1121 

ii  tense  pressure  set  up  by  the  extravasation  due  to  the  bloekiiiK  of 
thu  exits  of  the  blood  stream,  hemorrhagic  necrosis;  localized  pressure 
,1  the  part  engorged,  with  extravasation  exerting  influences  upon 
\h9  .1  i^aboring  brain  tissue,  leading  to  its  disorganization  and  death, 
tlie  intensity  of  the  inflammatory  action  depending  on  the  nature 
of  the  micro-organisms,  inducing  rapidly  advancing  necrosis  (Mac- 
i.\veu).  The  brain  membranes  are  rarely  involved  in  such  u  slough. 
As  a  rule,  there  is  ocular  evidence  (Fig.  579)  of  the  pathway  taken 
by  the  infective  material  in  reaching  the  i)urulent  collection  within 
the  brain;  the  majority  develop  by  direct  extension  from  the  nuddle 
car.  But  there  may  be  no  visible  tract,  the  infection  spreaiUng 
inward  through  the  vascular  or  lymphatic  system. 

Tubercular  disea.ses  of  the  middle  ear  seldom  give  rise  to  bram  ab- 
scess; this  is  due  to  the  fact  that  they  are  more  apt  to  set  up  a  rapidly 
fatal  tubercular  leptomeningitis,  and  the  extensive  bone  destruction 
permits  of  free  e8ca])C  of  the  purulent  secretion. 

The  sanu'  micro-organisms  have  been  found  in  the  purulent  collec- 
tions of  leptomeningitis  and  encephalitis  as  in  the  otorrhoca. 

The  brain  abscesses  caused  by  purulent  otitis  media  are  usually 
.•situated  in  the  temporosphenoidal  or  cerebellar  lobes,  and  are  much 
more  frequently  consetiuent  upon  the  chronic  than  upon  the  acute 
I  process  in  about  the  proportion  of  six  to  one. 

\bscesses  of  the  temporosphenoidal  lobe  range  in  size  finn'.  a  few 
drops  to  a  number  of  ounces.    They  are  single  in  87  per  cent,  of  the 
cases,  according  to  Macewen.    Together  with  the  disintegration  and 
•  loath  of  the  afft  :;ted  brain  tis.sue,  the  surr-unding  living  tissue  l^egins 
to  throw  out  material  which  is  eventually  transmuted  into  a  fibrinous 
membrane,  at  first  non-vascular,  but  later  supplied  with  bloodvessels 
Mild  of  a  verv  low  grade  of  vitality.     Thus  a  capsule  is  formed,  which, 
when  complete,  generally  brings  the  suppurative  process  to  a  stand- 
still.    How  long  it  may  take  a  cai)sule  to  form  is  dependent  upon  the 
character  of  the  inflammation.    Abscesses  three  weeks  old  have  been 
found  without  capsules.     In  acute  abscesses  tht;  surrounding  ti.ssue 
is  actively  inflamed,  with  a  surface  flocculent,  shaggy,  and  irregular, 
docked  here  or  there  with  minute  sloughs.    The  escape  of  blood  from 
tlie  small  vessels  has  been  jirevented  by  thrombosis  in  advance  of  the 
molecular  disintegration.     But  it  may  happen  that  disintegration  is 
M)  rapid  tha+  thrombosis  does  not  occur,  and  then  bleeding  takes 
place  into  the  abscess  cavity.     In  older  abscesse.'i  there  usually  exists 
a  rounded  capsule,  varying  in  thickness  from  one  to  more  than  five 
millimetres,  whose  internal  surface  is  generally  smooth,  while  the 
oxternal  surface  is  rather  ragged  and  flocculent.     Occasionally  the 
poriphery  of  the  cajisule  is  reinforced  by  a  layer  of  connective  tissue, 
!iiid  at  times  this  lai'or  is  more  or  less  calcified. 

The  contents  of  "a  cerebral  abscess,  consisting  of  pus  and  disinte- 
U'vated  brain  tissue,  is  usually  of  a  giwuish-yellow  color.  When  there 
has  been  blee<ling  into  the  cavity  the  color  is  dark  })rown.  In  other 
cases  the  contents  nuiv  be  thin,  serous,  fetid,  and  contain  many 


112: 


rHK  EAK. 


minute  sloughs.     "^<»mctiiiuvs  the  upper  part  of  the  ahscws  eavity 
may  contain  more  or  less  fetid  gas. 

It  has  liappenetl  that  smother  abscess  may  form  outside  of  an 
encapsulated  abscess,  because  the  compression  and  i  onsecjuent  irri- 
tation of  the  original  one  hiul  induc(>d  a  purulent  encephalitis,  the 
encapsulated  absce.«s  remaining  intact.  Again,  the  inner  surface  of 
the  capsi  le  may  begin  to  graimlate  with  the  production  of  more  ))us 
and  th'-      largement  of  the  original  ab.scess. 

It  i.  .  ^ibie  for  a  cerebral  abscess  to  be  absorbed.  The  fluid  por- 
tion of  the  pus  may  become  absorbed,  and  newly  formed  vessels 
originating  from  the  living  brain  tissue  and  f)enetrating  the  capsule 
may  bring  about  tlie  absorption  of  the  purulent  tlebris  through 
phagocytic  action. 

Brain  abscesses  have  discharged  l)y  (>rosion  through  the  tegmen 
tympani  or  antri,  through  the  external  wall  of  the  skull,  and  through 

the  internal  wall  of  the  mastoid  cells.  But 
it  rarely  haj)pens  that  a  cure  is  brought 
aboutin  this  way. 

Usually  the  abscess  breaks  through  the 
surface  of  the  brain,  setting  uj)  an  acute 
leptomeningitis,  or  into  the  ventricles. 

The  infective  process,  originating  in  the 
middle  ear,  sometimes  picks  out  a  course 
towartl  the  sigmoid  groove,  and  when  it 
hai)pens  that  the  osseous  wall  is  deficient 
at  any  point,  being  replaced  by  fibrous 
membrane  only,  the  infection  may  quickly 
extend  to  the  contained  sinus.  More 
usually,  caries  of  the  bony  wall  results  in 
erosion,  with  ultimate  exijosurc  nf  the  sinus. 
(Fig.  580.)  Less  frequently,  i^  there  are 
veins  from  the  tympanum  <■  ijjtying  into 
the  sigmoid  and  jx'trosal  sinuses,  a  vein 
may  become  thrombosed  and  the  thrombus 
extend  into  the  sinuses;  this  generally  pro- 
duces thrombosis  of  the  sigmoid  sinus  first, 
extending  tlience  into  the  other  siiuises,  hut 
occasionally  the  petrosal  sinuses  are  first 
affected,  and  the  sigmoid  is  implicated  later 
a.s  a  result.  However,  vei-y  few  cases  of 
sigmoid  sinus  thrombosis  occur  without 
extensive  disease  of  the  bone.  This  is 
especially  true  in  tul)ercular  affections  and 
in  carcinoma  auris.  .^s  the  right  sigmoid 
groove  is  generally  wider  and  rjeeper  and  is 
projected  more  outward  and  forward  than  the  left,  it  is  but  natural 
that  it  should  be  somewhat  more  frecjuently  affected. 

Infective  thrombosis  of  the  sigmoid  sinus  occurs  chiefly  in  adults. 


l'«rt  (if  skull  „f  yniing  girl  who 
•lied  of  infective  sinus  thnimbosls. 
Shows  internal  dnrnl  wall  of  sintis 
rellecteil  liack,  cxiKj«ing  i)erfora- 
tiou  in  wall  ol  sigmoid  groove; 
also  the  dark,  diseolored  appear- 
ance of  i.inns  wall  cunlng  to  the 
edge  nf  the  tione.  Arniw  fxiinls  to 
sinus.  I  b'rom  a  sfieciineii  in  the 
amhttrs  collection.) 


"S^ 


I'VHVLKST  ISFI.AMMMIOS  OF  TltK  MIDOLE  EAR.      112.1 

,  Nc.-i>»ionnllv  in  children,  and  rarely  in  tlie  aged.  It  is  often  asso- 
liaK'd  in  its  later  stages  with  meningitis,  and  not  infrecjuentiy  with 
(•erel)ral  or  eere'-'-llar  abscess. 

As  hai)|)ens  in  all  cases  of  venous  thronilwsi.'i,  tlie  internal  endo- 
tlielial  lining  of  the  sinus  becomes  roughened  through  swelling,  soften- 
ing, disintegration  and  desquamation  of  the  cells,  and  the  fibrinous 
constituents  of  the  blood  current  find  a  lodgement  on  the  roughened 
-urface;  the  mass  so  formed  gradually  encroaches  upon  the  lumen  of 
the  vessel  until  it  is  jiartially  or  wholly  occluded.  WTien  the  sinus 
i<  whollv  (.cciuded,  the  clot  spreads  for  a  greate-  or  lesser  distance 
above  and  below,  and  so  effectually  stops  the  How  of  blood  through 
t he  sinus.     At  this  point  the  clot  may  become  organized,  the  \nrule  ice 


Fill.  .'«!. 


I^^J-ommHntcanonihrongKparitial 

fitmmen  with  txtemciwlm  of  AM. 


Ext.jugvlarvetn 

Inl.  jugular 

vein 

I  .i„..ram  showing  the  foramunloitlon,  enisling  between  the  sui^rior  longitudinal  «n.1  lateral 

slnu«e«  and  the  external  veins,  Indicated  In  the  figure  by  •.    (Lki'BE.) 

of  tlie  infection  having  exhausted  itself  naturally  or  because  of  opera- 
tive interference  with  the  affected  bone,  or  the  clot  may  l>egin  to  ilis- 
iiitegrate  with  more  or  less  formaiioii  of  pus.  This  disintegration 
icxults  in  a  purdent  fluid,  greenish  brown,  grumous,  and  often 
streaked  with  pus,  collecting  around  the  original  site  of  infection  for 
the  «inus,  and  beyond  this  in  both  (Urections,  upward  and  down\vard, 
ilicre  usually  extends  a  healthy  clot.  In  some  cases,  sloughing  of  the 
external  wall  of  the  sinus  occurs,  with  evacuation  of  the  fluid  c.jn- 
i.nts  into  the  mastoid  process;  the  extension  of  the  olxstructing  clot 
vvithiii  the  healthv  •>ortion  of  the  sinus  preventing  any  hemorrhage, 


1124 


rilH  EAH. 


ius  a  rule.  Shoulil  tlio  visceral  layi-r  of  tho  sinus  bocomo  iiffprtcd,  an 
acute  lt'i)tom('iiinKitis,  wliich  may  hv  loralizod,  usually  results.  Tiic 
Immic  and  the  soft  tissues,  in  the  immediate  neighhorhooil  of  t'>e  dis- 
inteRratiiift  jiroeess  within  the  sinus,  get  to  be  dark  greenish  or 
brownish  in  color,  an.i  the  surface  of  the  bone  becomes  roughened 
or  eroded.     Finally,  softening  of  these  tissues  takes  place,  if  the  ])atient 

lives  so  U>ng. 

Kio.  :«% 


Anl./aciuXve:.i 


Fxt.  Jttfful  xvin 


Communication  ivithveitiM 
at  back  of  neck 


IMagram  showing  the  communlratlons  exlrtlng  between  the  lateral  and  cavernom  »inus«!- 
and  the  external  veins,  indicated  In  the  figure  by  *.    (I.ki'be  ) 

The  infective  sinus  phlebitis  may  CAt'.'nd  downward  into  the  internal 
jugular  vein,  and  even  into  the  superior  vena  cava.  The  soft  tissues 
.surrounding  the  affected  veins  may  become  a'deinatous  and  infiltrated 
with  plastic  material,  and  tho  cervical  lymphatics  involved  fnnii  a 
continuous  line  of  swelling  down  the  neck  under  the  deep  ccr\-ical 
fascia.  The  swollen  ma.^s  may  undergo  purulent  disintegration,  form- 
ing an  abscess  in  the  neck,  sometimes  directly  connected  with  the 


It.'.^t!  '^1^^   ."w     ll,-^-.M-Jli 


'jivm 


ri'Rl'LKXT  ISFLA.VMATIOS  Oh'  TIIK  MlintLK  EAR.      112.-) 


(lisintcp-ating  thrombu.s  within  the  vein.  Evon  hen-,  however,  there 
(xists  often  ocntrally  a  firm  thrombin  which  for  a  time  prevents 
fiirtlier  (Usscniination  of  the  infective  material. 

Infective  material  mav  be  carried  into  the  general  circulation  by 
wav  of  the  internal  jugular  vein  or  by  way  of  the  posterior  condyloid 
v.«in  the  occipital  sinus,  or  the  mastoid  vein,  which  communicates 
indirectly  with  the  subclavian  and  innominate  veins  without  passing 
through  the  internal  jugular.  (Figs.  581  and  582.)  Whiting  states 
that  "there  is  great  likelihood  that  general  infection  may  also  take 
place  bv  Ivmphatic  absorption  of  the  pyogt>nic  organisms."  Maeewen 
say^  "Infective  matter  may  spread  through  the  sinus  walls  into  the 
neighboring  parts,  where  it  may  be  taken  up  by  the  cong<«8ted  vessels 
and  periva.'icular  spaces  and  carried  into  the  circulation. " 

Within  the  skull  the  dura  may  be  stripped  up  from  the  bone  by 
purulent  exudation  or  bv  the  evacuation  of  the  purulent  contents  ot 
the  sinus,  and  the  pus  may  seek  an  exit  externally  by  way  of  the 
mastoid  foramen  or  through  the  posterior  condylar  foramen,  where 
it  form.x  an  abscess  under  the  deep  fascia  in  the  upper  third  of  the 
posterior  cervical  triangle.  When  the  pus  forms  on  the  visceral  side 
of  the  sigmoid  sinus,  it  may  gain  an  exit  through  the  anterior  condyloid 

"occiusionally  the  cerebi-ilar  veins  become  thrombos<>(l,  thus  admit- 
ting i)athogenic  organisms  into  the  cerebellum.  From  the  sigmoid 
sinus,  the  disease  ma>  take  its  way 
to  thecavernous  sinus,  from  whence 
it  may  extend  along  the  ophthal- 
mic vein  into  the  orbit,  inducing 
a    purulent   cciii. litis.     (See   Fig. 

582.)  .  . 

Septic  material  once  m  the  cir- 
culation is  carried  along  until  de- 
posited in  the  lungs,  brain,  intes- 
tines, or  muscular  structures;  lea.'^t 
often  in  the  kidneys  or  liver. 
Wherever  the  septic  particles 
tinally  lodge  there  results  a  metas- 
tatic abscess. 

There  exist  two  tracts  by  which 
the  infective  process  extends  from 
the  middle  ear  to  the  cerebellum. 
First  through  the  labyrinth  (Fig. 
.583)  with  the  neighlwring  portion 
of  the  ma.stoid  antrum  land  second,  ^,     ^  n     i     i    ♦„ 

through  the  sigmoid  groove  and  sinus.  The  f^rst  usually  leads  to 
Ihsce.!  in  the  median  portion,  while  the  second  leads  to  abscess  in 
the  lateral  portion  of  the  cerebellum.  •  „  ;„  u=a 

There  has  been  no  record  of  a  cerebellar  abscess  forming  in  less 
time  than  from  two  to  five  weeks.    These  abscesses  are  usually  small, 


Fio.  .'V'W. 


1 

View  of  middle  «nd  lntern»l  ear  from  In 
front.  1.  Floor  of  tympsnum.  2.  Membrana 
vlbrans.  3.  ehorda  tympanl  nerve.  4.  Handle 
of  hammer.  .'>.  Incus.  6.  Fallopian  canal.  7. 
SUpen.  ».  Vesllbi  •  ibyrlnth,  with  open- 
ingsofsemlclrciila.  .-  .».  (Fromaipeclmen 
in  the  author')  collection.) 


1126 


THE  t:AR. 


although  they  may  grow  so  larnt*  its  lo  lia\e  i  •  npacity  of  four  ouiico 
Only  one  cif«'  has  dccurrtHl  hofon-  \:A'.  furlh  y«-ar.  ThfV  an*  v('r\ 
rare  in  th«'  first  ten  years  of  life  ami  fter  t  rty,  and  are  imwt  fn*<ju('nt 
Ijcfwtt'n  th«'  agi-s  of  ten  and  thiriy  yoar  The  oldest  |)atient  was 
fifty-five  years  old— a  female.  Koch  fAld«'rtnii's  translation)  be- 
lieves otic  abscesses  are  nearly  iis  fre<|U(vit  in  tiie  eerel)elluni  an  in 
the  eerebnnn.  K(wii  also  states  that  cerel^jllar  alseesses  oepur  twii  .• 
as  fre  (i.ently  in  males  as  in  females.  T'l.'  r,  in  a  -^I'^ht  preference  for 
the  right  hemisphere— tifty-three  in  ti\.'  .i'.hl  to  forty-eipht  in  fhe 
left.  Thev  are  usually  situated  close  nii'li  i  tiii  'ortex,  tlic  cortex 
itself  usually  offering  an  ai)precial)le  rsi-  "in',  fn  a  st-rics  of  44 
cases,  a  capsule  was  present  in  26  an<l  al>n  ;•  in  1  I  duitiple  alwcesses 
were  found  in  It)  out  of  IH  fatal  eases,  •>  »veio,  mii  'pie  al)sces.se8  in 
the  same  hemisphere,  2  had  one  in  (  ic  ;ieiriis| 'icn  1  li.id  set  tij) 
metastatic  abscesses,  and  7  had  anoihir  al'Sif  ither  in  he  tem- 
poral or  occipital  lobes.  As  with  the  (i'li'^r  in;' 'raniul  s»quela-  of 
purulent  otitis  media,  cerebellar  al)»ci'  -  usually  foH.iws  u!H)n  the 
chronic  form;  in  only  15  (mt  of  KX)  cases  did  it  sih  .-tv, ■  to  the  acute 
form. 

The  figmoid  .sulcus  is  the  usual  place  of  commuiiicatiuii.  and  the 
majority  are  in  direct  contact  with  the  igmoid  sinus,  wliiil;  is  often 
thrombosed.  In  63  out  of  76  cases  of  rlmmic  otorrhcea  \'  rii  cpreli*'l- 
lar  abscess  there  were  present  on  the  anterior  wall  of  lin'  posterior 
cranial  fos,sa  marked  and  important  changes.  The  area  of  attack  of 
the  carious  process  extends  from  the  superior  to  the  inf(>rior  f>t)rder 
of  the  pasterior  surface  of  the  pyramid  and  fruin  tlic  posterior  edgt 
of  the  sigmoid  groove  to  the  anterior  edge  of  the  internal  auditory 
meatus,  occasionally  involving  the  tip  of  the  pyramid.  Tlu  arus  is 
not  in  the  sigmoid  groove  in  the  majority  of  ca-"s,  but  antcri.c  to  it. 
Koch  says  that  the  situation,  position,  and  form  of  the  sigmoid  proove 
ha.'^  little  to  do  with  the  genesi.^  uf  cerebellar  absci  •>.  The  whole  de- 
velopment of  tho  cerebellar  abscess  is  inward  into  the  :iie(lul!ar>' 
substance.  Cortex  abscesses  are  much  rarer  than  in  the  temporal 
lobe,  a'though  the  cortex  may  bimme  so  thinned  as  tvi  diF!'- pear,  and 
the  dull  or  tentori'im  e.tiie  to  form  a  wall  of  the  abscess. 

Cerebellar  abscesse-  .-cldom  contain  such  pieces  "f  necroti<  brain 
ti.ssue  as  do  temporal  abscesses.  The  contained  pus  is  usually  of  t 
creamy  coiLsisteicy,  of  a  yellowish  or  greenish  color,  frequently  fetid, 
but  free  from  f;:Ls  bubbles.  Blood  clots  have  Ijeen  seldom  found. 
The  neig^'iorhodd  of  the  ab.sce.ss  is  usuallv  microsc-ipicaily  intact. 
Sometii  les  there  is  a  surrounding  zone  of  red  rr  white  softening,  in 
which  may  exist  small  hemorrhages  and  small  ab.scesses. 

In  several  instances  the  cerebellar  abscess  and  its  .accompanyinc 
meningitis  ha'-e  produced  a  state  of  internal  iiydrocephalus.     Tf  rui 
turc  •;-(-ur?,  ;!ir  pus  may  entvr  the  aiachnoid  :^pa"-%  -  *'in«^  up  ;i  y--- 
lent  leptomeningitis,  or,  a  cementing  of  the  meninges  previously  ocr     - 
ring,  the  pus  may  form  a  subdural  absc< .  s  by  spreading  between 
dura  and  the  brain,  especially  under  the  tent'rium;  or.  ami  thi 


/    ^ 


Pl.ATL-;    XXXV 


1  in      Mii.niT     K\K       KilKirtioii    .if    ihe 
s  KMiiijit.   wiUiiii  ttic 'rvmjKmuitl  :  Ciirxcd 

Injccliiiii  .>!'  llu-  K.-iiliatiiiK  CaiMlliirics  mikI 


1-n.  I  Ciiki.Mi  Sik"is  c.\r\riRn  in 
Tyini,anic  Miiuhrane.  with  Cnlltclicin  c,f  StM 
Fluid  l.iiu  in  I  i.iiil  ot  tlic  Iml«i 

I-'li..  •.  Aci  1 1  c  \  I  \KHii  M.  I  >i  n  IS  Midi  . 
the  Mallcal  PUxn- 

I'li.  ,;.  A..rri.  SrriTKATiM  otitis  Mki.ia  Miukt-il  lliilniiix  .if  the  I'.istcrior- 
suiKTi.ir  yua.lrant.  Iliiliim  Hiniillc  .if  llHinmei  .  Kccliym.iwi.  in  (In-  Kngor(;eil  Tyniimnio 
Meinlirane 

Fl.;  4  AciTK  Sri'lMR  iiivi,  OTITIS  MilUA  Tviiipaili.  Mfnil.rane  (.-.iMKeslfd  ;  .mlv 
thf  Sli..rt  Process  an. I  riipfr  I'art  of  the  MaMul.riniii  is  Visil.Ir  .  a  Small  I'lrf.iration  in 
the  Anli-ri.ir  inferior  ijuailrant.  lhriMii:h  which  i.inl.l  lie  seen  a  I'lilsatinK  I,i«ht  Keflex 

'    ITIS    Ml  iiM      iliirinK   an   exactrl.ati.ini      Ki.lney- 
,nm     li'lye        Miu-.Mis      Mtinlitane    <if     Tvnipannm 
Conxesteil. 

l-l...  6.     CltH.iNU 
l.rane  ;  Incus  Cari.ni 

Fu;.  7.  Chri.nh  Sti'iTKATivK  UTiris  Mki.ia.  I'crf.irati.in  .if  ^hn.i.ncll~  Memlirane, 
through  which  I'r.itrudes  a  I'olylKii.l  Cianulali.in     Caries  of  the  Walls. .f  the  Attic 

II.,.  H.  TllK  RKSl  IT  F.il.l.iiWlN..  IlKAIlN..  ..I  \  CHR.iMC  Smi  RATIVK  OTITIS 
MKl.lA.  Chalk  I)ep..sits  in  Fr.mt  ami  Hehiii.l  Mannl.rinin  :  Ki.lnev-hai*.l  Cicatrix 
occupyinu  Inferior  Half  .if  Tymimnic  Meniliralie. 

■  I-r-MH  Br'thi"'  Aii:i-  ;kr  ohrcnhcilUilli.le.  ; 


Fl.;    5.    Chronic    St'i'iTHArivi    ( 
^hajieil     Perf.iratj.in     with    c.ranula 


Si  iM'ik  A  ri 


OTi  ris    Ml  I.I  ■, 


I'erf.. ratio 


sliraiinells   Mem- 


I'VRl'LESr  ISFhAMMAriOS  >>F  THE  MIDDI.K  EM!.      1127 


frcciupnt,  a  tistulii  forms  through  the  dura  to  the  petrous  bone.     Kx- 
(cptionully  the  abscess  may  break  into  tlie  fourth  ventricle. 

Only  one  case  of  spontaneous  heahng  of  an  otic  cerebellar  abscess 
iijis  been  noted,  the  healing  resulting  in  the  formation  of  a  thi<k  cic- 
atrix. 

Otitis  Media  Purulenta  Acuta.  This  form  of  otitis  media  is  a 
continuation  of  the  process  described  under  the  heading  of  serous 
exudation,  much  intensified  becaus(>  of  the  greater  virulence  of  the 
infection. 

Symptoms.  In  the  beginning  the  same  ymptoms  make  their 
appearance:  hardness  of  hearing,  a  feeling  o.  fulness  or  stuffiness, 
and  tinnitus,  which  is  nmch  more  marked.  The  tinnitus  is  of  a  hissing, 
roaring,  iiulsating,  or  throbbing  character.  Pain  is  <iuickly  in  evidence ; 
it  is  usually  intense,  radiating  over  the  affected  side  of  the  head,  and 
seems  to  be  worse  at  night.  There  is  a  sense  of  heat  around  and 
in  the  ear,  together  with  a  feeling  of  numbness.  If  there  is  great 
intratympanic  pressure  the  patient  complains  of  dizziness  and  vertigo. 
The  bodily  temperature  ri.ses  sometimes  to  101°  to  103°  F.,  and  occa- 
sionally there  is  delirium.  Sometimes  there  is  impairment  of  the 
senses  of  taste  and  smell.  In  children  the  condition  sometimes 
simulates  an  attack  of  meningitis,  the  temperature  ri.'-ing  at  times 
to  105°  F.,  with  great  restlessness  and  s'-reaming.  In  them  the 
attack  sometimes  begins  with  a  convulsio..  'r  vomiting.  In  infants 
the  hand  is  frequently  applied  to  the  affected  ear.  Some  patients 
refer  the  pain  to  the  teeth;  unless  the  attendant  is  ac(iu,,inted  with 
this  fact  an  error  in  diagnosis  is  possible.  Those  patients  who  have 
a  ilefect  in  the  bony  wall  of  the  Fallopian  canal  may  experience  nui>- 
cular  twitchings  due  to  irritation  of  the  facial  nerve:  rarely  facial 
palsy  may  appear,  due  to  the  same  condition. 

In  the  tubercular  form  of  the  aff'ection  the  process  is  very  insidious, 
often  painless,  and  sometimes  exists  without  perforation  of  the  drum 
membrane.  In  the.-ic  ca.ses  the  lymphatic  glands  around  the  auricle 
are  frequently  enlarged.  Caries  and  necrosis  of  the  ossicles  are  apt 
to  occur. 

Objectively,  there  is  noted  congestion  of  the  drum  membrane 
Ix'ginning  in  Shrapnell's  membrane,  along  the  posterior  of  the  hammer 
handle,  in  the  jjeriphery  at  the  attachment  of  the  membrane  to  the 
aimulus  tympanicus,  and  in  the  capillary  twigs  radiating  from  the 
piTiphery  toward  the  umbo,  the  rest  of  the  membrane  being  dull  gray 
:ind  lustreless.  ( Plate  XXX\'.,  Fig.  i.^  Soon  this  congestion  spreads 
over  the  whole  surface  until  the  drumhead  becomes  pink,  or  red.  or 
.■rimson.  If  the  infection  is  very  iutonse,  for  instance,  in  cases  caused 
t>v  the  grippe  or  sea-bjithing,  the  capillary  twigs  may  rupture  antl 
the  hemorrh.age  raise  the  dermal  layer  until  ipiite  large  blood-blebs 
:ippear  on  the  outer  sufac(>  of  the  drumhead  and  neighboring  parts  of 
liie  canal  wall,  wliicli  is  also  congested.  The  congestion  is  usually 
much  less  marked  in  tuberculous  cases.  Serous  or  purulent  exudation 
may  take  i)lace  within  the  texture  of  the  dnun  membrane,  forming 


11  I'M 


rm:  i:.ni. 


serous  cysts  or  lociilizoil  abscesses,  or  tlie  life  of  the  ileniial  layer  iiiav 
be  destroyed  so  that  it  finally  exfoliates.  Before  exfoliation  takes 
jdace  tiie  a|)j)earance  of  the  dniin  nicnibrane  is  apt  to  bo  deceptive; 
one  niipht  think  that  the  dull  leaden  looking  drumhead  concealed 
no  active  inHaniniatory  process  within  the  tympanum:  but  the  use 
of  cotton  on  a  cotton-carrier  gently  rubbed  over  the  surface  removes 
the  exfoliating  dermal  layer,  leaving  behind  a  smooth  red  surface 
which  may  bo  mistaken  for  a  polypus.  As  the  congestion  increases 
the  landmarks  normally  present  on  the  drum  membrane  are  obscured 
and  finally  become  invisible ;  thus,  the  light  reflex,  the  hammer  handle, 
and  often  the  antciior  and  ])osterior  folds,  are  gradually  lost  to  view. 
The  increasing  (juantity  (jf  fluid  in  the  tympanum  begins  to  exert 
l)ressure  on  the  tym|)anic  membrane,  which  begins  to  bulge  outwardly 
(Plate  X.\X\'.,  Fig.  3),  most  frequently  in  the  posterior  half,  but  some- 
times at  the  site  of  Shrapnell's  membrane,  or  both  of  these  sections 
may  be  involved.  Kxeeptionally,  bulging  may  not  appear,  although 
exudation  exists.  The  lymphatic  glands  behind  the  auricle  and  over 
the  l']ustaehian  tube  may  be  enlarged  and  tender,  especially  in  chil- 
dren, and  in  severe  cases  there  may  be  an  area  of  tenderness  over 
the  mastoid  antrum. 

Shortly,  unless  the  condition  is  relieved,  perforation  of  the  drum- 
head takes  place  in  anywhere  from  a  few  hours  .;)  a  number  of  days. 
Immediately  following  perforation  a  discharge  makes  its  appearance: 
at  first  serous  or  serosanguinolent.it  soon  becomes  purulent  or  muco- 
purulent, except  in  cases  of  tuberculosis,  when  it  is  apt  to  remain 
thin  and  watery.  The  perforation  is  most  usually  situated  in  the 
inferior  half  of  the  tympanic  membrane;  exceptionally  in  Shrapnell's 
membrane,  if  the  inflammatory  process  is  mo.st  intense  in  the  attic. 
(Fig.  569.)  The  perforation  is  generally  round,  uiJos-  there  has  been 
marked  necrosis  of  tissue,  such  a*'  occurs  with  alarming  rapidity  in 
scarlatinal  otitis.  In  children  the  drum  is  naturally  thicker  than  i.i 
adults  and  the  Flustachian  tube  is  wider,  permitting  the  escape  of 
fluid,  for  both  of  which  re:u<ons  perforation  may  fail  to  take  ))lace 
or  occur  much  later  than  in  adults.  ICven  in  adults  a  well-marked 
jturulent  inflammation  i.  ay  exist  in  the  middle  ear  without  any 
jx'rforation  of  the  tympanic  membrane. 

(Jenerally.  after  perforation,  con.'<iderable  relief  from  the  subjective 
symptoms,  especially  pain,  is  experienced.  As  the  discharge  con- 
tinues, the  skin  of  the  external  auditory  canal  may  become  congested 
and  swollen  and,  in  children,  an  eczematous  dermatitis  extending  to 
the  auricle  may  be  set  up. 

Acute  purulent  otitis  media  seldom  leads  to  intracranial  complica- 
tions. Krysipelas,  usually  beginning  in  the  auricle,  has  been  noted 
as  a  complication,  and  may  extend  to  the  scalp  and  face,  occasioning 
considerable  constitutional  disturbance.  In  children  a  secondary 
otitis  externa  may  arise,  which  later  nuiy  extend  to  the  mastoid  peri- 
osteum, forming  a  subi»eriosteal  mastoid  abscess.  The  most  fre(|uent 
cuniplication  is  that  of  mastoiditis. 


I'lltlLKSr  ISt'l.AMMATlDS  OF  Till:  MIIHiLE  AM/.'.      112!» 


Tlif  iiiHaiuniatory  process,  if  intelligently  treated,  tends  to  reso- 
lution in  from  a  few  tlays  to  as  many  weeks,  usually  with  the  return 
of  good  functional  ability.  The  jjcrforation  heals  with  or  without 
the  formation  of  a  cicatrix.  In  soim-  cases  the  membrane  is  left 
permanently  thickened  or  in  jiarts  calcified,  from  interstitial  myrin- 
jlitis,  and  occasionally  adhesions  form  in  tlie  tym|)anum.  Should 
these  changes  occur,  the  hearing  may  be  considerably  imi)aire(l. 

The  prognosis  is  vmfavorable  in  patients  suffering  froin  cachexia, 
whether  scrofulous,  tuberculous,  or  syphilitic;  when  the  disease  occurs 
in  the  course  of  severe  attacks  of  influenza,  dijihtheria,  or  the  exan- 
themata: and  when  the  inflammation  is  mainly  confined  to  the  attic,  • 
witli  perforation  of  Shrapnell's  membrane. 

The  diagnosis  is  indicated  by  the  presence  and  course  of  the  symj)- 
toms  a.s  detailed.  The  presence  of  a  pulsating  light  reflex  on  the  .sur- 
face of  fluid  at  the  fundus  of  the  canal  is  usually  taken  as  jjresump- 
tive  evidence  of  the  existence  of  a  |)erforation  ( Plate  XXX^■.,  Fig.  4) ; 
but  it  may  be  due  to  the  great  va.scular  tension  within  the  tympanum 
transmitted  tlirough  the  drum  mcml)rane.  If  stringy  mucus  is  found 
in  the  di.scharge  it  must  certainly  have  come  from  the  tympanum 
through  a  jierforation.  Inflation  of  the  middle  ear  may  cause  a 
blowing,  bul)bling,  or  hissing  whistle  when  a  perforation  exists,  unless 
that  perforation  is  situated  in  Shrapnell's  membrane,  or  in  a  i)ortion 
of  the  membrane  covering  a  part  of  the  tym])anum  shut  off  from 
the  Lustachian  tube  by  adhesions.  Suction,  exerted  by  means  of 
Siegle's  otoscope,  or  inflations  of  the  i  liddle  ear,  may  show  the  pres- 
ence of  a  ])erforation  by  the  appearance  of  <lischarge  in  a  canal  which 
has  previously  been  thorougl)'>  dried. 

Harr  well  says  that  "obscure  illne.ss  in  young  children,  consisting 
of  feverishness,  irritability,  and  symptoms  of  cerebral  disturbance, 
are  sometimes  explained  I  *'ie  ultimate  api)earance  of  a  discharge 
from  the  ear."  Occurring  .u  the  course  of  infectious  diseases,  its 
ajtpearance  is  usually  marked  by  a  sudden  accession  of  temperature. 
In  the  tuberculous  form  the  jjerforation  tends  to  enlarge  l)y  the 
melting  away  of  its  edges,  the  tissues  are  pale,  and  graimlations  are 
rarely  present.  My  colleague.  Dr.  Hurnett  C.  Collins,  found  oiily 
4  ca-ses  in  which  the  middle  ear  was  involved  in  62  j)atients  with 
well-marked  tuberculosis.  This  is  ab(>ut  the  proportion  usually 
reported. 

The  tareatment  of  acute  sui)puration  of  the  middle  ear  may  be 
divided  into  that  a]iproi>riate  to  the  condition  before  perforation 
and  that  after.  While  there  are  many  methods  of  treatment  in 
vogue  among  aurists  in  g(>neri '  ;nost  of  which  are  of  value  in  appro- 
priate cases,  the  writer  beii  w  at  the  object  of  tliis  article  will 
best  be  met  by  confining  hi^  i  •'  iption  to  those  methods  which  he 
habitually  uses  in  his  own  pi  •  .•  and  hospital  practice  and  which 
have  stood  the  test  of  his  expciience.  lie  does  not  believe  in  the 
use  of  the  various  anodyne  instil!ati<jns  or  suppositories  sometimes 
recommended  for  use  in  the  external  auditory  canal.     The  patient 


11. -iO 


rift:  i:.\n. 


w\ 


slioulil  1m'  jnit  iii)on  a  liglii  Um  mitritious  diet,  alcohol  and  toliaccn 
anil  coffee  siioiild  l)e  den-.d  and,  if  jxissihle,  rest  at  homo  shouM  l>e 
enjoined.  A  mild  (■l'.,>l:if.;.>Sin'  laxative  should  he  administer<'<l  ut 
the  very  heginninjr.  iU'd  M'lier.  iiarcotics  are  given  for  ])ain  the  con- 
stipating tendency  slinuK!  ''C  overcome  hy  the  sinuiltaneoiis  exhi- 
bition of  a  laxative. 

When  there  is  iuark<'d  fever  aconite  in  small  and  repeated  doses 
is  of  great  value,  preferably  the  tincture  in  minim  or  half-minim 
doses  hourly.  There  is  rarely  any  time  t(  correct  eridrs  in  the  general 
health.  The  inflammatory  condition  existing  in  the  nasopharyngeal 
cavities  should  receive  the  indicated  treatment.  \'ery  gentle  ixilitzer- 
ization  is  sometimes  of  great  licnefit  in  the  very  earliest  stage,  before 
there  is  much  exudation  and  bulging;  afterward  it  often  does  harm 
by  increasing  tension  and  driving  the  infected  exudate  into  the  fur- 
thest recesses  of  the  middle-<'ar  cavities.  Politzerization  should  only 
be  used  after  a  thorough  and  painstaking  clean.sing  of  the  nasopha-ynx. 

Local  bloodletting,  by  means  of  Bacon's  .artificial  leech  (Fig^.  .i.59 
and  5()0)  or  l)y  the  live  Swedi.sh  leech,  is  fre(|uently  of  great  ^alue.  but 
shovild  onlybe  used  insturdy.plethoricpatieni:.  never  in  tho.se  who  are 
weak  or  anaMiiic.  They  are  to  be  applied  either  immediately  in  front 
or  behind  the  iiuricle,  as  close  to  it  as  ])ossible,  and  from  two  to  four 
of  the  natural  leeches  must  be  used  to  obtain  much  of  an  effect.  After- 
ward, if  it  is  desirable  to  encourage  hemorrhage,  tiic  bleeding  may 
be  prolonged  by  the  use  of  lukewarm  watiT.  The  bleeding  is  usually 
well  controlled  by  jjressure;  but  occasionally  styptics  have  to  be  used. 
Needless  to  say,  the  skin  before  ai»i)lication  and  the  wounds  after- 
ward should  be  rendered  aseptic. 

From  lie  beginning  heat  should  be  ap|)lied  to  the  esir,  either  by 
means  of  the  hot-water  bag,  the  hot-water  douche,  or  both.  A  mild 
antise])tic  may  be  added  to  the  douche.  The  writer  believes  the 
thorough  drying  out  of  the  external  auditory  canal,  after  each  douch- 
ing, to  be  of  the  utmost  importance  if  the  skin  of  the  external  ear  is 
to  be  maintained  in  a  he.ilthy  state.  This  drying  should  be  done 
by  means  of  cotton  pledgets  formed  on  a  cotton-carrier,  then  removed 
fiuin  the  carrier  and  gently  introduced  into  the  ear  canal.  The 
douching  is  to  be  re|)eated  every  two  hours,  and  between  times  the 
hot-water  bag  shouM  be  ;(pi)lied  freiiueiitly.  In  the  intervals  a  soft 
wad  of  cotton  should  be  placed  in  the  covlia  to  i)rotect  from  draughts. 
At  night  the  patient  shouhl  sleej)  with  tiie  head  high,  on  two  or  three 
pillows. 

The  writer  would  heartily  indorse  the  remarks  of  Duel,  which  are 
a.s  follows:  "In  dijihtheria  and  the  exanthemata  the  only  way  to  be 
sure  that  ;in  acute  otitis  is  not  developing  is  by  daily  in.spection  sif 
the  lympanic  membrane.  In.asmuch  as  this  is  impr.acticable,  it  would 
seem  wist-  to  liaVf  tjie  oaiiai  r^torilized  daily  by  irrigations  with  1 ;  KXK) 
bichloride  solutions  in  order  to  avoid  infection  in  those  ca.ses  where 
spontaneous  rupture  occurs  without  warning  s\niptoms."  I'lvery 
meilical  attemlant  on  a  severe  case  of  these  disea.ses  .should  feel  a 


VVHlLKyT  ISFLAMM.xriOS  OF  THE  MIDDLE  EAR.       H.Jl 


moral  nblipation  to  have  a  competent  aurist  periodically  examine 
his  patient's  ears,  at  least  as  frequently  as  once  a  week,  since  the  field 
of  prophylaxis  here  is  as  broad  as  that  of  treatment.  Many  a  child 
consigned  to  the  despair  of  a  postscarlatinal  or  pt)stiliphtheritie 
chronic  otitis  has  good  grounds  for  condemning  the  criminal  negli- 
gence of  his  family  physician. 

Incision  of  the  tympanic  membrane  under  the  most  careful  anti- 
septic precautions,  including  thorough  treatment  of  the  external  ear 
canal,  is  always  indicated  in  the  ca.se  of  intense  pain  unrelieved  by 
treatment.  Also,  in  the  writer's  opinion,  whenever  tiiere  is  bulging, 
liowever  slight,  if  accomjjanied  by  pain.  It  is  undoubtedly  trxie 
that  in  the  majority  of  cases  we  wait  too  long.  Karly  incision  ensures 
an  a.septic  field  and  a  probably  les.sened  intensity  of  infection:  this 
is  especially  true  in  influenza,  diphtheria,  and  the  exanthemata, 
llarly  incision  has  the  added  value  of  ensuring  against  tissue  necrosis 
and  of  being  at  the  point  of  election  for  the  most  efficient  drainage. 

The  operation  of  incising  the  drum  membrane  is  j)referably  begun, 
under  the  use  of  nitrous  oxide  anaesthesia,  near  the  |)osterior  border, 
on  a  level  with  the  umbo,  and  carried  around  parallel  to  the  inferior 
border  until  a  point  is  reached  anteriorly  at  the 
end  of  a  line  drawn  through  the  point  of  begin-  ''""'  ^^ 

ning  and  the  umbo;  in  other  words,  the  whole  in- 
ferior half  Of  the  drum  membrane  is  turned  into  a 
Hap.  (Fig.  584.)  The  knife  should  be  a  straight 
or  curved  bistoury,  and  .should  he  carried  through 
the  membrane  only,  not  so  deej)ly  as  to  score  the 
inner  tympanic  wall.  If  tliere  is  bulging,  the  cut 
is  to  lie  so  modified  as  to  include  the  most  de- 
pendent part  of  the  bulg. .  An  entirely  different 
form  of  incision  is  indicated  when  the  attic  is  in- 
volved, with  bulging  of  Shrapnell's  membrane.  Here  the  writer  be- 
lieves in  carrying  a  bistoury  from  just  above  the  short  process  of  the 
hanmier  upwaril  and  inward,  to  divide  any  folds  of  mucous  membrane 
imtil  the  bony  edge  of  the  superior  canal  wall  is  reached,  .ihence  the 
incision  is  continued  along  the  junction  of  the  posterior  and  superior 
canal  wall  to  and  including  the  part  overlying  the  mastoiil  antrum. 
SiN)ntaneous  ru|)ture  does  not  always  provide  for  drainage  efficiently: 
in  which  ca.se  the  perforation  should  always  l)e  enlarged  along  the 
lines  above  indicated. 

Following  early  incision,  and  only  when  done  under  the  strictest 
antiseptic  precautions,  the  writer  habitually  introduces  a  slender 
Kaiize  wick  up  to  the  fundus  of  the  canal,  being  careful  not  to  i)ack 
it  into  the  canal,  then  loosely  packs  gauze  into  the  concha,  and  covers 
the  dressing  with  a  layer  of  alworbent  or  raw  cotton,  held  in  place 
'>v  a  strip  of  ^inc  nxidf*  plast/r  .attjiched  to  the  auricle.  This  dressing 
should  be  renewed  at  intervals  of  twelve  hours  for  the  first  few  dress- 
ings, the  discharge  being  removed  each  time  by  aseptic  cotton  pledgets, 
.iiid  often  the  ear  is  found  to  be  healed  after  a  few  treatments.     If  the 


I.i  ne  of  incision  on  tym* 
panic  membmne. 


11. Jl' 


Tin-:  EMI. 


pauzo  wick  is  saturatcil  at  each  dressing  and  ilic  irritation  in  th(< 
iiiiiiillf  car  and  canal  increases,  tliis  form  of  treatment  must  he  ilis- 
continued  in  favor  of  syringinp.  Some  cises  do  well  simply  l)y  dryinj;- 
otit  the  canal  at  fre(|iient  intervals— every  three  hoiirs--hy  means  of 
])ledjiets  of  absorbent  cotton,  without  syringing. 

The  ear  failiiiK  to  do  well  under  the  above  methods,  then  resort 
must  be  had  to  syrinninp.  As  the  n'ain  ol)jert  of  syringing  is  to  re- 
move the  discharges,  this  is  best  acr<..(ii)lishcd  at  home  by  the  use  of 
the  hand  syringe,  either  a  Davidson  or  a  Goodyc  ir  one-ounce  hard- 
rubber  ear  syringe  ( Fig.  585)  or  a  Davidson  aural  and  ulcer  soft-rubber 


Flo.  ."«.■>, 


Bulb  syringe. 


Eur  »>rinKC  :  hard  rubber. 

bull)  syringe.  (Fig.  586.1  The  douche  in  the 
patient's  hand  rarely  meets  the  indications  at 
this  .stage.  A  pint  of  hot  water  should  be  ased  at 
one  sitting,  and  the  sittings  should  be  at  inter- 
vals of  two  or  three  hours.  The  auricle  should 
be  held  out  from  the  side  of  the  head  and  the 
nozzle  of  the  .syrii>ge  introduced  to  just  within 
the  external  orifice  of  the  canal.  Any  of  the 
antiseptics  in  ordinary  use,  boric  acid,  bichloride 
of  mercury,  or  carbolic  acid  may  be  added  to  the  water,  which 
should  always  bo  boiled  before  u.se.  No  effervescent  remedy,  such 
as  peroxide  of  hydrogen,  should  be  employed  in  acute  ca.ses,  for 
obvious  rea.sons.  The  writer  prefers  tlu>  bichloride  of  mercury  solu- 
tion, when  he  does  not  u.se  ordinary  sterile  water,  in  strengths  (>f  from 
1 :  3000  to  1 :  .')000.  The  syn-ingo  between  treatments  should  be  placed 
in  a  solution  of  carbolic  acid  or  bichloride  of  mercury,  having  pre- 
viously been  Hlh'd  from  the  solution.  Always  after  syringing,  the 
ear  canal  should  be  gently  but  thoroughly  dried  out  by  means  of 
pleilgets  of  iuseptic  absorbent  cotton,  and  a  soft  wad  of  cotton  should 
be  placed  in  the  concha.  The  injected  fluid  sometimes  enters  the 
middle  ear,  the  Kusfichian  tube,  and  the  throat,  in  which  case  care 
should  be  taken  to  use  only  the  milder  antiseptics. 

The  writer  does  not  believe  in  the  u.^e  of  powders  in  acute  cases; 
they  blur  the  picture  and  an;  prone  to  lead  to  retention. 

Some  ])olitzerization,  at  intervals  of  one  to  three  days  after  free 
incision,  is  gen<'rally  very  beneficial. 

After  the  subsidence  of  the  inflammatory  jirocess  and  the  healing 
of  the  perforation,  the  ear  should  i)e  inflated  gently  from  time  to 
time  and  a  soft  cotton  wad  worn  in  the  concha.  Precautions  should 
be  taken  against  tho.se  things  likely  to  cause  recurrence  of  the  trouble, 
such  as  exposure  to  cold  or  bathing  the  head. 


i'iiui.i:si'  i.\FL.iM.MATio.\  Oh'  Till-:  Mii>J>i.i:  i:Mt.     \\:\:\ 


Otitis  Media  Purulenta  Chronica.  Wh<>ii  \\w  iinitc  process  pfi- 
~ists  for  a  period  longer  than  iive  or  six  weeiis  it  is  usually  considered 
to  have  entered  into  the  chronic  phase. 

Hardness  of  hearing,  of  varying  degree,  i.s  usually  present :  hut  it 
is  by  no  means  invariable.  The  hardness  of  hearing  is  due  to  presence 
of  secretion,  to  swelling  of  the  .soft  parts,  to  existence  of  newly  formed 
fibrous  tissue  in  the  shape  of  adhesions  or  bands,  to  rigidity  of  the 
ossicular  articulations,  to  presence  of  granulations  or  polypoid  growths, 
or  to  accumulation  of  cholest<'atoniatous  ma.s.ses.  The  existence  of  a 
perforation  has  little  to  do  with  the  loss  of  hearing.  Painful  .sensa- 
tions are  not  usually  present  imle.ss  there  is  retention  of  purulent 
products  or  an  infection  of  the  structures  of  the  external  ear  canal. 
Sometimes  there  is  complaint  of  more  or  less  dull  headache,  especially 
by  weak  and  ana-mic  patients.  Noises  in  the  ear  or  head  are  not 
|)roinineiit,  as  a  rule,  and  are  often  absent.  Dizziness  or  vertigo  at 
varying  intervals  is  an  element  in  certain  cases. 

(Jbjectively,  enlargement  and  tenderness  of  the  lymphatic  glaiuls 
ill  the  neighborhood  of  the  ear  is  often  noticed,  j)articularly  in  children ; 
if  the  infection  is  .severe,  even  the  deej)  cervical  lymphatic  glands  may 
be  involved.  The  skin  of  the  auricle  and  canal  may  be  the  seat  of  a 
dermatitis  or  an  eczematous  inflannnation,  and,  in  children,  a  pustular 
eczema  may  spread  to  the  siile  of  the  face,  due  to  the  irritating  ((uali- 
ties  of  the  discharge.  The  discharge  varies  in  character  from  thin 
serous  or  serosanguinolent  to  purul.'nt  or  bloody:  often  fetid  if  tlie 
parts  are  not  kept  scrupulously  clean.  Especially  in  children  these 
discharges  may  enter  the  j)haryny  through  the  Eustachian  tube  and 
bring  about  a  general  toxa'niia.  The  drum  membrane  is  perforated, 
thickened,  or  calcareous  in  parts,  and  of  a  grayish  or  pinkish  color. 
The  |)erforation  is  u.sualh  single;  rarely,  a  number  may  coexist  in  the 
same  membrane.  The  jjcrforations  (Plate  XXW'.,  Fig.  5)  are  round, 
ovoid,  or  kidney-shajjcd  and  may  have  granulating  edges.  Sometimes 
the  edges  are  adherent  in  places  to  the  inner  tympanic  wa'l.  When 
tiie  perforation  is  in  Shrapnell's  membrane  the  outline  may  be  irregu- 
lar from  erosion  of  the  bony  margin,  the  pars  epitymjmnica.  Perfora- 
tions are  usually  situated  in  the  lower  or  posterior  halves  of  the  mem- 
brane. The  drum  membrane  is  probably  never  entirely  destroyed. 
Through  the  jierforation  may  be  seen  the  intrat^'inpanic  structures 
existing  opposite  its  location,  more  or  less  modified  by  the  inflamma- 
tory process.  The  mucous  membrane  lining  of  the  tympanum  may 
l)e  thickened,  or  granular,  or  ulcerated;  it  is  usually  red  in  color  from 
congestion.  In  very  old  or  sluggish  cases  the  mucous  membrane 
may  be  grayish  or  yellowish  in  color.  There  is  often  present  carious 
degeneration  of  portions  of  the  bony  walls  of  the  tympanum  or  of  the 
ossicles.  Granulations  and  poly|)i  ( I'late  XXXV.,  Fig.  6)  are  frecjuently 
-'•en  jirntrudit'g  through  the  j^erfuri'.tion,  especially  when  the  attic 
is  involved  and  the  perforation  is  in  Shrapnell's  membrane,  ^>ry 
rarely  these  granulations  may  be  an  outgrowth  from  the  dura  exposed 
l)V  osseous  erosion. 


ll.U 


r///-;  t:.iJ:. 


The  diagnosis  is  mii(l(>  by  tho  history  and  the  i)rcsciK'o  of  the  above 
symiilcins,  subjective  autl  objective.  The  element  of  tviberoulosis  is 
indicated  l)y  a  brachial  nieltinp  away  of  tlie  tissues  of  i:ie  drum  mem- 
brane and  tympanum,  the  constitutional  condition  of  tho  patient, 
and  tlic  presence  of  tiie  tubercle  bacillus  in  the  di.scharge. 

The  prognosis  depends  to  a  considerable  extent  upon  the  state  of 
health  of  the  patient,  there  being  always  less  chance  of  a  cure  in  those 
afflicted  by  the  tubercular,  scrofulous,  or  syphilitic  diathesi.s.  So 
long  as  tlie  ]>roce,ss  jx-r.-ists  there  is  always  danger  to  life  from  intra- 
craiii.il  complications.  The  business,  habits,  and  jMisition  in  life  of 
the  j)atient  exert  more  or  less  influence;  the  more  favorable  these  are, 
the  better  the  chance  of  recovery.  Certain  conditions  obtaining  in 
the  affected  i)arts  adversely  influence  the  progress  toward  healing: 
thus,  the  presence  of  granulations  or  jjolypi  indicating  a  deep-seateil 
affection,  atresia  of  the  external  auditory  canal,  retained  and  de- 
composing purulent  or  cholesteatomatous  material,  and  caries  or 
necrosis  of  the  osseous  walls  or  ossicles.  The  lack  of  intelligent  hoine 
treatment  very  greatly  milit.ites  against  a  favorable  prognosis,  as 
does  also  failure  with  long-continued  treatment. 

The  prognosis  as  to  the  maintenance  of  hearing  dejMMids  uiw)n  the 
amount  of  interference  with  the  vibrating  power  of  the  sound-con- 
ducting apparatus.  As  none  of  the  middle-ear  structmes  except  the 
membranes  of  the  round  and  oval  windows,  together  with  the  foot- 
plate of  the  stapes,  is  absolutely  essential  to  function,  we  hence 
(piite  fre(|uently  see  ))atients  who  hear  well,  notwithstanding  the 
loss  of  the  dnnn  nieml)rane  and  larger  ossicles.  Such  obstacles  to 
hearing  as  inspi^sated  secretion,  polypi,  and 
the  presence  of  fibrous  bands  and  adhesions 
are  always  susceptible  to  removal,  with  im- 
provement of  function. 

When  healing  of  the  mi(klle-«'ar  inflanmia- 
tion  takes  place  with  a  persistence  of  the 
perforation,  the  edge.>j  cicatrizing,  the  so-called 
"dry  perforation"  results,  and  the  patient  is 
more  expo.sed  to  a  recurrence  than  when  the 
jierforation  is  doseil  by  cicatricial  ti.ssuc. 
('losure  of  the  perforation  sometimes  les.sens 
the  hearing  ability.  Ir  is  not  inrni^sible 
sometimes  to  bring  iibout  the  cicatrization  of 
very  old  jHTforations.  even  when  of  consider- 
able size. 

There  arc  certain  seipiela'  which  may  result 
from  a  chronic  purulent  inflammation  of  the 
middle  ear.  '.'aus  may  be  mentioned  aural 
polypi,  peiioslilis  of  iju-  iiuL-^loid  process,  nia.sloid  i^b^cess,  choie.s- 
teatoinatous  tumors  within  the  mastoid  i)rocess,  facial  paralysis, 
labyrinthitis  (especially  in  .syphilitic  subjects),  and  the  various  intra- 
cranial   infective   lesions.     The   semieircular   .'anals    (Fig.   .587)    are 


View  of  lympanlc  iiuic  from 
Hbuvi'.  1.  External  wall  of  uttic 
or  |«t>et>ityint4iTiiea.  i>.  llair.- 
intT  hcacl,  :1.  Incus  4.  VnUit- 
liian  canal  for  facial  iicrvf  .'>. 
Vertical  scmicircillHr  CH^al.  t',. 
Ilorizontal  semicircular  caiml. 
7.  Aiitruin.  M.  Iiicu'lostajH' 
dial  jitiir..  Folds  uf  luciilbninc 
noftrly  shilt  off  the  attic  from 
thcatriinn.  (From  a  speciiaen 
ill  tlic  author-  collection.) 


I'VRVLEST  ISFI.AMMATIOS  OF  TlIK  MlliDLK  EAR.       H.'Jo 

xniietiim-s,  altliough  rarely,  affectcil,  diHturbaiices  uf  (><|uilibriuin  and 
u'iildiiifss  beinj?  produccil.  A  faciid  paralysis  arising  from  middle-ear 
clisca.xe  is  a  lesion  of  the  nerve  and  is  usually  niueh  more  complete 
than  when  the  cause  is  in  the  central  nervous  system;  in  the  latter 
the  patii-nt  can  generally  close  the  eyelids,  and  the  face  is  not  so 
(wpressioiiless. 

The  ai)pearance  of  the  drum  membrane  after  healing  varies  greatly. 
It  niay  be  thickenetl  and  opacjue,  may  contain  calcareous  plaques 
Plate  XXX\'.,  Fig.  7),  may  1h*  adherent  in  j)laces  to  the  inner 
structures,  may  present  cicatrices  (Plate  XXXV.,  Fig.  7)  which  are 
darker  in  color,  with  well-defined  edges,  maybe  atrophied  in  spots, 
or.  finally,  may  present  one  or  more  "dry  perforations." 


DiKkc  M  pulypm  unarr. 

Ill  the  treatment  of  chronic  suppuration  of  the  middle  ear  the  first 
essential  is  thorough  cleanliness  of  the  accessible  parts.  Next  conies 
ilie  establishment  of  as  perfect  drainage  as  |)ossible.  and,  finally,  the 
vriiioval  of  diseased  tissue  when  not  contraindicated.  In  order  to 
meet  the  first  two  indications  it  is  essential  that  any  marked  fibrous 
atresia  or  stenosis  of  the  external  ear  canal  should  be  remedied.  Also 
ilial  any  ]iolypi  or  jiolypoid  graiiuiations  should  be  removed.  Polyj)i, 
if  iarge.  should  bo  removed  by  the  aural  snare,  Blake's  (Fig.  588) 


Fii.   ^-s. 


Hartinann'fi  ear  forceps  wUb  cutting  edge. 


'liinr  a  convenient  form,  under  cocaine  antesthesia.  Polypoid  jjranu- 
aiii'iis  may  be  removed  by  the  sluup  curette  or  by  Hartmann's 
. metfe-forceps  (Fig.  589)  or  by  the  use  of  caustics.     After  the  re- 


ii.ti; 


riih:  h:.\i!. 


iiioval  of  a  polyp  the  Imsi'  slimild  Im-  treated  l>y  eurettan''  •""  'aiifei- 
izatioii.  In  ai^plyiiij;  causties  to  ftranulatioiis  eare  imist  he  cxercise.l 
not  to  touch  tlie  skin  of  the  "Xternal  ear  eanal  or  any  other  pari 
than  the  jjranuhition:  tlie  >tranulatin>t  snrfaee  mIiouIiI  first  lie  thor- 
ou^lily  'Iri''*!  <•""••  "f^'"'"  •'"'  eauterizins  applieation  has  Ixeii  left 
siifliciently  lonp;  to  proiliiee  the  desired  effeet,  thi-  exeess  slionid  he 
syringed  imt.  Tiie  usual  caustics  einph.yed  are  chromic  acid,  tri- 
chloracetic acid,  or  the  solid  stick  of  nitrate  of  silver.  A  small  ImnuI 
of  the  solid  silver  stick  or  of  the  chromii-  or  trichloracetic  aciil  crystals 
should  he  fused  on  the  end  of  a  prohe  previoii.sly  heateil  over  an 
jilcohol  lamp.     In  sensitive  patients  the  parts  should  first  l«'  cocain- 

Klii.  VJli. 


^^ 


.\ulluir's  caiitila  Biul  |ius  basin  III  usu. 


ized.  Always  wait  for  the  .slouuli  to  separate  hefore  reapplyinji. 
The  i)arts  should  he  made  as  a.septic  as  jxis-sibh'  hefore  any  uf  these 
operations,  to  guard  against  infection.  It  should  always  ho  home 
in  mind  that  tlie  granulations  may  he  an  outgrowth  from  the  exposed 
dm-a,  and  an  ■ittem])t  should  he  made  with  the  prohe  to  discover  the 
true  condition  hefore  undertaking  any  measures.  Chnmiic  acid  aj)- 
plied  to  graiaiiali'Mi^  in  ihe  region  of  the  Fallojiian  canal  rau.sed  an 
attack  of  herpes  i  cialis  from  irritation  of  the  nerve  in  one  of  the 
writer's  patients;  ui  anniher  patient  it  set  up  an  intense  localizeil 
intlanunation  invilving  the   facial  nerv.',  which  lay  expose.l  un<Ier- 


I'VRILKST  ISFI.AMMATIOS  itF  TUK  MIIHX  H  E.iR       \\:\1 


iicalh  the  granulntiims,  and  caused  a  facial  palsy,  relievtHi  only  by  tlio 
radical  o|)cration.  If  the  j)rrforatif)n  is  tew  small  or  iK)iitinR,  it  should 
1k!  enlarged  by  excision,  including  a  sufficient  portion  of  the  surround- 
ing drum  menibrane.  During  the  period  that  these  measures  to  secure 
drainage,  where  necessary,  have  been  instituted,  the  parts  shouM 
lie  kept  clean  by  syringing  at  home  and  at  the  ollice,  after  the  method 
ile.s<'ribec|  in  the  treatment  of  the  acute  i)rocess.  Likewise,  attcnti<(ii 
should  be  devoted  to  the  removal  of  any  pathological  conditiotis  in 
the  nasopharyngeal  cavities,  especially  adenoids  in  chiltlren.  Coinci- 
dcntly,  improvement  in  the  general  lualth  shoultl  be  brought  about, 
if  possible. 

For  routine  cleansing  at  the  office,  the  writer  is  very  fond  of  an 
apparatus  (Fig.  500)  that  he  has  devised  for  use  insteail  of  the  ordin- 
arv  ear  svringe.     This  apjia- 

ratiis  consists  of  an  Alpha  "  E  "  ""  '""_ 

continuous  flow  syringe,  made 
by  Parker.  Stearns  &  Sutton, 
of  New  York,  weighted  at  the 
inlet  to  keep  it  in  the  solution, 
and  provitled  at  the  nozzle 
with  from  two  to  three  feet 
(if  small  rubber  tubing  which 
carries  the  solution  to  a  glass 
or  metal  catmla  for  introduc- 
tion within  the  ear  canal.  For 
iirdinary  syringing  the  glass 
surgical  nozzle  answers  very 
well.  Uiiiler  illumination  this 
canula  is  carried  well  within 
the  orifice  of  the  c.-mal.  The 
returning  .solution  is  caught  in 
the  pus  basin  devised  by  the 
writer,  which  ha.s  an  outlet  in 
the  bottom  fitted  by  means  of 
,1  water-tight  joint  to  a  hollow 

metal  tube  from  six  to  eight  inches  long  and  about  one-h.iif  inch  in 
diameter.  This  metal  tube  serves  the  purpose  of  a  hanul  for  the 
patient  to  u.se,  and  has  a  half-inch  rubber  tube  attached  us  lower 
fiid  to  carry  the  liquid  into  the  wa.stc  receptacle.     (Fig.  .");»!.' 

At  each  visit  the  ear  should  be  thoroughly  cleansed  by  syringing 
with,  any  good  mild  antiseptic  solution.  This  procedure  is  much 
tided,  wiienever  the  tym])anic  mucous  membrane  is  swollen  or  liyper- 
irophied.  by  syringing  out  the  discharge  in  the  canal,  then  drying 
ind  applying  to  the  mucous  menibiane  a  1:5000  solution  of  adre- 
nalin chloride.  In  a  few  minutes  the  mucous  mcir'Tane  will  so 
shrink  that  a  further  syringing  will  empty  many  of  the  tympanic 
Mces.ses  which  otherwi.se  could  not  be  reached,  and  so  further  the 
'  ffect  whi'ii  a  remedial  application  is  made.     Tlie  tympanic  cavity 


.\ulhor*(»  P'ls  liiLvin  (or  ear  H!*e. 


li:w 


TUt:  /■;  I H 


must  Ih'  tlinroujjlily  drifd  aftt  s  syiiii^iiiK  In'fdre  !iny  remotly  is  up- 
plitd,  whi'thcr  by  instillation  "r  oiliiTwisi-.  VVhativtr  remedy  is  ime«i, 
it  inaxt  never  be  forKutteu  Ihtt  there  if»  no  panne*"'.,  and  that  no 
remetly  eau  take  the  plaee  of  ilioiouKii  cieai.-iini!  and  ^txid  dridnage, 
and  that  every  remedy  derives  its  grt'stestt  etlicacy  from  ♦••'w  meas- 
viret". 

For  home  treatment  the  |.  lient  should  syinge  the  ear  two  vT 
three  times  daily  ui'h  boiled  water  or  mild  antiseptic  solutionw,  using 
u  pint  at  a  time,  uiviays.  of  course,  warm;  afterward  dryinjj  out  the 
ear  ean.i!  ttioroughly  with  j-bsorbent  i-otton  wr  pjkhI  on  a  toothpick. 
When  tip  iiatient  com[)laiiis  of  vertigo  from  syringing,  reniemlx^r  that 
it  is  geni  rally  a  matter  of  ten;perature — the  water  is  used  either  too 
hot  or  t'K)  cold.  In  a  few  eas«>s  it  may  be  necessary  to  8\Tinge  with 
the  patient  in  the  recumbent  picture.  Tl:e  remedy  to  iw  us<'d  at 
home,  after  syringing,  depends  on  the  condition  present  in  the  middle 
ear.  If  the  mucous  membrane  is  hypertrophic,  astringent  sohitions 
are  indicated,  such  as  chloride  or  sulphate  of  zinc  (five  grains  to  the 
ounce):  if  granulations  .ire  jinsent.  alcohol  more  or  less  diluted  at 
first  and  containing  boric  acid  or  l)i<liloriile  of  mercury  (1:5000); 
if  fetor  is  present,  the  alcohol  and  bichloride  .solution  or  .soluticm  of 
peimanganate  of  potassium  (lifj.  pot.  jwrnian.,  Hlx-xl;  a<|.,  5i^)- 
When  there  is  :i  greai  ileal  of  e|)iili(Iial  debris  in  the  discharge  anil 
in  the  middle  e;u',  peroxide  of  hydrogen  may  Im'  useii  ix'fore  syringing, 
to  bleak  up  the  collections.  After  leaving  the.se  'irious  solutions, 
always  warim  il  belore  using,  it.  the  ear  for  a  few  niiiiiit"s.  the  canal 
should  again  Im-  thoroughly  dried  out  by  me  !  s  of  cotton  on  ..  tooth- 
j)ick. 

The  above  treatment  may  ;dso  be  used  al  the  iffice.  and  is  much 
aided  by  a  previous  inflation  of  the  ear  to  drive  out  any  fluid  retained 
l)y  capillary  attraction.  The  writer  is  also  very  fond  of  nitrate  of 
.silver  in  solution,  the  strength  varying  according  to  indications. 
ii-\ially  beginning  with  from  fi\('  grains  to  the  ounce  and  increasing 
for  effect. 

In  attic  ca-ses,  with  perforation  of  SliraiiiieH's  membrane  (Plate 
XXXV..  Fig.  8),  after  syringiiig  the  canal,  a  Hartm.-mn  canula  or  thai 
form  of  it  a.s  modified  by  tlie  writer  (Fig.  .")9()),  should  be  attached  to 
the  rublxT  tubing  and,  under  good  illumination,  carried  into  the  per- 
foration so  a.s  to  wa.sh  out  the  attic.  Remedies  may  then  be  intro- 
duced into  the  attic  by  means  of  Buck's  glttss  |)i[)ette  fFig.  592)  or 
Blake's  miildle-«>ar  syringe  (Fig.  59.'J),  the  former  being  just  ;is  effi- 
cient, much  cheaper,  and  non-corrodible.  Care  should  !»■  taken  not 
to  use  force  in  .syringing  into  the  attic. 

A.S  the  (lischarge  (hminishes  and  the  (lathologica!  conditions  l>egin 
to  disappear,  re,'.Grt  may  lie  had  to  one  of  the  various  forms  of  the 
Ko-call;-d  "dry  treatment."  Thu?  the  p.itient,  at  hf-ne.  -u-iy  simply 
dry  out  the  discharges  instead  of  syringing,  and  may  use  insufflations 
of  powder  afterward  once  or  twice  daily.  Very  littie  powder  should 
V)e  used  at  a  time.     Pure,  finely  divided,  boric-acid  {lowder  is  probably 


I 


t'VnVLKST  ISFl.AMMATIOS  ,,f  THK  MlltltLK  FAR.      l\Mi 

the  l>c8t  all-round  jwwder  for  (his  {)iirpo8f\  Occasionally  boric  arid 
iriitntofl  the  niucous  nw'iiibraiio,  in<iupii>^  a  watery  discharKP,  in 
which  case  its  use  must  be  diHcoiitiiaied.  The  same  treatment  may 
l)e  iisid  at  the  office.  An  awptic  g.iuie  drain  sometimes  suffices  to 
carry  the  patient  from  one  office  vi.sit  to  another. 


ri'i.  w; 


<-  ^^ 


lOii'k'i  gUua  plpe(l». 

If,  notwithstaiifling  a  thorough  ivr.  I  intelligent  trial  of  these  meas- 
ures lor  a  lengthy  period  (a  number  of  months),  the  middle-oar 
inflammation  continues,  then  the  (juestion  of  removing  the  ossicles 
comes  up.  ffemoval  of  the  ossicles,  however,  even  although  they  art- 
found  to  l)e  more  or  less  carious  at  the  first  visit,  should  never  be 
considered  unlc^^'^  the  above  consi-rvative  treatment  has  been  given 
a  fair  trial.     And  all  cariou.-^  areas  in  the  accessiijis.  portions  of  the 


!'"lo.  .'iHS. 


Blake'i  mlddleeikr  syriiiice. 


tympanic  bonv  wall  should  first  hf  curetted  and  placed  in  a  liealthy 
state.  It  has  frequently  l)een  the  w Titer's  good  fortune  to  see  liealing 
take  place  in  cases  that  looke<l  niost  unfavorable  l)ecause  of  carious 
areas  involving  the  tympanic  walls  and  the  ossicles.  Ossiculectomy 
must  also  be  considered,  even  although  tli<-  proceas  heals  at  times,  if 
recurrences  of  the  inflammation  occur  i^  quently  with  retention 
symptoms;  but,  where  yiossible,  the  o|)eration  should  be  avoided  if 


1140 


THE  EAK. 


FlO.  9M. 

9     10      11 


«  S' 


the  hearing  ability  is  anywiiere  near  normal,  for,  while  the  operation 
frequently  and  generally  improves  hearing  which  has  already  been 
gravely  impaired,  it  also  in  some  cases  makes  the  hearing  much  worse, 
and  sometimes  has  been  known  to  leave  behind  a  paralysis  of  the 
fpcial  nerve.  In  other  words,  the  operation  of  ossiculectomy  should 
not  be  considered  simply  because  there  exists  a  chronic  purulent 
otiiis  media,  if  the  latter  is  of  a  mild  unirritaiing  type  and  the  hearing 
ability  is  serviceably  good.  Many  patients  live  out  the  allotted  span 
of  life  and  many  cases  recover  completely  from  a  long-enduring  sup- 
puration, cither  by  natural  processes  or  by  j)rolonged  treatment. 

Generally,  however,  the  existence  of  an  obstinate  chronic  middle- 
ear  suppuration,  with  areas  of  caries  on  the  ossicles  and  tympanic 
walls,  and  especially  with  periodical  recurrences  of  symptoms  of 
retention  with  or  without  gravely  impaired  hearing,  is  sufficient  indi- 
cation for  the  removal  of  the  larger 
ossicles.  (Fig.  594,  and  see  Figs. 
569,  571,  and  573.)  The  frequent 
occurrence  of  giddiness  and  head- 
aches and  the  presence  of  cholestea- 
tomatous  masses  in  these  cases  still 
further  emphasizes  the  necessity  for 
operative  interference.  The  writer 
always  does  the  operation  with  the 
patient  sitting  upright  in  a  conve- 
nient chair  and  under  the  influence 
of  nitrous  oxide  aniesthesia.  This 
form  of  ana'Sthesia  is  preferred  be- 
cause of  the  quickness  with  which 
the  patient  is  ana'sthetized,  the  lack 
of  danger,  the  ability  to  keep  the 
patient  in  the  most  desirable  posi- 
tion, and  the  rapid  recovery  from  the 
effects,  usually  without  nausea.  Just 
before  the  ana'stlietic  is  given  the 
ear  is  made  as  nearly  ."urgically  clean 
as  possible,  and  a  warm  10  to  20  per 
cent,  solution  of  cocaine  hydrochlor- 
ate  is  instilled  into  the  ear  and  left 
there  for  five  minutes,  after  which 
the  solution  is  thoroughly  dried  out.  A  warm  solution  of  adrenalin 
chloride,  1:.')(KX),  is  then  instilled  and  also  left  in  jilace  for  five 
minutes.  A  sufficient  number  of  cotton  jjledgets  wrapped  on  tooth- 
picks has  |)r('vinusly  been  prepared  to  wipe  out  blood.  The  patient 
is  now  anirsthetiz«'d  and,  under  good  illumination  by  reflected  light, 
the  operation  is  proceeded  with.  The  remnant  of  the  drum  mem- 
brane is  freed  from  all  ailhesions  ami  a  straight  bistoury  (Fig,  595^ 
eircunici.ses  the  membrane  about  a  line  from  its  attachment  to  the 
annulus,  continding  down  on  eacli  side  of  the  manubrium  to  the 


View  of  tymiwiiio  outer  wall  from  uitltin. 
1.  Annulun.  J.  Tymiwnic  membrane.  ;t. 
UamiiuT  handle.  4.  Long  procets  t\i  inoiw 
■n<li«orhi(Milar)K.  .'>.  <'lioniatyini>ani  nerve 
In  foUl  (if  niucuiis  membmne.  6.  Cut  tendon 
of  tensor  tynjpani  muscle.  7.  Ilody  of  Incu?. 
8.  Short  pnK-esa  of  incus,  9.  Suspensory  liga- 
ment (tf  liatnnicr,  10.  .\ttip.  11  Tegmen. 
I'J.  liead  of  malleu!!  or  ha  nmer.  (From  a 
specimen  in  the  author's  cotiectiou  ) 


\      \ 


rVRVLKSr  ISt'LAMMAl'lOS  OF  THE  MIDDLE  EAR.       1141 

umbo;  the  detached  nu'rnhruiie  is  then  removed  by  forceps.  Tiie 
tendon  of  the  staixnlius  muscl(!  is  now  cut  with  the  same  knife.  Tliis 
is  followed  by  dividing  the  ineudo-sta{)edial  articulation,  if  intact, 
by  means  of  a  sickle-shaped  or  spade  knife  bent  at  an  angle  and  by 
severing  the  tendon  of  the  tensor  tympani  muscle.  To  do  the  latter, 
the  point  of  the  sickle-shaped  knife  (Fig.  595,  r,  and  .V)  is  carried  up- 

Flu.  .">9.). 


Uartmann's  inMrumeiiu  for  oiiemtion  on  the  middle  ear. 


wiird  under  the  posterior  or  anterior  fold  until  the  shank  touches  the 
fold,  when  the  cutting  edge  is  rotated  forward  or  backward  behind 
the  malleus,  so  as  to  engage  the  tendoii,  which  is  severed  by  a  sawing 
motion.  The  anterior  and  posterior  folds  are  ne.xt  cut  through  close  to 
the  hammer.    The  manubrium  is  now  gras{M»d  close  to  the  short  process 

Fio.  59«. 


McKay's  ear  forcci«. 


by  McKay's  (Fig.  596),  or  a  fine  alligator,  or  Hartmann's  forceps  fFig. 
597),  and  traction  from  side  to  side  and  downward  exerted  until  the 
bone  descends  into  the  tympanum,  when  it  is  turned  on  its  side  and 
renuned  by  one  end  from  the  canal.  Very  often  the  removal  of  the 
malleus  brings  the  incus,  generally  its  long  process,  into  view,  and 


. 


1142 


I'HK  KAR. 


its  removal  thon  follows.  Shoukl  tho  incus  be  out  of  siplit,  it  is 
drawn  down  into  the  tympanum  by  means  of  Ludewig's  im-us  hfH)k 
(Fig.  598,  H  )  or,  what  has  served  the  same  purpose  in  the  writer's 
hands,  by  a  right-angled  spoon  (Fig.  598,  G ).  The  hook  or  tlu  si)oon 
is  .^arricd  up  behind  the  pars  epilffmjxinica  in  a  vertical  jjosition  and 


llartmann'B  ear  fcrcepji. 


as  far  forward  as  possible  until  the  shank  touches  the  bone.  It  i.s  then 
maintained  in  the  same  position,  but  carried  backward  close  to  the 
inner  wall  of  the  pflr.v  until  it  reaches  the  position  where  the  body 
of  the  incus  shoulil  ho,  when  the  end  of  the  hook  or  spoon  is  rotated 


IV 

r«  » 

^*-« 

i 

i          i 

]  s^^^ 


MBvwewiTi. 


8  "       y» 


PnlitzerV  inslrunuiii". 

backward  tn\\:inl  !h<>aditus  until  it  engages  the  incus,  which  is  then 
brougiit  ititn  view  by  faction  in  :i  downward  and  forward  direction. 
The  incus  is  then  removed  by  lln'  t'orctps. 

The  use  (if  cocaine  and  adrenalin  makes  the  oijeration  practically 
a  l)l(Hi(ll{'-s  (  ^•   it)  tlio  great  majority  of  cases. 


I'VRVLKSr  INFLAMMATfON  OF  THE  MIDDLK  EAR.       114:5 

The  chorda  tympani  nerve  is  almost  necessarily  destroyed,  but  the 
loss  of  taste  resulting  is  very  generally  only  tempora-  y. 

The  attic  is  now  syringed  out  with  an  antiseptic  solution  to  remove 
pus  and  cholesteatomatous  material,  and  what  granulation  tissue 
exists  in  the  attic  is  carefully  removed  with  the  curette  or  with  All- 
port's  curette-forcei)s  for  use  in  the  attic.  (Fig.  599.)  The  curette 
should  not  be  used  in  such  fashion  a.-<  to  endanger  the  facial  nerve 
or  a  possibly  ex|)().sed  dura.  The  prob<"  should  always  first  be  used 
to  discover  an\  erosion  of  the  tegmen.  The  writer  has  not  made  up 
his  mind  as  to"  whether  the  introduction  of  a  gauze  wick  at  this  stage 
is  desirable  or  not;  but,  if  used,  it  should  be  of  plain  aseptic  gauze 
and  not  bichloride  or  iodoform,  either  uf  which  may  act  as  an  irritant. 
\Vhen  gauze  is  not  used  the  ear  is  simply  thoroughly  dried  and  the 
concha  filled  with  absorbent  cotton  held  in  place  by  adhesive  zinc 
oxide  plaster.  The  patient  is  instructed  to  lie  as  much  as  possible 
on  the  operated  side  to  ^-r  or  drainage.  The  dres.sings  are  to  be 
removed  at  intervals  of  twelve  to  twenty-four  hours  for  the  next 


'  I 


FlO.  5W. 


Alli>ort'8  ear  forceps. 


few  days  until  all  irritation  has  subsided.  The  patient  is  directed  to 
keep  in  the  recumbent  ixxsture,  the  diet  is  restricted,  and  the  bowels 
are  kept  open. 

Formerly  the  writer  was  of  the  opinion  that  the  incus  was  fre- 
quently destroyed  or  that  the  portion  lef  >vas  .so  aiikylosed  to  the 
neighboring  parts  as  to  be  impossible  of  removal;  but,  with  the 
increased  expertness  which  comes  from  doing  the  operatic.ii  fre- 
quently, he  rarely  fails  to  find  some  remnant  of  the  body  of  the  bone 
(Fig.  572),  and  suspects  even  then  that  a  small  fragn  nt  may  have 
been  paslu'd  out  of  i)lacc  by  the  manipulations.  In  fact,  it  has  ha))- 
pened  that  the  jjostoperative  syringing  has  brought  such  a  fragment 
into  view.  In  but  one  ease  was  it  certain  tiiat  ankylosis  interfered 
with  removal,  and  in  ihis  ease,  after  fraeture  of  the  manubrivun  by 
traction,  the  ankylosis  of  the  hanimer  liead  and  incus  to  the  sur- 
rounding bone  wiCs  so  hnn  as  to  turn  flic  right-angled  curette  against 
the  binding  screw.  Wliere  the  manubrium  i.s  brittle  from  disea.sc  it 
ireqiientlv  fractures;  but  a  hold  can  usually  be  obtained  on  a  levrj 
witii  the  sliort  process  by  which  to  remove  the  rest  of  the  l)one. 


1144 


TlIK  EAR. 


When  the  pars  epilympanicn  is  found  by  the  probe  to  lie  carimis 
it  may  be  removed  in  part  by  the  use  of  Dencli's  punch  (Fig.  60(1  > 
which  is  the  most  satisfactory  instrument  for  the  purpose,  although 
not  as  efficient  as  one  would  like.  A  secondary  jiost-auricular 
operation,  with  turning  out  of  the  membranous  canal  and  the  use  of 
the  chisel,  is  nnich  more  efficient.  Bacon  recommends  the  use  of  a 
sharp  sjioon  for  this  purjxjsc. 

Complete  recovery  immediately  follows  the  operation  in  a  certain 
l)roportion  of  cases;  but,  in  the  majority,  after-treatment  is  neccs- 


(•viichVear  punch. 


sary  in  order  to  bring  about  the  cessation  of  the  di.scharge  and  the 
cicatrization  of  the  cavities.  This  after-treatment,  in  the  writer's 
hands,  consists  in  thorough  cleansing  of  the  affected  attic,  aditus. 
and  antrum  by  means  of  absorbent  cotton  or  syringing,  using  ii 
special  canuhi  dcvi.sed  by  iiim  fur  tlii.-  purpose  (Fig.  (>01)  and  the 
Alpha  "E"  syringe,  iis  described  above.  After  syriisging.  the  parts 
are  thv»roughly  dried  by  means  of  cotton  on  a  fie.xibl(>  applicator 
which  reachi's  up  into  the  attic,  and  even  into  the  aditus,  the  head 
being  bent  forward  from  time  to  tirr.e  to  drain  the  antrum.  The 
parts  being  dry,  the  indicated  remedy  in  powdered  form  or  in  solu- 


n'RCLKST  ISFI.AMMA'noS  OF  TUK  MIDDLE  EAR.       1145 


Fm.  iX)l. 


tioii  may  be  used.  The  patient  is«  not  iKrniittrd  to  treat  the  ear  at 
home,  other  than  to  (!ry  it  out,  if  necessary,  but  i"  directed  to  call 
for  treatment  at  the  office,  even  so  fretiuently  as  twice  a  day  during 
the  first  few  days  after  the  operation.  The  time  the  discharge  takes  to 
reform  indicates  tlie  interval.<  between 
treatments  in  the  later  stages.  Treat- 
ment is  ivept  uj  >  utii  the  parts  have 
remained  free  from  discharge  for  from 
one  to  two  years,  the  intervals  between 
treatments  toward  tiie  last  being  to 
ifing  as  t  -vo  or  three  months,  some  scal)- 
bing,  though  no  ilischarge,  necessitat- 
ing treatment. 

Stacky  reports  24  cures  in  29  ossic- 
ulectomies. In  18  there  was  no  im- 
provement in  hearing.  The  writer  has 
taken  notes  of  22  consecutive  cases  of 
ossiculectomy  in  private  i)ractice,  for 
chronic  suppurative  inflammation  of 
the  middle  ear  of  long  duration,  many 
from  childhood.  Cure  resulted  in  lo, 
4  were  improved,  and  3  were  not. 
Of  those  inji)roveil  2  were  cholestea- 
tomatous  cases  and  only  suffer  at  lora; 
intervals  from  some  scabbing.  Of 
those  unimproved,  1  is  a  scrofulous 
;firl   in  whom  only  the  hannner  was 

removed,  1  an  ansemic  hard-working  w man,  and  the  other  a  man. 
rill'  liearing  was  made  In-tter  in  13,  remaineu  about  the  same  in  5, 
and  was  made  worse  in  2;  unrecorded  in  2.  Two  of  the  unimproved 
<:i.-<es  and  one  of  the  improved  cases  did  not  continue  after  treatment. 
Ill  no  case  was  the  facial  nerve  involved. 

Following  ossiculectomy,  patience  aiid  attention  to  detail  often 
woT'k  a  wondrous  cure. 

There  is  no  doubt  in  the  writer's  mind  that  this  operation  should 
nlways  \h'  done  }>y  |)reference  before  undertaking  the  radical  opera- 
tion.' He  is  fcrtain  that  it  will  show  .is  large  a  percentage  of  cures; 
it  floes  not  en<lfinger  life  or  health,  .iiul  there  is  no  resulting  deformity. 
It  idfn(>st  iiiviiriaiilx  relieves  the  dizziness  and  headache,  not  due  to 
intracranial  lesions,  when  these  have  been  pre,«ent;  but,  as  las  pre- 
viously been  said,  the  operation  is  only  a  step  toward  cure,  the 
after-treatment  being  fully  as  important. 

The  radical  operation  will  be  described  under  the  heading  of 
Mastoiditis. 

It  is  often  desirable  to  attempt  the  inijirovement  of  the  hearing 
111  cases  of  otitis  media  purulenta  chronica,  which  have  healed  with 
marked  imjiairment  of  function  through  the  formation  of  adhesions. 
This  iiiiprovement  may  often  be  brought  about  by  dividing  and  re- 


Author's  cknula  for  nyrliiging  out  Ibe 
attic,  etc.  1.  For  use  after  oMlculectomy. 
'i.  Forme  in  place  of  Hartmann'j  canula. 
The  Drat  la  In  'wo  shapes,  rtghl  and  left. 
(Made  by  Miv  lOWiTZ.) 


lUK 


rilK  EAH. 


inoviiif;  such  baml.s  wlicrr  thi-y  luiid  (Idwii  thf  iiicu(l()-sta|)fili;il 
articulation  or  the  stajx's  to  tlio  fossa  of  the  oval  winilow.  Where 
the  haiiuiicr  is  Ijound  down  ti.  he  promontory  division  of  the  adhesion 
rarely  iini>rii\cs  the  hearinn;  itut  when  united  to  the  inciulo-stapedial 
joint,  division  followed  hy  traction  on  the  inanuhriuin.oreven  removal 
of  the  inanultrium.  is  sometimes  very  i)eneHcial.  Often  tlie  removal 
of  the  chalky  |)lai|ues  in  the  anterior  and  ixtsteiior  ((uadrants  of  the 
ilrunihead  will  improve  the  hearinp::  thus  the  hearinjt  for  the  whisper 
was  permanently  advanced  from  4  feel  to  20  fi'et  l>y  such  an  operation 
on  one  of  the  writer's  patients. 

A  patient  wiio  ha^  a  healed  chronic  suppuration  of  the  middle  ear 
nmst  Ih"  cautioned  ajrainst  the  danp-r  of  getting  water  into  the  ear. 
ei;her  in  sea  bathing  or  in  ordinary  washing. 

Acute  Mastoid  Periostitis.  Harely  primary,  it  is  then  usually 
due  to  iiiiurv  or  to  cold.     It  is  generallv  due  to  extension  from  an 


Fl(i.  tK 


Flo.  0)3. 


Front  anil  tfur  view  of  &uch  11  cHse  in  the  practice  of  the  author. 


otitis  <'\terna  or  from  a  purulent  process  in  the  middle  ear.  It  is 
most  fre(|uent  in  children,  and  is  usually  due  to  extension  from  the 
mastoid  ceils  or  through  the  niastosi(uaniosal  suture.  Occasionally 
a  superficial  ah.scess  forms  over  the  periosteum  in  the  suhcutaneou-; 
tissue:  this  form  generally  results  by  extension  from  fiirunculous 
di.sease  of  the  external  auiliti>rv  canal.  In  children  the  pus  from 
the  middle  ear  sometimes  dissects  away  the  membranous  canal  from 
the  bone  and  ap|)ears  under  the  jieriosleum  l)ack  of  the  ear:  bur 
even  in  these  cases  there  is  o>-  linarily  in\(ilvenieiit  of  the  mastoid 
antrum.  When  the  subperiosteal  abscess  has  followed  mastoiditis.it 
sometimes  ha|ipei;s  iliat  large  necrosetj  masses  of  bone  are  fouii<l  iii 


l-lRII.E.\r  l.\ht.AM.\fAriO.\  OF  TIIK  MIDDLE  EAR.       1147 


the  niiustoiil.  The  boundaries  of  the  abscess  are  generally  fornie.l 
bv  the  sutures,  where  the  periosteum  is  adherent,  and,  tus  the  i)eri- 
..steuni  is  less  adherent  in  an  upward  direction,  the  abscess  tends  to 
spread  above,  and  even  at  times  in  front  of  the  auricle,  over  the 
temple  and  toward  the  eve,  inducing  great  oetiema  of  the  aflected 
^ide  of  the  head.  ( Figs.  (M)2  and  6()3.)  It  is  a  rare  complication  ol 
cerebral  abscess  and  is  a  usual  accompaniment  of  an  extradura 
abscess  which  has  perforated  the  siiuamous  portion  of  the  skull  and 
apjH-ared  <"xternally.  dironie  periostitis  is  a  frequent  accompaniment 
of  sinus  thrombosis  if  the  miustoid  vein  is  involveti. 

Prompt  evacuation  gives  immediate  relief,  but  the  lundamental 
cause  shoultl  be  searched  for  and  eradicated. 

Mastoiditis.  This  condition  occurs  with  about  equal  freciuency 
in  adults  and  in  children:  but  the  disease  is  much  more  frequently 
acute  in  children  than  in  adults.  Perforation  of  the  mastoid  cortex 
with  subperiosteal  abscess  is  more  than  thrtn-  tunes  as  fre<iuent  in 
children  iis  in  adults.  Intracranial  complications  occur  much  more 
frciuently  in  chronic  ca.ses.  Duel  states  that  in  from  4000  to  oOOO 
cases  of  infectious  diseases  26  mastoid  abscesses  occurre(  1 :  2  m  measles 
■>  in  scarlet  fever,  20  in  combined  scarlet  fever  and  diphtheria,  and 
"'  in  combined  scarlet  fever,  mciisles.  and  diphtheria.  Edwin  W. 
Pyle  reports  that  4o  acute  cases,  mostly  in  children,  furnisheil  i.i 
per  cent,  of  intracranial  complications.  ^     ^^ 

while  55  chronic  Ciuses  furnished  (Mi  per 
cent.     The  mastoid  ^Figs.  578  and  604) 
is  most  freciuently  affected  as  the  result 
of  a  recurrent  puriil(>nt  otitis  media  or 
as  the  result  of  exacerbation  of  a  chronic 
process.     In  children  it  is  more  apt  to 
lollow  an  acute  otitis  media  purulenta 
than  in  adults:   also  it  is  more  apt  to 
follow  an  acute  influenzal  otitis  media. 
The  jmtients  usually  complain  of  (min. 
■ither  deep   within   the   ear   or    in    the 
mastoid  ])roce.ss.     This  pain  fivquently 
is  of  a  throbbing  character:   in  others 
I  here  is  present  simply  a  dull  aching  paiii. 
There  may  or  may  not  be  fever:  usually, 
however,  low  fever  is  present,  somewhat 
'ligher  in   the  evening.      Pul.s'iting  tin- 
nitus is  a  signilieant  symptom,  as  indicating  intense  vascular  tension. 
Discharge  from  the  eiiV  is  g(  nenilly  evident,  although  there  are  cases 
111  which  no  discharge  occurs  and  the  drum  membrane  is  intact.     The 
lischarge  when  unusually  profuse  is  always  indicative  of  po.ssible  mas- 
•oid  involvement.    Temierness  is  usually  present,  except  in  those  ca.ses 
>f  long-standing  chronic  suppuration  in  which  the  mastoid  process 
las  become  sclerosed  or  "  eburnated : "  in  other  ca.ses,  however,  it  may 
liso  be  absent.     The  tenderness  is  usually  most  marked  in  one  or 


I'neunialic  mmtolcl.  1.  I.arge  cull 
ill  tip  lined  «iih  luurous  memlirane. 
J  Mastoid  antnioi.  3.  .Sigmoid  gnHue. 
I  From  ft  spciiiiieii  in  the  uuthor'a  ool- 
b'ction.) 


^1 


. 


114S 


Tllh:  EAR. 


all  of  throp  Idoaiitifs,  cither  ilircctly  over  the  iiijustoid  antrum,  nr 
over  the  tip  of  the  mastoid  pr-ccss,  or  ovor  that  portion  of  the  ihi>- 
terior-.sup('rior  canal  wall  which  overlies  the  position  of  the  antrum. 
SwellinR  and  redness  in  the  neighl)orho<id  of  any  of  the  abow;  three 
positions  may  be  present,  more  often  in  children  than  in  adults,  ami 
indicates  the  l)eRinninn  <>f  "  periostitis  due  to  the  underlying  disea.-e 
of  the  bone.  In  Hozold  ctuses,  the  swelling  begins  under  theti|)aii(l 
si)reads  downward  in  the  neck.  Slecples-sness,  due  to  pain,  is  an 
important  symptom  usually.  Lo.sa  of  appetite  is  freciuently  present, 
as  well  as  a  furred  tongue,  fetid  breath,  and  constipation.  Headache 
is  com|)lained  of  at  times.  In  some  cases,  fistula-  opening  on  the 
external  surface  of  the  mastoid  process  or  througli  the  posterior  canal 
wall  may  l>e  |)resent.  In  some,  .symptoms  of  cerebral  irritation  may 
app'^u  .  None  of  tliese  symptoms  are  invariable;  any  may  be  absent 
in  any  pariicular  case,  and  the  intensity  of  the  .syrnptoms  does  not 
always  serve  as  an  indication  of  the  amount  of  disorganization.  It 
may  hajjpen  that  a  numb-r  of  these  symptoms  may  coexist,  and  yet 
on  operation  the  mastoid  process  may  be  found  not  involved. 

The  diagnosis  is  made  by  a  consideration  of  the  symptoms  j)resent, 
usually  in  connection  with  the  {)resence  of  a  suppurative  process  in 
the  middle  ear.  A  mistake  may  arise  by  confounding  an  external 
otitis  with  this  condition;  in  external  otitis  the  tenilerness  is  usually 
limited  to  tlie  auricle  and  most  marked  on  traction  of  the  auricle, 
there  is  swelling  in  the  outer  portion  of  the  ear  canal,  the  pain  is 
not  so  deeply  located,  and  rational  treatment  usually  soon  clears 
up  the  picture. 

The  treatment  may  be  divided  into  the  abortive  and  the  operative. 
Tlie  abortive  treatment  consists  in  esr.iblishing  as  free  drainage  iis 
possible  tliiough  the  middle  ear  and  tympanic  membrane  by  a  gen- 
erous incision  into  the  membrane,  carried  along  the  posterior-supe- 
rior wall  of  the  osseous  canal,  when  there  seems  to  be  present  peri- 
osteal irritation  in  this  region:  frequent  hot  douching  through  the 
canal  combined  with  the  application  of  the  hot-water  bag  over  the 
mast(<id  j)rocess;  withdrawal  of  blood  in  vigorous  patients  by  the  arti- 
ficial or  natural  leech  applied  in  front  of  the  ear  (it  would  be  preferable 
to  apjily  them  back  of  the  auricle  did  not  the  -rritation  from  the  Icecli 
bites  produce  a  localized  tenderness  which  masks  theclinical  appearam 
afterward):  rest  in  bed.  light  diet,  the  administration  of  cholagoguc 
laxatives,  and  the  exhibition  of  tincture  of  aconite  root  in  minim 
doses  every  hour  or  two.  Formerly  the  use  of  the  ice-coil  over  the 
mastoid  process  was  highly  recommended  by  most  aurists;  l)ut  it 
was  found  that  while  it  gave  great  relief  to  the  pain,  it  so  numbed 
the  nervous  sujiply  of  the  parts  as  to  mask  the  symptoms,  the  process 
within  keeping  on  in  its  destructive  work  meanwhile.  For  the  same 
rea.son  it  is  ii't  well  to  give  narcotics,  if  it  can  possibly  be  avoided. 
Poultices  are  also  objectionable,  for  evident  reasons.  Should  no 
marked  and  progressive  improvement  in  the  .symptoms  follow  imme- 
diately or  soon  upon  the  installation  of  the  above  treatment,  then 


I'VRllESr  L\h'l..lMMAri".\  OF  TlIK  MIUhl.E  KAIt       114!> 

„,,orati..n  «lu.ul.l  l-  rc-,.urte.l  t...     Tlu-  ..,,.;ratu.n  in  itself  h  free  (nmi 
.lanKor  to  lifo:  ih.'  mn.litioa  of  tl.o  inasu.i.l  may  and  frctim-ntly  iloes 
imperil  it.     Thon-for..,  one  shoul.l  always  .Tr  on  the  safe  M<le  and 
„t,?rate  oarlv.     An  nnne..-ssary  o,.<'.alion  .>  much  pref.-ral.le  to  one 
that  is  done  too  late,  and  an  early  operation  is  the  best  prophylaetic 
..K,.nt  against  intraeranial  eon.plieations.     How  sor.n  disintegration 
;,f  the  inastoi.!  may  set  in  is  well  shown  by  the  histor>  «•/  Y"- '" 
tt,..  writer's  service  at  the  Kings  County  Hospital,  Brooklyn.     The 
patient,  who  was  an  alcoholie  with  a  tubereiilar  family  history,  was 
uud-r  treatment  for  a  general  c.nM.'.aint  inthe  h..spital.    On  u  i^atur- 
,hiy  afterno....  he  began  to  eomplain  of  pam  in  li.s  right  ear    which 
logan  to  discharge  the  ne.xt  day  without  relief  to  the  pain,  and  some 
fever  and  headache  appeared.     Monday  mormng  the  mu<U'.<\  was 
lender  over  the  tij)  an.l  antrum,  aiul  toward  afirrnoon  .swelling  l-.gan 
lielow  the  tip.     At  8  I'.M.  Monday,  the  writer  ..p.-nued  ai;d  found  a 
localiml  coli..ction  of  pus  in  the  cells  of  the  tip  and  anuiner  purulent 
....llection  in  the  antrum  and  neighboring  cells,  with  exposure  of  tlu, 
aura  over  the  tegmeii  aiitri.     Beuv-en  these  two  foci  the  bone  was 

congested  and  softened.  .    ,     ,    •      .1  ifinn  A'> 

\l  the  lirooklvn  Kve  and  Ear  Hospital,  .luring  the  year  1900,  62 
.■ases  of  nuisf.idi'tis  were  a.lmitted.  an.l  42  of  tlu;se  came  to  operation 
\s  ca«es  an.  not  a.lmitte.l  to  the  hospital  until  the  mastoid  symptoms 
;.re  prominent,  this  fairly  wll  shows  the  proportion  ^^^»;»> ;»"  ^e 
abort.-.l;  in  private  practice,  with  .■arlier  attenti.m  an.l  better  sur- 
roundings, the  proporti.in  shoul.l  be  greater.  .  .     ,  ^  , 

Th.  iimstoid  operati.>n  varies  in  extent  from  th.'  original  Schwartze 
„„cration,  in  which  the  mast..i.l  .-ortex  is  p.>rforat.-.l  ui.  to  the  antrum 
.n.l  which  is  appr<.priat.>  t..  the  cases  of  acute  mast.n.litis  follovnng 
:™te  purulent  ..tit's  media,  to  the  so-call.-.l  "ra.lical  operation,"  in 
which  the  cellular  structur.'s  of  the  mastoid  process  up  to  the  inner 
lancl  inchaling  th..  tip.  ti,:-  p.>stciior  wall  of  the  external  cana 
,b.n-e  a  line  .Irawn  .liag...udly  iron,  the  tl..or  ..f  the  orifice  to  the  floor 
I    ,h,.a.i.;>-,the  pars  cfut,fmp.,mcr.   an.l  the   larger  ossicles  are 
vmovetl.      Th..    various    m...lifications    of   the    original    Schwartze 
.n'rati.m  have  simplv  been  tentative  steps  toward  the  final  ra.hcal 
o)erati.>n;  for  instan(.e,  the  Stacke.  rh.-  Ivuster,  etc. 

The  oatient  is  prepared  f..r  the  ,, K-ration  in  the  usual  way.  wheie 
„os.sibl,',  bv  a  laxative  the  nigb.t  prece.ling.  followed  by  a  «ilme  in 
ho  m..  ning  an.l  abst-.ntion  fn.m  f...Kl  f..r  rom  f..ur  to  five  hours 
lH.fore  the  tin.,.  s..t.  Th..  instruments  an.l  -Iressings  aiv  prepared 
,he  wav  usual  to  all  surgical  operations.  Half  the  scalp  .uid  th. 
huirv  parts  around  the  ear  ..f  the  affected  si.le  are  shaven  f.n.r  or 
veh.  urs  before  the  time  ..f  operation,  the  parts  thorough^-  scrubbe. 
wilh  s'mp  solution.  wa.«hed  .,ver  with  al.-oh.>l  or  ether,  then  dressed 
with  a  moist  bichlorid.?  pack  and  bandag<>d.      ,     .     ,     .  „, 

Just  iH.fore  operation,  the  patient  being  a.uesthet.ze.l,  th.'^e.ar  canal 
is  first  ihor.,utrhly  cleans...!    with  a    bichl.mde  solution  of   1 .  oOtW, 


dried  out  .111 


,1  packed  with  aseptic  gauze,  and  the  skin  in  the  region 


1150 


TlIK  EAR 


of  tl.o  (JM  n.rk,  aurirlo,  nii.l  sralp  ijuin  scnihfxvl.  uwh.-d  witli  oU  .  r 
an.l  scruhfMH  witl,  l.ichlon.l..  .nlution.  The  ., titer  half  of  the  h.-ul' 
th.-  iHTk.  an.1  slM.ul.lrrs  arc  (-ov.r.  d  by  stcril.-  towr  Is  I„  ,„,it..  ca^.^ 
It  the  nHMnliran.'  m'.'<is  inrisi,,!,  for  hi-ttrr  (irairmgc,  il,,'  aauze  wick 
is^iiovv  withdrawn,  th..  wicisio,,  ...ado.  (h.-  cai.al  aKain  drip.!  ,„,<  arui 
the  pauze  w.ck  r.;.,,  w^.  If  a..  ..rdii.ary  Schwartz.-  o.MTation  is 
done,  then  the  auricle  is  hel.J  forward  l.y  an  assi.fai,  and  a  scaiiJ.! 
or  straight  bistoury,  held  with  tl..-  ....ttinR  e,!,.  at  an  a'.e'aS';' 
the  line  of  moision  and  not  (.eriH-ndieularly,  is  inserted  at  a  point  a 
quart.-r  of  an  inch  above  the  upper  aitachr^ent  .,f  the  auricle  to  the 
side  of  the  head,  directly  above  the  orifice  of  the  ex(. ma!  auditorA- 
canal  and  carried  backward  and  downward  parallel  to  the  tmsterior 
auricular  fold,  and  a  quarter  of  an  inch  from  it  until  the  p.'sition  of 
the  antrum  is  reach.-<l,  and  from  (his  ,h.u,(  the  incision  is  carried 
rZ'ri'f  t;''  l^^T.^^'/o  the  apex  of  the  tip  of  the  mastoid. 
(1-ig.  605.)     It  should  be  the  aim  of  the  ojierator  to  reach  the  bone 

by  this  first  incision :  if  this  is  not  pos- 
sible, then  the  jXTiosteum  must  be  di- 
vicled  by  a  .second  operation.     Thi'  in- 
ci.sion   may,  if   the  operator   prefers, 
begin  at  the  tip  and  progress  upward; 
considerable  hemorrhage  follows,  and 
should  be  contrt)lled  by  the  assistant 
with  sponges  until  the  ble«"ding  vessels 
are  cauglit  uj)  by  ha>mostatic  forceps. 
There  will  -iJH  be  present  more  or  les,s 
general  oozing  after  the  large  vessels 
are  iindi-r  contioi;    but    this  usuallv 
.soon  eea.ses  aft«'r  the  fjcriosteum  hiis 
been   elevated.      For   convenience  of 
exposure  in  the  Sehwartze,  and  as  a 
neecssii;    in  the    r.idical   operation,  a 
horizontal  incision  is  made  on  a  level 
with  the  centre  of  the  external  auditorv 
canal,  beginuins^  ,it    the  primary  in- 
cision and  ruT'iiiiig  backward  for  one 
inch.     A  periostfal  elevator,  guardeii 
by  the  index  finger  of  the  left  hand, 
is  now  inserted  under  the  anterior  and 
„  ,  .        ,    .       posterior  flaF)s  of  the  periosteum,  an.! 

the  membrane  stripped  from  the  bone  lorw.-.rd  to  tiie  posterior 
canal  wall  an< I  backward  for  a  sf)ace  suflicient  to  expose  the  mastoid 
process.  At  the  tip  it  is  necessary  to  cut  away  the  tendinous  inser- 
tion ol  the  sternocleidomastoid  muscl<>  witli  a  pair  of  blunt  curve.  1 
•scLssors.  lletractors  are  now  applied,  one  to  the  anterior  flap,  ii>- 
eluding  the  auricle,  and  one  to  the  posterior  flap  opposite  If  tli- 
retractors  have  been  placed  on  a  level  with  the  external  can:-l  tl,- 
mastoid  proces.s  is  sufhcientlv  well  exposed  and  the  surgical  Itivi 


l.lnos  of  liiri-i.  ii  ill  oi^mliug  mi  tne 
mHstolil.  I  Iijii  I.  11  (or  the  ordinary  or 
sthwArtK'  ojiemlton.  ooniliiuoci  ii|.H»nl; 
-'  for  llif  ■ralloal  o(«r«tloii,"  ami  u, 
I'litir  the  klt;inoiii  ((HKHc  or  pontcranlal 
fos.-a:  3.  for  eniinii?  the  uiKiilIo  cranial 
fa^HJl    liacUwan.. 


I'VRVI.KSr  IXFI.AMMATlO.\  OF  THE  MIIHHK  EAR        WTtX 

iiiarkrt  vimble.     (Fig.   577.)     Al»ovc  in  neen    the  t«'m|K>ral    Mfif, 
niit»Ti<trly  tin'  iMwterior  cdgp  of  tho  orifipe  of  the  pxtrrnal  canal,  with 


Achwkrtie'a  bajronet-Kluiped  chisel. 
Via.  ril9. 


Hoh»art7^'a  HtniiKht  aural  guuge. 
Fio.  611 


gchwabt's  stralifht  iHlifc  aural  clil»cl. 
Imtrumeuls  used  in  operallont  on  the  mastoiil. 


?1 


MICROCOPY    KESOIUTION    TEST   CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0 


t  ii£  mil  2.0 


11.25   iu 


2.2 


1.8 


1.6 


^     APPLIED  IIVHGE     Inc 

—         '  ''6'    *e^       CJOO  -  Phone 


lir,2 


THE  hAJ!. 

Kl'i.  f'U. 


O"     o— 


o 


Buck's  ear  ciiri'tli'. 


Kto   «|:i. 


I> 


3  UIM,.    '-   2 

iival  nmstoi.l  runlk. 


Flii.  r.l-l. 


Kl,^.  lil 


Mastoid  Ruicleuml  in-oleclor. 
Vir,.  iliCi. 


llarimRnns  ri)iigiMir  fnroci*. 
Fiii.  i;i7. 


ilartliiuiiiiM  roiigi'iir  l'orci'|is. 

Itl^lru^lCIlt.■!  used  in  op<'rali.,u»  <m>  liie  luai-ioiii. 


I'vnri.i-.sr  im-i.ammatiox  or  rnr.  miu'h.e  em:.     \\-v.\ 

Km.  lil". 


Kici.  ilJU. 


Slaolie's  pnileotor  lor  ladal  nerve. 


Km.  liJl. 


^ 


I'lililzi-r's  knifi'. 


Buck's  knile. 


lii>lrMiuMii»  iiseil  In  (ipcrauimKim  Hw  inii'^i"i'l. 
78 


I  1 04 


rill-:  i:.\u. 


the  si)iii!i-su])rimi('atuiii  al)()V(',  below  the  apex  of  the  mastoid  \\\<. 
Just  lu'liiiiil  and  al)()ve  tlic  spina  and  hetweeii  it  and  the  tenii)oral 
ridfte  is  a  fossa  inarivinj;  tiie  j-osition  of  Macewen's  supraineatal  tri- 
angle. It  is  now  necessary,  in  the  writer's  opinion,  to  proceed  with 
artificial  illumination,  j>referahly  in  the  form  of  a  good  in'candescen' 
electric  lijiht,  hacked  by  a  reflector,  and  held  l)y  an  assistant  in  such 
a  position  that  it  thoroujthly  illumines  the  operative  field  without 
heiiift  in  the  way  of  the  operator. 

This  method  is  much  better  than  the  attempt  to  dinct  light  liv 
means  of  the  forehead  mirror,  which  needs  a<ljustineiit ;  this  adjust- 
ment caimot  be  managed  !)y  the  sterile  hands  of  the  o]>erator,  and 
is  unsatisfaetory  when  ilone  by  an  a.-*sistant.  The  writer  now  takes 
a  fair-sized  gouge  or  clii.sel.  about  three-eighths  of  an  inch  broad,  and 
with  the  hammer  proceeds  to  drive  the  cutting  edge,  slightly  inclinci 
to  the  bone,  into  the  corte.v  for  an  eighth  of  an  inch  along  the  line 
of  an  oval  half  an  inch  in  its  shortest  horizontal  diameter  an<t  one 
inch  in  its  longest  vertical  diameter.  The  anterior  edge  <  '  this  oval 
lies  abotit  an  eighth  of  an  inch  back  of  the  posterior  wall  of  the  (>xter- 
nal  canal,  the  ui)iier  edge  lies  an  eighth  of  an  inch  below  the  temixiral 
ridge,  and  the  lower  I'dge  goes  pretty  well  down  to  the  apex  of  the 
mastoid  tip.  This  button  of  bone  is  then  lifted  off  fi-om  the  mider- 
lying  jjarts  by  a  broad  chisel  held  horizontally  so  as  not  to  penetrate 
any  deeper  than  an  eighth  of  an  inch  into  the  bone:  the  button  usually 
coTiies  off  in  one  piece.  As  a  rule,  the  removal  i>f  this  button  exposes 
the  cellular  structure  of  the  mastoid  jH-ocess,  and  it  has  never  been 
deep  enough  to  endanger  the  sinus,  in  the  writer's  experience.  From 
this  opening  as  a  base  a  pyramidal  section  of  bone  is  removed  to  the 
antrum,  under  illuminati(ui  and  the  constant  u.se  of  the  probe.  Thi' 
upper  surface  of  the  |)yramid  is  made  to  ])a.ss  horizontally  inward, 
care  being  taken  not  to  penetrate  the  inner  table  into  the  middle 
cerebral  fossa;  the  anterior  sin'fac'  of  the  |)yramid  passes  inward 
parallel  to  the  posterior  canal  wall  in  its  up])er  part  until  it  reaches 
the  position  of  a  line  drawn  from  the  floor  of  the  orifice  of  the  canal 
to  the  floor  of  the  aditus;  below  this  it  gradually  shelves  into  tlie 
inferior  surface,  which  is  cut  out  along  an  extension  of  this  line  to 
the  tip  r)f  the  mastoid:  the  posterior  surface  is  inclined  forward  and 
inward,  keeping  a  constant  watch  tor  the  iimer  table  overlying  the 
sigmoid  sinus.  In  other  words  the  ai)ex  of  the  pyramid  is  (lirecte<l 
upward,  forward,  and  inward  from  the  base.  As  th(>  operator  ap- 
proaches the  region  of  the  antrum  careful  inspeciidii  i'l  necessary  to 
avoiil  the  faci.'d  c;inal,  the  horizontal  .semicir"ui:i'  canal,  and  tin- 
middle  cerebral  fossa.  The  two  fotmer  can  usually  be  recognizc'l 
by  the  greater  com])actness  of  their  l)ony  wails.  When  the  antrum 
is  reached  a  spoon  is  introdi:ce(l  and  its  external  wall  carefully  reamed 
out.  Before  this,  a  s|)oon  should  only  i)c  used  in  cavities  to  remove 
necrotic  bone,  granulation  tissue  and  pus,  under  the  careful  guidance 
of  the  probe.  If  the  sigmoid  groove  encroaches  well  into  the  mastoid 
process,  it  is  necessary  to  modify  the  o])eration  by  keeping  above  and 


i'riiih;:.\r  /.v/v.  i.w.u.r/vo.v  nr  riii:  mii>i>i.e  i:mi.     ii.V) 

forward  of  its  ix.siti.m.  which  ca.i  only  1)P  rccognizcl  by  the  jireatcr 
roinpactiH-ss  of  its  l.<.uy  wall.  If  the  mi  l.ll.'  cerroral  fossa  .lips 
,lown  into  the  t.on.^  .Iccpor  than  usual,  similar  precautions  arc  to  he 
taken.  kcopin>i  the  upi.cr  surface  of  the  hone  wound  just  i.eh.w  the 

iiuier  table.  .       .  .      .  ,  •  , 

The  object  of  every  nia.«toi(l  (.peration  is  to  .       >  the  niastoi.l 
antrum,  and  nothing"  short  of  this  .satisftes  the  indications.      The 
■mtrum  is  now  cleansed  of  purulent  debris  and  jrranulation  tissue 
•uul  its  walls  searched  for  areas  of  erosion,  .vhich  are  to  be  curetted 
carefully,  or  for  the  presence  of  a  fistula.     In  acute  cases  of  mastoid- 
itis following   acute  suppuration  of  the  ini.Idle  ear,  it  is  l>etter  iiot 
to  curette  the  aditus  or  attic  for  fear  of  disturbinp;  the  ossicular  chain, 
•,nd  so  impairing  the  hearing.     The  oi)eration  wound  may  now  l)e 
rently  Hooded  with  sterile  water  or  a  nuld  antiseptic  solution,  no 
fi.rcible  ini.'ction  b(>ing  permitted  to  carry  infected  material  into 
unaffected  regions,  or  the  wound  cavities  may  simply  be  dne<l  out 
with  aseptic  gauze  sponges.     The  gauze  wick  is  now  removed  from 
the  <>xternal  auditory  canal  ami  the  blood  and  .secretion  •I™'''  ""t. 
after  which  the  ."Uial  is  finally  packed  with  sterile  gauze.     I  he  b.me 
wound  is  then  firmlv  packeu  with  the  same  kind  of  gauze,  which 
shculd  be  in  the  form  of  narrow  strips  with  selvaged  edges,  so  that 
no  threads  are  left  behind  on  its  removal.     T.sually  the  bloo.  vessels 
in  the  soft  parts  are  already  occluded  or  are  easily  controlled  by 
torsion:  very  exceptionally  i.  ligature  is  nee<l<>d.     The  incision  in  the 
^oft  i)arts  is  not  sutured  (except  the  horizontal  portion),  and  the 
wound  is  then  lightly  packed  with  gauze.     (  »n  er  this  a  pad  ot  gauze 
is  placed  i)osterior  to  the  auricle  and  up  against  its  posterior  surt.ncc 
to  give  it  supix.rt.     r)yer  all.  auricle  an<l  wound,  is  now  placed  a 
larger  gauze  pad;  this  in  turn  is  coverwl  by  a  pad  of  wood-wool  or 
Hudson's  cotton  dressing,  which  is  held  in  place  by  stnps  of  adhesive 

i)laster.  .  ■     i  „ 

Finally,  tiie  whole  dressing  is  included  in  a  two-inch  gauze 
h'lndage  carried  around  the  head,  but  not  around  the  neck,  in  this 
wiv  the  dirssing  i^  kej.t  firmly  in  contact  with  the  head,  and  is 
not  disturbed  by  changes  in  position  which,  after  the  oozmgs  have 
hardened  in  tiie  dressings,  are  so  painful  if  the  dressing   .uis  been 

loosely  applied.  ,        i  •      i  ■ 

There  are  certain  anatomical  points  to  be  remembered  in  <lomg 
a  ma.stoid  oi)eration.  In  infants  the  antrum  is  the  only  cell  in  the 
mastoid  !>rocess.  and  is  nearly  as  large  as  in  adults:  in  older  children 
ui)  to  i)ubertv  the  structure  outside  of  the  antrum  is  cancellous  and 
dois  not  usually  becom.'  pneumatic  until  arouiul  or  after  puberty. 
( iccasionallv  the  mastoid  process  is  double.  Th.«  lower  border  of  tne 
posterior  root  of  the  zygoma  is  about  on  a  level  with  the  root  ot  the 
mastoid  antrum  and  near  the  level  of  the  floor  of  the  middle  cerebral 
Figs  ()04  and  027.)     The  depth  of  the  antrum,  m  the  a<lult 


tossa. 
from 
triang.e  varies 


the  external  >urface  of  the  miustoi.i  process  at  the  supr 


tal 


from  one-eighth  to  three  .piarters  of  an  inch,  rarely 


1 1  .vi 


Titi:  i:\i! 


so  little  as  the  tmiiicr  and  occasionally  iIcciht  than  the  latter  rnoa-- 
uremcnt.  The  writer  does  not  believe  that  the  aiitruin  is  ever  ahsent 
or  obliterated:  he  has  examined  ix'tween  two  and  throe  hundred 
temporal  bones  taken  consecutively  from  the  dissect inp-room  without 
onro  finding  this  cell  absent.  The  sijimoid  fjroove  may  encroach  so 
far  into  the  mastoid  process  that  its  anterior  wall  is  the  posterior  wall 
of  the  canal;  but,  usually,  there  is  sufficient  s[).;ce  in  the  region  of 
the  suprameatal  triangle  to  go  above  it  to  the  antrum.  The  de{)th 
of  the  inner  tympanic  wall  from  the  posterior  edge  of  the  orifice  of 
the  osseous  canal  will  indicate  approximately  the  ])robable  depth  of 
the  mastoid  antrum.  The  facial  canal  should  be  looked  for  as  the 
antrum  is  approached,  lying  as  it  does,  just  interiorly  and  externally 
to  the  floor  of  the  aditus;  an  assistant  should  keep  watch  for  any 
twitchings  of  the  facial  muscles  during  this  stage  of  the  operation. 
Just  above  and  internal  to  the  facial  canal,  where  it  lies  in  relation 
to  the  aditus,  is  the  external  semicircular  canal.  Granulation  masses 
should  l)e  removed  carefully,  under  the  guidance  of  the  probe,  in  this 
region. 

The  nvnnbei  of  assistants  required  varies:  it  is  desirable  to  have, 
besides  the  antesthetizer,  one  a.ssistaiit  to  retract  the  anterior  flaji 
and  sponge,  one  to  retract  the  jiosterior  flap  and  hand  instruments, 
and  one  to  hold  the  electric  light,  with  one  or  more  nurses  to  meet 
ordinary  demands.  ()f  course,  every  operator  meets  cases  where  he 
is  fortunate  if  he  lias  one  a.«sistant  anti  ;i  nurse  besides  the  aniesthe- 
tizer. 

Iodoform  dre.>;sings,  powder,  and  gauz(>  are  much  used,  hut  are  apt 
to  cause  much  irritation  and  even  jjoisoning  in  sensitive  ])atients. 


Mttcew  t'ii>*  l)iuT- 


Macewen  prefers  the  dental  burr  ( Fig.  (>'_*.') i  to  tlu'  hammer  iiiiii 
chisel:  it  should  be  of  the  globular  form,  with  a  very  sharp  and  har'i 
spiral  '^utting  edge. 

If  the  mastoiditis  is  of  the  chronic  variety  or  follows  a  chronic 
mid  'le-ear  su[)i)urati()n,  then  tlie  Schwartze  operation  ha.s  to  l>i' 
inr  .ified  to  meet  the  indications,  a  lywhere  up  to  the  so-called  "radical 


rri!ii.i:sr  imi.ammmjos  <>r  iiii:  Minni...  t:.\it      \\:u 

„i..'riti..i.  ••     (FifJ.  ti-'(i.)     The  radical  ..iM'ratioi.  ••an  n.-yer  be  tnily 

K  L  it  i^  an  anatomical  i .ssihilny  t..  oxt.'nd  the  ol)orat.ye 

i'i  to  It  ..-  .Iti.nat..  ra-niHcluions  ..^f  tl.c  cellular  structure  m 
ehtio  ith  tl...  n.ast.ml  pn.cs.s  an  1  have  the  p-t.ent  survive  It 
nu^  ah^v  he  a  con.pn.mise.  and  ts  such  th.- operafr  sh.mlcl  nut 
en  mfShv  i:  su..  other  than  ' 'at  xvhich  ...■cv.rs  u,  the  ordnuir> 
;;, ;;:X,pemt?v..  attack,  sin,>ly  !.e.  ..use  it  n.ay  chance  to  be  anaton>- 

Klii.  IVJil. 


=:3Ht-=St=;=,:=:r:=r= - 

i,..illv  relate<l  to  the  cellular  structur.'  of  the  niastoi.l      St..tter  has 
lown  that  th.'  radical  operation  as  performed  by  its  ongmators 
il    to    u  e  in  a  considerai,le  number  of  cases.     The  fact  that  thrs 
o   l„es  not  detra.-t  from  the  value  of  the  operation  m  appropriate 
c^L^es    but  does  e.n,.hasize  the  necessity  of  usiiiR  ordinary  surpica 
common  sens.>  in  not  attempting  Ih.'  impossib  e.     I' or  instance     t 
.        t  be  nec-ssarv  to  remove  the  tip  of  a  densely  eburnated  mastoid 
;!      he  entire  pathological  pn.cess  is  confined  to  the  neighborhood 
f  he  .  trum,  aditus.  and  afic.     Something  ha.s  to  be  left   o  nature, 
.  „d    t    "  onlv  our  dutv  to  make  her  work  as  light  as  p..ssible.    Ihe 
Scd  oiKTation  is  alwavs  in.licate<l  when  a  chronic  suppurative 
;     df -e       1  la.nination  persists  after  tlu.rough  treatment  through 
r'u.a    including  ossiculectomy,  especially  when  the  patient  com- 
an    more  or  les^  of  perio.lical  attacks  of  dizziness  a.ul  hea-lach,-. 


1 1  .-.s 


Till:  i:m! 


\\ 


liiij;  tlic  lailicul  u|)('r;itii)ii.  Ihc 


nitiT  lliiiiks  it  licst  lo  n 


IIHIM 


tlic  hirircr  ossiclfs  and  rciiiiiatits  of  (Iriiiii  iiiciiilnaiic  fiist,  tlnuiiirli 
tlic  cxti'inal  car  canal,  timlcr  niirmis  o.xiilc  ana-stlicsia.  \vitli  the 
pafii'iit  in  the  ni>ri}rlit  |Misifiiin.  After  tliis  has  been  ditnc,  the  [laticnt 
is  Irt  ildwn  In  llic  hnriziintal  |M)sitiiin,  and  citlicr  nitrous  oxide  anaes- 
thesia luntiinied  tlinmsrhout  the  radical  o|>eration  or  the  chaiip' 
<|uickl\  made  to  ether  narcosis.  In  either  case  the  |)rirnary  stap' 
of  anasthesia  is  greatly  shortened. 

The  ineinhranoiis  external  auditory  canal  is  then  se|iarated  from 
the  hone,  cut  across  liy  tlic  ]ieriosteal  elevator  or  by  Stiicke's  knife, 
at  its  junction  to  the  aninihis,  and  witiidrawn  from  the  os.seous  caiiiil 
hy  Hartmann's  clamp  or  l.v  a  t;i|K'. 

The  antrum  is  reached  in  the  ordinary  way.  and  then  iV\g.  (»27i 
all  of  the  posterior  wall  of  the  external  canal  ;il)ove  a  line  drawn  from 
if  the  orifice  to  the  floor  of  the  .•ulitus  is  removed  liv  tlie 


the  fl( 


combined  use  of  the  chisel  and  lione  force|>s.  Sutticieiit  of  the  supe- 
rior wall  of  the  canal  is  also  removed  with  the  /^»r.s  fiiiti/mfxiHica  U< 
ijive  a  <:oo(l  view  of  the  tegmen  tyni|>ani.  making  a  smooth  surface 
directly  continuous  with  the  tepmen.     Staeke's  protector  should  be 


Klu.  tliJ(. 


Kli.  i-T  A|i|i«'Mranio  "I  l»inu  .ipimti-il  ii|»ili  afliT  llii>  "  rmlinil  uii'lhi)il."  except  Ibnt  the  tlpmul 
cells  arounil  fni'ial  laiml  have  iH'eii  lell  li>  five  relative  liK-aliciis,  1.  .Vililus  ad  anl'uni,  ■-'.  Tegmeii. 
:'.,  llori/diilal  si'niicireular  eanul.  1.  Inner  wall  oraritnim.  :<.  Wall  of  >iBinoi«l  griK>ve.  ♦».  Aiwrture 
lor  vein  to  sif^'ltinid  siini>.  7.  /.ytionialie  pnK'ess.  s.  Fossa  ot  (he  oval  wiihlovv.  *,*.  Kustachiaii  tube 
mouth.  111.  Fallopian  iniial  lor  lacial  nerve.  II.  i'oslerior  os«e.iils  eviernal  eanal  wall,  eut  i>tI'diRg- 
onalh  up\\ard  and  muard.     t .'.  Tip  of  ina.'sloid  priM-ess. 

Flo.  i.Js.—Deiorniity  loUowmc  a  |>erlehoiidri(i>  ami  eliondriii-,  .liie  to  liiei.sions  In  the  eartilage  ol 
the  •-anal  made  in  thedoinj^of  a  radical  o]H.Tation,    (From  Trantniann  s  (l|K.Ta'ionenairi  liehiirorgan. - 


introduced  into  the  aditus  during  this  stage  of  the  ojieration  to  protect 
tlie  sliuctures  of  the  inner  tymjianic  wall  and  the  liorizont.il  semi- 
circular and  facial  canals.  The  cellular  structure  of  the  mastoid  tip 
is  now  removed  or  may  previously  have  been  removed  to  the  inner 
table,  and.  hnally.  '.lie  mastoid  tip  is  itself  removed.  The  civity  of 
the  aiitnim.  aditus.  and  attic  is  now  made  smooth  by  the  removal 


i;i:ri.i:yr  i\hi.  i.w.v  i/7o.v  or  riii:  v.tnni.i:  i:.U!.     ll.V.i 


an 


fmiiul 


of  c-lli.lar  partitions,  aiul  fistula-  s.-arcli(.l  Inr,     If  tistnhr 

IVrsonallv  tho  wriK-r  .loos  not  l.clu'v.-  n.  tmnii.j:  st-m  Haps  K.nu.  1 

fn  ,M  th       -Ifrinr  osU-rm\  rartila^i.K.us  .-unal  ,»to  ti..-  l'<"-.^^;'"  'j  ; 

.    .     i.  i  of  tl.-  ski..  ...al<cs  the  op.-„i..K  f.'o...  ti.r  <;a.K.l  •"<"     " 

II  sin;.,  pori.-ho,..iritis  a...i  .•ho..a.-itis  "f  J'""  I';'-"';;,;  s,  "^ 

an.  mo.r  apt  to  .Icviop,  a...l  (■.■r..n.i.H.us  .■oiiect..  ..s  •"•<  1>'  '  ' 
.(•..,•  wl....Tvrr  tho  ski..  (•o..tai..i..S  oo.-........o..s  jrlai.as  .s  oarr. 

ll.   thinks  it  nmch  proforahlo  to  n>...ovo  o.,t.,oly  tho  sop..o„t  ot  tho 

-oft  oai.al  wall  opposite  tho  bono  \vou..(l.  ,,     .    ■     ,    .  ^.u.,  ., 

\ft  r  ....oiatio.   tlH'  parts  shouM  ho  thonmjjhly  .rriRatod  vv.th  a 

lixi  111  ri.l.'  solution,  unless  th.-  .lura  is  oxposo.l  or  a  h.stu  a 
xi"^t^tl  en  ro  shouhl  U-  oxoreiso.l  a.xl  tho  o..ti.-o  r^vtv  'I'orough  y 
Irio  I  o     bv  ,.le.l«ots  of  Rauzo.    The  ty.npa..ie  eav.ty  .^  then  packed 

"h  :;nHnUuzo'pie.i,Hs,  with  or  ^7'i-"vt';;;:t'; .  otrt  z" 

^.l^lt  thl'^K.  way,  aftlr  whieh  the  ...o...l,ra...u.s  ami  carUUj«- 

,o,.s  canal  is  replaced  a..d  hel.l  in  pos.tton  by  j;:.u/.o  pa ck  .  g.     My 

L  n.astoid  cavity  is  packed  and  the  w<.«nd  .hos  o,    ...  the  way 

,lo«oril)ed  above  with  reference  to  Schwartzc  s  oporatioi  . 

'%"'  th..e  dJri...  which  the  original  dressing  '-^V  -J^   .-  ^J  ;  ;' 

varies.     If  ....  c....trai..dicatio.i  arises,  such  a.s  undue    '  '»  «  ^^^^^^^^ 

,     ,  or  .......plications,  it  .i.ay  b<-  left  i..  l.laco  for  a  week  ...  ><"  «  ^hat 

'■     ,r     The.-o  is  ..uito  a..  .  bjoct  in  U'avb.g  it  as  l.mg  as  practicable, 

Hr«t  .lr<>ssinir  to  adn.inistor  nitrous  ..xido  gas  or  t..  gn.  .preMous'v 
'"ni  dm  .1  hi  Sin  of  ...orphi..o  and  atr..pi..o.  osp...-ia  ly  .  ho 
aS  is  .10.10  so  oariy  that  granulation  has  ....t  ..ccuit.mI  a.i.l  the 
i.r.>cess  is  b.iun.l  to  be  unduly  j.ainful.  ,„„,.»„.  thnn 

Acceding  .Iressings  should  be  .l..n<-  at  intervals  no    groato    than 

'•■■*j1m  *..v...  .1.-  "»i >•  ■" »-  t\"ti'';,,;.r'i»,;': 

•  .  \u-         ,>  1  of  tlic  phnmic  iiuniio.it  otitis  i.i.'.ua.  oui   a 


ll(il) 


Tin:  h: Ml. 


I 


car  process,  especially  if  tlieic  is  a  cliolcstcatoiuntous  coiiditidii  prc.>- 
oiit  (I'iji.d'JItlniil'  I  Ik  o|)ciati()n  has  Im-cikIoih' upon  iidiatlietic  patieiii 
lint  even  in  these  ca.-is  the  safety  against  intracianiul  coniplicutinn- 
h;is  lieen  vastly  increased. 


K ■*'. 


shuwlni;  |n>i»Uli'nl  li>iiilii,  i'|.Uli'rini/i''l.  A'vi  ihc  incisl<Mi!i  iii  TrauiiMaiiir«<ip«nitliiii  forllsrIOLUri' 
Thi'  iwoiiiiiiT  IIhih  urv  «t'H  n  iiiiicthiT.  iiiiM  ihcn  tlie  two  ouIiT  (lii|i«  art'  lir.iuithl  tom'thiT  over  Ihi'm 
Hn<l  Ht»t«<>un.     iTrHUttimiiii''«  OiHfriiliMiieii  hiii  iit>li<irnrKiin.  i 


Intracranial  Complications  of  Suppurative  Inflammation  of  the 
middle  Ear.  Th-'se  occur  mm  h  more  mMiuently  than  was  formerly 
su))posed.  Those  most  commonly  met  with  arc  external  pachymi'M- 
injri'is  with  extradural  al)scc>>,  suixhiral  abscess  and  ulceradcr  of 
the  brain  surface,  leptonienin<;itis,  c(>rebral  or  cerebellar  abscess,  and 
infective  sijriiioid  sinus  thrombosis.  Pyle  noted  at  the  New  York  Kyc 
and  Ivir  Infirmary  in  IIM)  mastoid  oDcrations,  .3.'5  per  cent,  of  intra- 
cranial complications  in  the  ca.-^es  of  icute  mastoiditis,  mostly  in  chil- 
dren, and  (■>()  per  cent,  in  the  ca.-^es  f)f  chronic  mastoiditis.  He  did  not 
state  what  relation  these  complications  bore  to  acute  or  chronic 
suppurative  processes  in  the  middle  ear,  and  he  ;ippareiitly  classed 
amoufj  the  inlracraiiial  complications  simple  cMosure  of  the  dura. 
Most  observers  state  that  such  complications  are  comi>ar;itivcly  rare 
as  sequela'  of  an  initial  acute  purulent  otitis  media. 

Pacbymenin£'  is  Externa  with  Extradural  or  Epidural  Abscess. 
This  is  the  most  /r  |uent  of  intracranial  complications.  .\  low  grade 
of  pachymeninjiitis  e.xterna  fre(|uently  exists  over  the  tcfimen  tympani 
or  antri.  can.sed  by  the  nnderlyinp  bone  disease;  it  is  chronic  and 
essentially  protective.  The  dnra  ;it  these  ))oints  becomes  at.t.ached 
to  the  bone  and  nnich  thickened  by  the  development  of  fibn.iis  tissue; 
but    no  pus  or  }:ramilations  exist   between  it  and   the  bone.     The 


rriiri.Hsr  isilammmios  df  iui:  mii>i>i.i:  t:Mt. 


lUit 


oatinits  ut  tinu-s  n.ini.laii.  uf  .lull  hea.liu-h.'  a.i,l  s(.iiietin..'s  havo 
dizzv  MH'lls.  I...ti.  .iue  to  the  lunilizcl  irritation,     lu  other  eas.-s,  pus 
Kaiiw  access  to  the  dura  an.l,  Htrij.pir.K  it  fro...  the  ho.ie.  f<jr...s  a.i 
extradural  abscess;  the  dura  is  the.,  usually  coated  w.th  a  layer  of 
granulatious,  at  the  saiue  time  U-mfi  thickened  a.id  hyi.erie....c 

SymptomR     G.'..eral!v  the  presence  of  an  extrad.jral  collect.....  of 

pus  is  onlv  dis,.ov.>r.-d'a.  th-  tin.e  of  operat..ig   unless  .hiis  found 
V  way  t.."the  ext.>r..al  s.,ft  tissues  through  the  ho.,e  o    the  s.,uan  a 
Fie  ft  Mi)  ..r  al....«si.le  ..f  th.'  ...ast..i.l  ve.n  <.r  through  the  co...lylo.d 

.Znen      Its  pn.s....<r  ...uy  Ik-  suspected  if  the  pat.c.t  ......p  a...s 

„f  co..tinued  lateralize.1  h.-adacl.e.  .nore  or  less  .l.zz.ness,    "W  fever 
(s<.PM-tin..'s  al.s,-nt),  fnd.-r.iess,  a..d  perh.nps  swellu.g  .nvoUing  the 
.k>ep  cervical  gla...ls  in  th.-  sui)erior  porf    .  ..f  th.'  posterinr  cerv.cal 
trianEle-  if  th.^re  is  an  area  of  persistent  t,.„.lerness  .,ver  the  s.p.ima 
or  cerebell......  s..n.....le..ce,  .)Ccasionally  nausea  and  vo....t...g,  a..d 

s.,.neti.n,>s  stifr.u-ss  ..f  the  ..ck,  or  swelling  a... lt....,ler...-ss  around 

the  exit  of  the  ...ast..id  en.issary  vei...     Ot  these  the  .nost  ....l.cative 

Ire  the  lateralized  p.-rsiste..t  hea.la.-l.e.  with  low  fever  or  no..e  at 
•ill  the  areas  ..f  teu.l.'rness  ..ver  the  s.niaina  or  c'rehelluni,  and  the 
"tclderness  an.l  swelling  in  the  superior  p..sterior  cervical  triangle  or 
over  Mie  .nast.)i.l  en.issary  vein. 

Prognosis  is  ah.iost  always  had,  exce|.t  when  the  pus  h.i.ls  a.,  a.le- 
.mate  outl.'t  externally  (which  rarely  happens),  unless  the  cas.^ js 
.Iperate.!  ,.po...     A  tho.-..ugl.  operation  ge..erally  results  .n  a  con.plete 

"""'The Teatment  c.u.sists  in  the  extcisio..  of  the  mastoid  operation 
to  the  region  affecte.l.     If  th.'  .lura  is  exp-.s.-d  by  carioifs  en.s..m  the 
[re\  .,f  erosio..  is  t..  be  ei.large.l  until  all  parts  of   h.>in.s  cav.ty  a 
u.Kler  .,b.s..rvation.  if  possible,  up  to  the  hue  of  a.lh.-s.on  o   the  du  a 
uVthe  1  .on.-.     iM  ' '.lie  iM  th.'  du.^a      ->  t..  be  searched  f..r  an.l  explored 
with  a  vi.w  to  p.>ssn4e  .■o.nplicat..ms.     If  the  internal  table  is  no 
brok.-..  <      'Ugh.  then  rhe  ii  ^d.lle  ..r  p..steri..r         'al  f.jssa;  are  to  b- 
Sc      V  ....?.-re.l     ul  tlK-        .  expo.sed  ac '  ..■  .  -k  to  the  ...d.cat.ons 
ff."      .  bv  the  ..vmpt..-  n.e    "US  is  evacate.    and  granulat.on 

W  re.,.ov..d.  a,.d  '  h.-         ity  .hvsse.l  with  p..w.  ere.    lo.loform  or 
"^^"  ..der.  1  lift  to  4,  a.i.l  io.loforni  gauz.-. 

aoiil.l  '      I.).!''  veiy  gently.     The  writer 

1  .>f  !!i.    Mia.  lie  or  p.isteri.tr  f.)ssa  from 

ili\v:inl  a. id  backward  rather  'ban 


iod.)forni  and  boi'i.  -m 
If  syri.iging  is  .-.s.^rtt  m 
believes  in  .iiioveriiifi  i  ■  ' 

the  wound  in  the  mast., 
in  the  US','  of  the  ti-ephi 
Subdural  Abscess.     1 
])ractically  inipos-ible,  ih. 
Th.T.>  is  1  narked  pain  nv. 
perature  ru.is  hi^rl.er  thaii  i; 
in  McKernon's  ca.se).  the  p 
dence  of  sepsis,  such  as  f.nil  bn 
may  be  i.n^sent,  an.l  then    n. 
(iverlving  p.n-ti.ms  .)f  the  i^^kull. 


;iiii)n  is  rare,  an.l  its  .liagi      i^  if 

uii..n  being  found  .luring  o]       tion. 

atTcct.'d  sid.'  of  the  heji.l,  the  ten.- 

i-a.lui-al  abs.'.'s^  (as  high  as  102°  F. 

is  III'  >-e  fre<|U»'nt  tha.i  noii..al;  eyi- 

fun-,  1  tongue,  pr.ll.n-,  and  ana'mia. 

ir...r.     ;f  :--~   -rnd.'ni'-';^  on  the 

«n<i  i  .blc  I.I    he  skull  is  usually 


1^ 


IK.:: 


////••  h:\H 


criMli'd  ami  tlu'  iluia  ilisculuri'il.     Tlicrt'  U  nt'lcii  sii|iriiicial  ulci  latini 
<<i  the  liraiii. 

'I'lif  dura  is  iiiciscil,  the  pus  evacuated,  ami  tlie  cavity  very  ncnli\ 
syriiin«'d  with  a  ! :  U),(MHI  sululimi  of  liicliinridc,  prccautioiis  Ih-iihj 
taken  tu  1  ..vide  uiiipiy  fur  the  uuttlow.  Tlie  cavity  is  now  dried 
iiiid  tlie  iiidot'iirin  and  Ixiric-acid  powder  silted  in,  after  whirit  it  is 
loo.-<ely  packed  with  iodoform  Kaii/e.  No  drainap'-tuhe  is  reiiuired 
if  till'  opeiiinifs  thronnh  tiie  te^cnien  ;ind  dura  have  licen  sntliciently 
free. 

Serous  Leptomeningitis.  The  syrnptum^^  this  coiMlition  an' 
very  similar  to  those  of  cereliellar  ahscess:  heat'  '»e.  dizzines!*,  vorjiit- 
iiift,  ci-nstijiation,  often  slow  pulse,  j;enorall.  aormal  temperature, 
except ion.ally  fev(  r  l.'t.stin^  a  day  or  so,  optic  neuritis  in  the  nmjority. 
The  patient  is  very  restless,  and  delirium  may  alternate  with  sopor. 
Convulsive  attacks  or  cramjw  were  observed  in  one-third  of  the  cas<s. 
Disturli.'ince-  of  si^ht  ire  frp<|uenl.  The  occurrence  of  deafaess,  loys 
of  taste  and  smell,  \.  i  j  infre(iuent,  point  toward  meningitis  sero.sa 
when  present.  Sen.  menuigitis  ainl  ahsc-ss  frequently  coexist;  in 
over  ")()  per  cent,  of  .ne  cases  of  cerehellar  ahscess,  accordinji  to 
Koch. 

(Quincke's  lumhar  punctii;e  may  lie  einployed  to  determine  the 
presence  of  jin  excess  of  arachnoidal  fluid. 

Treatment  by  dei>letion  of  .all  kinds,  by  inunctions,  and  by  lumbar 
jjuncture  may  .sometimes  modify  or  oven  cure  the  disease.  ( )perati()n 
to  remove  the  infectiiwr  tissues  is  of  first  importance  in  the  majority 
of  ca.ses. 

Purulent  Leptomeningitis.  This  inf{anunato;y  |>roce:s  is  apt  to 
follow  acute  purulent  otitis  media  in  children  who  h-ive  the  tuber- 
cular diathesis.  It  may  follow  pac'.ymeninjtitis  ex'  'a.  with  jM-r- 
foration  of  the  dura  or  infective  sinas  thrombosis,  or  ilt  from  the 
ni|)ture  of  ;i  subdural  or  cerebral  or  cereb' il'tr  abi  s.  .1.  Oriie 
(irecii  states  that  "in  more  than  half  the  ''ases  i;  exists  alone,  and 
is  du<'  either  to  a  general  sepsis  or  to  infectii 'i  of  the  ;traohnoid  and 
l)ia  through  the  minute  blootlves  ■ '  "  It  i.i,.  ;>u'sue  either  a  rapid 
course,  endinp  fatally  in  from  fo-  '  r  ii\(>  iioii'-  to  several  days,  or 
the  jtrocess  may  be  protracted  ii|.  lo  two  oi-  lhr."e  weeks.  "It  is 
the  most  serious  and  ra|)idly  fatal  of  the  pyogenic  infective  brain 
diseases."  The  onset  is  often  marked  by  a  chill.  Headache  is  very 
intense,  at  first  confined  to  affected  jiarts.  later  becoming  general, 
and  .at  times  subject  to  remissions;  it  usu.ally  jippeais  e.arly.  Fever 
is  apt  to  run  higli  (104°  to  100°  F.).  ami  may  in  the  jintracted  form 
alternate  with  normal  or  subnormal  temperature,  but  usually  becomes 
continuously  high  toward  the  end.  The  pulse  is  usually  more  or 
less  rapid,  and  constipation  is  usual.  There  are  restlessness,  irrita- 
bility, dizziness,  nause.a,  vomiting,  over-acuteness  of  all  the  senses 
CTvlually  jiassing  on  to  delirium,  convulsions,  involvement  of  the 
cranial  nerves,  |)erhaps  inonoplegie  or  hem'  logic  jiaralysis,  drowsi- 
ness, and  coma.     Optic  I'ouritis  is  infre(|ueiit.     Ai)hasia  is  occasion- 


rii;ii.i:\r  />>/.  t  >/ 1;  i  rin.s  <>,  riii:  mii>i>i.i:  iah      ilti:J 
\u    ,  „....i.t      Th.-  Mirlac-  ..f  tlu-  l-o'lv  i-^  «.nt'riillv  hyi-crMiisitivc 

w  -1.  ...l-  '•crt.cn.l  .■■■rrl.r.l  n.cniiiKit.s,  as  !i  rule.  atT.Tts  Loth  puiaN 
;  ullv  ••....'  -v  a.r  th....  .•untra,.|.-.l  .a.til  tl..-  pn-sMT.-  symptoms 
1. '  ;  ati.    U.,    '  up..rv.......  .h.n  .1..  y  both  Ix.on...  .hlat.,1  an.   f.x.. 

Sh;t;/;h..m.n...n.nial....n.pli..a.i..n...fsu,,a.n.nv.^^^ 

!..,,tn,n.n.nK.t.s  ..,,i,„,„„is  is  ..asv  in  th.'  rapi.l  variety, 

.Mi::tl  f  -  ■        ..     m.iSl.-.la.-h...an.l  tlu-  hn.in  irritati..n 

fo  1.  ■  r.v  paraly-.i..  syn,,t...n..  U-av.  n..  .L.t.hl  wh.-n  tiu-  .i.^jo  o 
1.    .-.r   .nd  ..I  tl.-  l...n<-  has  In-.-n  ahva.lv  rcoKniz.-.l.     In  th.  pro 

L  '.    '  ,.ti.'  as  p..ssi»,l.-,  has  sav.-l  lifo  in  a  f.-w  instam-s. 
'  i^ertive  ThromUsis  oi  the  Sigmoid  SinuB.    Symptom..    Th,s 
,...S.  ••.■u^m..r..  .■..n.n,..nly  in  aclol-s-.-nts  an.l  -  "H^-  •"  >-'-; 
...    ho  rieht  si.l...     It  ..ccurs  much  nioro  frciiu-ntly  than  hra  n 

i    iwli-ilv  •.(•.-.■ntiiateil    >v  the  (.(•.■urrcnce  of  a  niarKo.l  ".•     ^^""' 
:     fn'     .'.   V  rop..at.-i.  folU-w.-.l    hy  a  high  f.-v.T.        her.-  is 

;:ft:n, ;;.,!:.:::/ vluniti^.,.  ii.-a.uu.h..,  if .- '••"^i^':';:-;;,  ;'^::x 

ftw         V  u  pn.fus..  porspiratu.n.     T.^o  tnnp.-rature /I-.p  f|31  . 

?,;.  ine     Tin  mt  •  t  fr.-ls  Joak  atu!  >,  k.uu.I  has  no  apiH-f  t-     Von- 
S;S,  ^I/h^sfr........  later  h>.^^^^^^^^^     ^^^  r^Z, 

„,o„lv  pr."s.-nt,  an.l  wh.-n  it   is  it  iiMialU   m       u(.    a  i 

,.;„■. .!,...■.-««    in  whicii  caso  consciousiuvss  is  gpn<>rall\    lost  m  tne 
.  u    .M    t  .e  il  .-a^'     Locallv.  thoro  is  gem-rally  ..torrh.va  from  sup- 

T.  li-rness  ov.-r  the  nmst..i.l  is  fr.-.iu.-ntly  present,  ,-speeialh  in  tlK 


11ti4 


THE  EAR. 


neighborhood  of  the  mastoid  emissary  vein,  where  (v(lenui  may  also  lie 
present,  sometimes  extending  over  tiie  whole  mastoid  jiroeess.  In  a 
good  proportion  of  the  eases,  there  is  swelling  and  tenderness  in  the 


I  liniPnl  (hurl,  vhiiuin.;  Ii'rii|.i'ralun'  atnl  pllNi'  rircml  \n  .i  rase  iil  iiifi-  limi-  -inn-  lliroiiil...«i- 

nppiT  part  of  the  posterior  eervieal  triangle  due  to  lyniphadiiiitis  of  tiic 
d<'ep  eervieal  glands,  to  phlebitis  of  the  ])osterior  condyloid  vein,  or 
to  the  bin'rowing  of  pus  which  has  passed  from  an  extradural  culiee- 


rri:ri.i:sr  /.v/v.  i.vw-i  rms  or  riii:  mii>i>i.i-:  emi-     I  itt.-i 
,,.,  ,.  the  ,...ste.w  condyloid  foranjo.     ^^^^^^^Z^^^ 

toad,  brow,  and  face,  ''^  7;f 'J;;;'^,'„"7Xk^^^^  i„„,  ,1„.  internal 
!:  '  T.h'ri^Ua  y\uffiStr:^^^^    .nrr„nndin„  ,l,e  Jufular 

pa?,:  ;5'  ■;:::  ..o.i;,,|»»*  ,';>;;rt"rrSeSroS 

their  appearance.     I  he  Jx"^    ">  '";  ™  »     ,|,^  y^j  i,„„,  ,he  dis- 

;;::;:; -^It'flh^cSVr  become  moi.t  and  the  expectoration 

'i;;":j;.;?'™S'r5LSe  enteritis  is  set  up   eiti^er  by  ingestion 
of  nfect  V  >  n  at  er  from  the  Eustacinan  tube  or  the  lungs,  or  because 
Senerd  ?ox.emia  develope.l.    Von.iting  is  incn-ased  m  frequency 
tu  ^^-iblniinal  pain,  tympanites,  or  meteonsm;  diarrhcea  of  the 
}     X     m^r       voe  ieat  prostration,  and  often  nmttenng  delirium. 

Vh  riSi«  1^^^^^^^         i"  ^he  course  of  infective  sigmoid  sinus 
,h^SS^tadache 'becomes  violent,  ;'-;-•-£;'— 
I     1  :™i.    ♦i.r.i-o  w  irii-it  excitement  and  iriiiaiinuv,  uyiiti 
!;:SnS.S.£c.:tn;;.Sl;^(tomc  and  donic,,  or  evanescent 
.  ,^   flue  uat  nc  paresis,  and  later,  delirium  t<.llowed  by  coma. 

N  ,  t  Site   d.rn>sses  o,.,.urring  in  the  muscles  or  art.culatu.ns  a.j 
,na!te.Tln  a  Hgor,  increased  fever,  local  pain  and  tenderness,  swelling, 

"*  The  diagnosis  in  ca^es  that  develop  typically   is    usually  possible; 
hn      h<Te   m   n,anv  cases  in  which  the  symptoms  are  not  marked 

'  rS;^-;:='.rrirzx:,;or^^ 

o    purulent  otitis  media  if  there  is  .hmmu tion  "'77^='^'^';,^;^" 
dUharge  coinci.lent  with  the  a,)pearance  of  cephala  g  a.  Ig      cm 
!  ^i  with  marked  fluctuations    rigors,  '"'^'T''!';^;  ,""  S" 
As  both  the  mastoi<lan.l  con<lyloid  .Mmssarv  u.ii.  ma>   bt  a!). em, 
external  signs  may  fail. 


ll«)fi 


Till-:  i:.\i! 


Prognosis.     W'itlioiu  'iicriition  most  <• 


:is('s  ciu 


fMtall\ 


ut  Ma 


(•('Wfll 


reports  that  "  instances  oi  long-standing  ol)literati()n  of  tin'  internal 
jugular  and  sigmoid  sinuses,  in  eonneetion  witli  infeetivi'  caries  and 
extensive  disintegration  in  the  tein|)oral  hone,  liave  heen  discovered 
at  autopsy."     At  tiie  present  time  the  iiereentage  of  iccoverii's  afte 


th 


lit: 


.., ..  _    ^  ous  ligation  ot  the  jugular  iha;i 

without;  according  to  various  statistiei.aiis  from  altout  "(•  per  cent. 
in  the  former  to  about  -"hi  l)er  cent,  in  the  latter.  Temperature  a> 
high  as  106°  F.  indicates  great  intensity  of  infection  and  the  prol)- 
ability  that  \u  t. .. stases  or  other  unfa voralile  complications  will  ijevejop. 
Recovery  is  prohable  if  the  case  is  operated  on  before  metastases 
appear,  su])posing  the  o])erative  attack  to  be  thorough.  Hut  with 
the  appearance  of  metastatic  formations  the  gravity  of  the  projrnosis 
increases,  thus  Hcssler  for.iid  only  12  recoveries  in  29  operited  metas- 
tatic cases.  l']vidently,  thi-refore,  oi)erative  investigation  should  b(! 
atlvised  just  as  soon  as  the  condition  is  iiistli/  suspected,  without 
waiting  for  certainty  of  iliagnosis. 

Treatment.  As  the  jn'rcentage  of  recoveries  with  ligation  of  the 
jugular  \cui  is  higher  than  witiiout,  I'very  operation  should  be  undt>i- 
taken  with  a  view  to  ligation.  Hut  ligation  is  not  to  be  i)ractised 
until  the  sinus  is  uncovered  anil  found  to  be  thrombosed:  th<'  more 
so.  since  ligation  is  not  a  certain  preventive  of  the  dissemination  of 
infective  ])articles,  which  may  find  a  way  into  the  cii'ciilatioii  through 
the  ])osterior  and  anterior  condyloid  \('ins  or  through  the  occijjital 
sinus.  (Figs.  .">S1  and  ")82.)  But  when  the  sigmoid  sinus  is  found 
to  be  the  seat  of  an  infected  thrombu.s,  the  jugular  is  best  ligateil 
before  clearing  out  the  infected  clot,  for  fear  that  l(K)sened  jyartides 
may  be  carried  down  into  the  circulation  during  the  oi)eratioii.  This 
also  i^revents  the  jio.ssible  occurrence  of  aerial  embolism,  a  fatal  case 
of  which  has  been  reporteil  by  Kulm. 

The  operation  begins  with  a  mastoidectomy  which  shall  meet  t!ie 
indications  existing  within  the  middle-ear  cavities.  The  mastoid 
tip  and  cellular  structure  is  removed  up  to  the  internal  table.  The 
knee  of  the  sigmoid  sinus  is  generally  on  a  level  with  the  upper  part 
of  the  osM'ous  extern;il  .iiiditoiy  canal,  and  the  depth  of  the  sinus 
from  the  external  surface  of  thi'  mastoid  process  varies  so  jireatly 
that  the  only  safe  rule  is  to  look  for  it  constantly  .after  removing 
the  external  cortex.  Of  course,  if  erosion  has  already  exposed  the 
dura  (Fig.  oSO)  or  a  fistula  exists,  the  difhculty  is  much  simplified. 
Chiselling  is  to  l)e  resorted  to  until  tiie  diiral  covering  is  in  view, 
when  the  exposure  is  to  be  sufficiently  increased  by  the  use  of  the 
bone  forceps  i.Ian.sen's.  Ilartmaiurs,  or  Hacoirs).  The  whole  of  the 
knee  and  descending;  portion  of  the  sinus  is  to  be  laid  bare,  .^^omi'- 
times  it  is  also  desirai>le  to  uiieover  a  good  part  of  the  lateral  simis 
as  well.  In  using  the  bone  forceps,  the  diiral  covering  should  be 
puslied  back  away  from  the  bone  by  a  director,  while  introducing 
one  blade  of  the  instrument,  otherwise  tlie  s.mis  wall  niiglit  be  nipjietl: 
this,  liowever,  has  never  happened  in  the  writer's  experience.     The 


■WS??-f 


!^FP-f^^^*lW 


I'liiri.Esr  IM  i.AMMAri<>.\  or  Till-:  Minni.i-:  i:mi.     iui7 

n..nnal  dura  has  ii  ftrayisli-bluc,  Rlisteninp.  tciMiiiH.us  api-caraiu-e 
whore  it  forms  the  siiuis  wall,  whoroas  the  same  mcinbrano  looks 
very  .liiTcrciitIv  wh.'i.  a  pcrisinus  abscess  or  infected  thrmnbus  exists 
The  dura  is  then  eith-r  covered  with  granulations,  thickened  and 
dulled  or  discolored.  The  i)resence  or  absence  of  pulsation  (jfiors 
no  certain  iiulication  as  to  the  condition  of  things  within  the  sinus, 
■w  -^uch  pulsation  niav  b.-  derived  from  the  brain.  It  pus  and  granu- 
lation tissue  cover  the  sinus  tiiey  are  to  be  removed  to  their  mi.rmost 
limit  and  the  cavitv  reii.lered  a.se|)tic  before  investigation  !  the 
.inus  The  writer  clo.>s  not  iM^liev.'  in  the  use  of  the  aspirating  lu-edle 
to  .leterinine  1h<>  condition  of  the  sinus  contents.  Its  hiidin<rs  are 
unreliable  and  its  use  may  carry  infection  where  none  previously 

'""it-'now   it    is   believed   that   the   sinus  is  affected,  then  the  next 
step  should  consist   in  ligation  of  tli<>  jugular.     The   skin   ot   the 
neck  having  b<.en  already  prepare-K  an  incision  i.s  made  along  the 
•Ulterior  border  of  the  sternocl.'idomastoid  mu«ele.  beginning  above, 
',t  or  near  the  lower  termination  of  the  mastoid  i.icision,  and  ending 
'below  as  far  down  as  the  clavicle,  if  there  is  reason  to  suspect  throm- 
l,„si<  of  the  vein.     The  muscl<.  is  retracted  and  the  vem  exposed  by 
opening  the  sheath.     In  two  of  the  writer'.s  ca.ses  the  vein  was  .lui  e 
collapsed  aiul,  ti.erefore,  .lifficult  of  r.-cognition.      This  .lifficultx  also 
exists  if  much  inHltiati<.ii  and  lymphadenitis  be  present,  matting  the 
uarts  together.     If  iiiHamed  Ivmi.hatic  glan.ls  are  present  they  arc 
to  be  rcm.ov.Hl.     Then  the  v.-in  is  ligated  at  the  upper  and  lower 
an-des  „f  the  wound,  care  being  taken  not  to  inji-e  the  luiderlymg 
'hvpoglo.ssal  or  i.neumogastric  nerves  or  -.rotid  i.rtery.     Ih.;     >cial 
vein  ne.Mls  ligation  also.     The  vein  is  now  cut  across  a  short  di>.   ncc 
inside  of  each  of  the  two  ligations  and,  if  found  to  be  involved,  re- 

'""Before  op.-iiing  the  sinus  wall  the  exposed  parts  should  be  carefullv 
examine.1  to  .liscover  any  fistulous  tract  leading  to  the  brain.     1 
such  tract  is  found  it  should  be  explored  an.l  the  indications  met 
before  incising  the  sinus.     The  operation  wound  shoul.l  now  be  gently 
H....ded.  not  sviinge.!,  with  1 :  .5000  bichloride  solutu.n,  which  is   then 
thoroughlv  dried  out  ami  the  cut  surfaces  of  th.-  bone  j.rotecte.l  h> 
irauze  nle.lgets  while  incision  and  evacuation  of  the  dot  is  in  jirogress. 
The  ii  cisim,  is  made  parallel  with  the  long  axis  of  the  smus  an.l  is 
long  as  the  aperture  in  the  bony  wall  will  permit.     Hu.d  or  grumous 
material  is  tluM.  moppe.l  out,  and  the  walls  of  the  containing  cavity 
"ilbbed  out  with  sponger  dipped  in  alcohol  before  a  '■""^"r  ^^  I"  7; 
duced  to  remove  the  obstructing  dot  above  and  bd.nv.    Tlu   <  lot  m 
1^  hiteral  sinus  tc.ward  the  torcular  shoul.l  first  be  dis  odged  l.y 
n'     he  cureue.  until  circulation  is  re-established,  then  the  clot  in 

"jugular  bulb  and  upper  vein  is  curette.!  out.  If  tl...  .,ugu lar  has 
,„,.  '  i:„ite.l  then  the  Inilb  mav  be  washed  out  with  a  1 . 5(K)U 
bid  ..ri.'l.^  solution.  Hem..rrhage  is  c.,ntr..iie.l  by  pr.-ssmg  the  .mU-r 
'irus  wall  against  the  inner  with  io.loform  gauze  ,.le.igets,  outsi.le 


IKiH 


Tin:  i:mi. 


of  wliifli  till'  oidiiitiry  mastdiil  drt'ssinjis  arc  applicil.  Whiting  rccoiii- 
mciuls  i)lafiii)i  a  pad  of  cotton  over  tii(>  jiijiular  vein  of  tin'  opixisiti 
side  to  ininimizc  tlio  prcssiwc  from  tlio  l)aiidajr<'  around  tlic  nvck. 
He  also  stron<rly  counsels  ai;ainst  "placitifi  tlic  nozzle  of  the  syrin};e 
in  tlio  divided  end  of  the  jugular  near  the  bulb  and  \v:ishiMfr  (dc' 
contents  forcibly  upward  and  out  of  the  oju'iiin}:  in  the  sinus  wall," 
for  fear  of  disseniinatinfr  in  ection. 

In  this,  as  in  other  proloufred  u])eratioiis  on  the  i,  racranial  con- 
tents, symptoms  of  collap.  e  may  aj.pear,  and  stimulation  must  hv 
resorted  to;  transfusion  of  about  sixteen  ounces  of  normal  saline  hoIu- 
tion  is  the  most  immediately  efficient,  introduced  either  into  the 
median  basilic  vein  at  a  temperature  of  108°  F.,  itito  the  cellular 
tissue  of  the  abdominal  wall,  or  injected  into  the  rectum.  Hypo- 
th-rinies  of  nitroglycerin,  strychnine,  or  whiskey  are  also  of  service. 

As  was  hinted  at  above,  metastases  may  make  their  aju'^arance 
after  ligation  of  the  jugular.  If  these  occur  in  the  lung--,  kidne>o. 
or  liver  the  outlook  is  bad.  If  they  are  peripheral,  the  usual  treat- 
ment of  local  j)us  collections  is  eminently  successful. 

Involvement  of  the  lungs,  digestive  tract,  or  meninges  is  to  be 
met  by  attention  to  these  conditions  along  the  lines  in  general  use. 

Infective  Thrombosis  of  the  Gavemous  Sinus.  This  subject  will 
receive  attention  in  its  relation  to  ear  disea.se  only,  ft  is  here  always 
a  sequel  of  the  same  affection  in  the  jjctrosil  or  si.<rmoid  sinuses. 
(Figs.  oSl  and  o^'?,.)  It  is  frequently  a.ssociated  with  basilar  menin- 
gitis and  occasionally  \vith  purulent  thrombosis  of  the  oi)hthalmic 
veins  and  abscess  in  the  (.ii)ital  cavity.  Macewen  reports  that  in 
more  than  half  the  cases  the  thrombus  spreads  through  the  circular 
sinus  to  the  cavernous  sinus  on  the  opposite  side.  The  symptoms 
indicating  involvement  of  the  cavernous  sinus  .are  exophthalmos, 
o'dema  of  thi'  eyelids  ,'ind  root  of  the  iidse,  and  move  or  less  chemosis, 
all  due  to  the  venous  obstruction:  |)tosis,  strabismus,  and  jiupillary 
manifestations  due  to  paralysis  jiroduced  by  ]iressur<>  on  ttie  nerves 
siuTounding  the  cavernous  veimus  plexus.  .Myosis  is  g<'nerally  present 
at  till'  outset:  but  as  the  jin'ssure  becomes  greater  stdbilr  inydr;a.sis 
ensues.  <)i)lithalmoplegia  may  b.-  complete  tov""''d  t!ie  later  stages. 
Defective  vision  exists.  ;md  later  there  is  amaurosis  from  |)ressure 
on  till'  ojitic  nerve.  If  the  other  eye  becomes  alTected  it  is  a  sure 
indication  that  the  infective  process  ha^  extended  over  to  the  oppo- 
site sinus.  The  symptoms  .are  a|)t  to  become  [H'ominent,  and  then 
recede  in  one  and  then  in  the  other  eye,  which  fact  forms  a  diagnostic 
distinction  between  infiammatioiis  confined  to  the  orbital  cavity  ami 
cavernous  sinus  thromliosis.  Infective  thrombo.^is  of  the  other 
sinuses  rarely  gives  pupillary  symptoms,  while  the  pro|itosis,  stabilf 
mydri.'isis,  and  blindness,  first  in  one  ey-  r.nd  then  in  the  other,  make 
the  diagnosis  easy  in  ca\ernous  sinus  thrombosis. 

Be.-idf.-  ihi'.-c  special  locali/Zllig  .--ymptonis  ;ili  liie  general  symplollis 
of  sinus  thrombosis  are  jiresent.  The  termination  is  invariably  in 
death  if  the  tliroinbus  is  infected:  but  if  the  symptoms  .arise  simply 


9fr 


rri!ii.h:.\r  imlamma 


ri<)\  nr  rill-:  mii'DI.i-:  I'-Mi      llHn 


\t('iisi()ti  fioin  tho  si}?iiioi(l  siiiius,  aiu 


froiii  ;m  olistnictiiif^  <.'lot  by  i  . 

this  dot  (Iocs  iK.t  iM'Ponic  infcfto.l  l.ci-aiisc  ..I  i"!irly  opcnttivc  later- 
Iciciicc,  iiiav  not  iccovcn   Im-  possil)!!' ? 

Infective' Thrombosis  of  the  Petrosal  Sinuses,  llns  ((UKlition 
.im|)lv  fonus  a  part  ..t  tl.r  natural  l.ist..ry  of  i.itVctivc  thnmihusis 
uf  th("'  •^i'Miuml  sinus,  wiictlicr  lli.-  petrosal  sinuses  become  afiected 
nriinariK'aii.l  later  involve  tlie  sifrinoi.l  sinus,  as  rarely  hapi.ens.  or 
bee(.ineatteete,l  s. mudarily  by  extension  from  the  si>rnioi(i,  as  g(>n- 

erally  happens.  .1  •    i     t  »i  „ 

Otic  Cerebral  Abscess.  I'iti  stat.-  that  almost  one-thira  ot  the 
eases  of  brain  abseess  are  due  to  disease  of  tiie  temporal  bone.  Iho 
vast  maiorilv  of  ntie  eeiebral  abscesses  occur  in  tin-  teinporosphe- 
noid'il  l('.be  "  ( [''iff.  <«->.)     Thev  follow  chronic  middle-ear  suppura- 


■  j 

f1 


,    |.ri>„«ry  »b>ee>s  .•avitv  ..onnoct.^  with  sinus  in  tyn„«nlo  r.K).'.    J.  Secondary  «l>»cefs  ..avity  in 
lemporoM.I..-n..i.t«l  lobe.     Ilmh  aWess  oavi.it^  f.mn.l  free  (Vom  pns  at  nuto,*y.    '"  ''-"N  • 

tiou  from  seven  tii  nine  times  as  fre(|uently  as  the  acut(  process. 
Thev  are  jiei"M-allv  connected  with  the  diseased  temporal  bone  by  a 
tistulous  tra;  t.  (Viji.  ■")79.)  Korner  found  that  in  06  per  cent,  the 
abscess  lay  within  the  brain  and  was  separated  frnm  the  bone  }>y 

normal  brain  tissue.  ,..,,•,,• 

The  svm|)toms  of  bniin  abscess  have  been  divided  inl.i  lour  .stages: 
the  initial  latent,  manifest,  and,  hnally.  tli(>  terminal.  .\s  a  matter 
of  clinical  exi.eilence,  it  is  generally  only  th<'  two  latter  stages  tluvt 
come  under  observation:  the  first  two  stages  pive  rise  to  indeHnable 
symptoms  which  are  usually  attributed  to  the  middle-ear  disea.se  or 

lu  other  causes. 

Tl-.e  symptoms  during  the  initial  .stage,  according  to  Maccweii. 
are  otalgia  with  oxcniciatiiig  neuralgic  pains  radiating  from  the  eai-. 

74 


I 


mk^pn^ 


1170 


Tllh:  KMi. 


often  vomiting.  giMU'ially  a  rigor,  sliglitly  elevated  temperature  coated 
tongue  r)rostratioii,  and,  !us  a  rule,  the  otorrhani  ceases  or  lessen.''. 
The  symptoms  during  the  manifest  stage  are  of  most  miportance 
for  diagnosis,  for  it  is  genendlv  in  this  stage  that  the  patient  demands 
relief.     Von   Hergmann   has  cla.-isified   the  symptoms  of  this   stage 

1.  Genenil  Si/mptouis.  Lo.ss  of  appetite,  furred  tongue,  foul  breath, 
cachectic  appearance,  general  lassitude  and  weakness,  low  tempera- 
ture tend.ing  to  intermit.  There  is  u.-ually  no  rignr,  and  emaciation 
often  appears  as  the  disease  progresses. 

2.  Brain  and  I'l-e.^sitrf  Si/mptotn.^:.     Versi.stent  headache,  moderate 
and  referred  to  the  region Df  the    ihscess  or  to  other  i)arts;  often, 
but  not  invariably,  slowing  of  i)ul.s(«,  sometimes  fluctuating:  nausea 
and  vomiting,  dizziness,  constipation,  slow  cerebration,  and  (Irovvsi- 
ness  are  very  .;ommonlv  pre.seiit;  the  patient  is  incapable  of  sustained 
attention:  there  is  usually  no  delirium:  tenderness  on  i)ercussion  over 
the  affected  area  mav  beVrP-^ei't;  convulsions  of  the  extremities  and 
of  the  facial  of  the  opi)osite  side  may  appear  if  the  iiressure  is  con- 
siderable: oi)tic  neuritis,  usually  slight,  is  frequently  present,  more 
pronounced  on  the  at^ecteil  side:  respiration  is  regular  and  may  bo 
slowed.     Tlieic  is  occasionally  retention  of  urine  followed  by  ove--- 
How,  incontinence,  and  th(>  urine  sometimes  contains  albumin.    Th.' 
brain  pressure^  s(>ems  to  exert  an  inHu(>nce  in  lowering  both  the  tem- 
perature aiul  i)ul.se,  since  the  moment  jjivssure  is  relieved  by  evac- 
uation of  the  abscess,  Macewen  says,  there  is  a  sudden  rise  in  pulse- 
rate  and  temperature.     Hut  the  abscess  ..lay  exert  no  pressur>",  occu- 
pying the  s;)ace  of  the  destroyed  brain  ti.ss-,c.  and  in  this  ca-se  the 
slowing  of  pulse  and  subnormal  temi)erature  will  fail  to  appear.    The 
eyesight  is  seldom  much  affected.     Little  dependence  can  be  placed 
on  the  reflexes,  superficial  or  deep. 

3.  Local  Brain  Si/mptom.f  or  Localizing  Symptoms.  These  ;ue  only 
occasionally  present  because  the  abscess  is  situated  outside  of  the 
motor  area",  in  the  majority.  Oi  th<-  cranial  rerves  the  thir.l  or  inotor 
oculi  is  most  fre(iuently  implicated,  on  the  same  suie.  Hemiplegia 
of  the  opposite  side  is  occasionally  found  in  large  abscesses,  due  to 
pre.ssure  or  inflammatory  action.  ''  If  one  finds  paraly.^is  of  the  third 
nerve  on  the  same  side  as  the  lesion,  paralysis  of  the  opposite  side 
of  the  body,  commencing  in  the  face,  answering  to  the  tests  of  i)ar- 
alvsis  originating  in  'he  motor  cortex  and  remaining  most  marked  m 
the  facial  muscles,  then  involving  the  brachial  nniscles  to  a  less  ext(-nt, 
the  lower  limb  remaining  free,  and  all  these  being  present  without 
loss  of  sensation,  the  great  probability  is  that  the  lesion  is  a  arge 
one  situated  in  the  temjioial  lobe"  f Macewen i.  Facial  paralysis, 
when  central,  is  on  the  side  opposite  to  the  lesion,  and  cortical.  The 
pupil  is  generally  sluggish  and.  not  infrequently,  the  pupil  on  the 
«'une  side  may  either  liecome  myotic  or  mydriatic,  accompanied  by 
a  degree  of  stability.  Knapp  believes  hoim,..;  lous  hennanopsia. 
which  has  been  notell  in  seven  cases,  would  be  found  oftener  if  regu- 


rrnri.Ksr  imlammmios  <>i-  inn  Minin.t:  /•-i/.'.     1171 


f 


lurly  sought  for.  Aphasia  sometimes  accompanies  left  teinporosphe- 
iioidal  abscesses ;  sensory  aphasia  indicates  involvement  of  the  pos- 
terior portions  of  the  temporal  convolutions;  motor  aphasia,  mvolve- 
ment  of  hrain  near  the  fissure  of  Rolando.  Word  deafness  and 
psychic  l)lindness,  due  to  disturbance  of  the  first  temporal  coiivolu- 
tidn  and  angular  jivrus.  have  also  been  recordf-l. 

The  d  agnosia  is  generallv  not  possible  until  the  manifest  stage 
is  reached,  and  even  theirit  is  often  uncertain.  Emaciation  a^o- 
ciated  with  headache,  low  temperature,  slow  pulse,  and  constipation 
in  a  case  of  ciironic  j)urulent  (.titis  media  should  direct  attention  to 
the  brain.  Caries  of  the  tegmen  tympani  or  antri  is  a  matter  for 
investigation:  sometimes  ])us  may  be  seen  oozing  through  an  erosion 
in  the  tegmen  tvmpani.  The  presence  of  an  excessive  discharge  of 
pus  is  sometimes  significant.  The  diagnosis  is  made  easier  if  local- 
izing symptoms  make  their  appearance.  In  most  cases  the  abscess 
is  only  found  by  following  up  the:  infective  tract  from  the  nuddle 

The  duration  varies  from  two  to  six  weeks  from  the  time  of  its 
formation  in  the  case  of  an  acute  absce-«,  to  a  number  of  months  or 
vears  in  the  case  (jf  an  encapsulated  chi  )nic  abscess. 
"   There  has  l)een  recorded  but  one  case  of  spontaneoas  recovery 
from  cerebral  abscess.     If  not  interfered  with,  death  finally  results 
from  profound  exhaustion,  probably  the  most  common  termination, 
or  bv  rupture  into  the  ventricles  or  on  to  the  surface  of  the  brain, 
or  bv  the  development  of  complicating  sinus  thrombosis  and  menin- 
gitis'.    Death  occurs  with  gradually  deepening  stupor  and  coma  in 
case  it  is  due  to  cerebral  pressure  and  oedema.     If  rupture  into  the 
ventricles  takes  i)lace.   the  pupils  become  widely  dilated,  the  face 
livid,  respiration  greatly  accelerated,  the  temperature  rises  to  104  - 
105°' F.  and  the  pulse  to   120:  there  occur  mu.scular  twitchings  all 
over  the  bodv,  possiblv  convulsions  and  tetanic  seizures,  followed 
bv  coma  and  "death  in  from  six  to  twelve  hours,  as  a  rule.     Rupture 
on  to  the  surface  of  the  brain  sets  up  an  acute  leptomeningitis,  unless 
•idhesion  of  the  membranes  has  i)revi(Uisly  taken  place,  in  which  case 
the  pus  mav  find  its  wav  to  tiie  skull  wall,  and  so  externally.     E-en 
when  discharge  of  the  p"us  thus  takes  place  through  the  bone,  it  is  a 
(luestion  whether  permanent  recovery  ever  takes  jjlace. 

The  result  of  surgical  interference  is  very  promising  if  the  pus  ca>i 
be  thoroughlv  evacuated  and  the  abscess  cavity  rendered  aseptic. 
Often  there  is  left  behind  no  impairment  of  the  mental  or  bodily 
functions.     Macewen  obtained  8  recoveries  in  10  temporosphenoidal 

ab.scesses.  ,    ,      ^t  r 

The   tempor<)si)henoidal   lobe   may    be   uncovered    by  the   use  o 
the  trephine  or  bv  continuing   fhe  use  of  the  hammer  and  chi.sel 
upward  from  the  niastoid  woun.l  to  the  s(iuama,  the  mitstoid  incision 
h'lving  bion  previously  s-xtended  uinvard   for  a  suffiru-nt  distance 
iti)()ve  the  auricle.     (Fig.  BO.'i.)     In  every  case  the  antnim 


i]ient 


■d  first  and  the  middle-ear  cavities  Explored,  especially  over  the 


117-2 

tcniiicii  nf  the  tyiii|i:iiiui 


Tin-:  F.M!. 


tract.     If  ^'U{•ll  a  tract  is 
cotiforiM  to  tlio  iliroctiou 


II  and  aiitniin,  for  the  presence  of  a  fistulous 
found,  the  ();)eratioii  should  be  extended  to 
it  tak( 


lous  tract,  tlie  oi)erator  may 


Without  the  existence  of  a  fistu- 

chisel  upward  from  the  mastoiil  wound 

I  foi-  an  area  large  enough  to  admit  the  hiting 


until  tlie  dura  is  expose( ^ ^-  .. 

Made  of  a  pair  of  Imne  forceps,  after  which  thorough  an<l  extensive 
exi)osure  is  ea.sy.     The  exi)()sure  of  the  dura  should  he  sufficient  to 
make  possible  t"he  thorough  exploration  ot  the  tegmeii  tympani  and 
antri      The  .lura  is  to  be  rendered  thoroughly  asei)tic  by  scraping 
otT  granulations  and  treating  with  antise|)tics  before  the  attempt  is 
made  to  explore  the  brain  through  it.    The  dura  wnll  usual  y  be 
fo-   'd  discolored  ov<t  the  site  of  the  abscess  and  the  brain  .should 
be  incised  with  a  straight  bistoury  at  the  centre  of  the  (hscolored 
area  care  being  taken  not  to  penetrate  far  enough  to  endanger  the 
ventricle:  the  knife  mav  be  carried  to  a  depth  of  one  inch  with  safety. 
Macewen  recommends  "the  use  of  an  exploratory  camda  devised  by 
iiimself  ■  but  it  s(>ems  to  th"  writer  that  the  bistoury  is  more  certain 
and  no  more  ilangerous.     If  the  abscess  is  of  considerable  size  it  will 
produce  bulging  of  the  brain  into  the  bone  opening,  which  may  help  to 
locate  the  abscess.     In  oi)eniiig  the  dura  do  not  extend  the  incision 
quite  t<.  the  margin  of  the  bony  oix'ning,  so  that  if  a  vessel  is  divided 
it  mav  be  easily  secured.     If  the  trephine  is  used,  the  centre-pin  of 
a  half-inch  trephine  is  placed  at  a  point  three  quarters  of  an  inch 
above  the  posterior  root  „f  ;l,e  zygoma  on  a  line  with  the  posterior 
wall  of  the  external  osseous  canal.     Personally  the  writer  prefers  the 
method  of  enlarg(>ment  of  the  mastoid  wound  with  the  hammer  and 
chisel  and  bone  forceps:  the  aperture  may  be  made  large  enough  to 
meet  anv  indications.  ,        ,    ,  *    i      1 1     + 

\fter  the  aliscess  has  been  incised  and  the  i)us  evacuated,  a  blunt 
curette  or  a  pair  of  forceps  should  be  used  to  remove  any  sloughs  that 
have  not  been  ( arried  out  bv  the  |)us.     .\t  the  present  time,  the  pre- 
l)onderanee  of  opinion  seems  to  be  against  washing  out  the  abscess 
cavitv      If  washing  out  seems  desirable,  then  a  very  weak  anti.septic 
s,',luti(.n  is  to  oe  svringed  gently  into  the  al)scess  cavity  through  a 
camil-i   alongside  o"f  which  a  much  larger  canula  for  the  outflow  has 
b'een  simultaneously  inserted.     If  any  resistanro  to  the  current  is 
met  with  the  tubes  are  to  be  withdrawn,  cleansed,  and  the  attempt 
made  over  again.     No  force  is  to  be  used,     .\fter  the  stream  returns 
dear  the  head  should  be  inclined  to  the  affected  side  to  drain  out 
the  fluid  before  withdr.awing  the  tubes.     Whiting  has  invented  an 
in«trutTient  which  he  calls  an  encephaloscope,  consisting  of  a  tube 
with  an  obturator,  for  the  purpose  of  examining  the  interior  of  the 
abscess   cavilv   and,   on   withdrawal,   the   fistulous   tract.     He   also 
introduces  gauze  drains  through  it.     Decalcified  bone  drainage-tubes 
„,.,.    :  p  u^od  or  the  c.avitv  mav  be  lightly  packerl  wath  gauze,  after 
dusting  with  the  iodoform"  and  boric-acid  powder.     The  outer  dress- 
ing'^ are  the  same  as  for  the  miustoiil  operation. 
If  all  goes  well  the  first  dressing  may  be  left  m  place  for  a  week 


iTiiii.i:\r  i.\Fi..\MMrrin.\  dh  mi:  Miinn.h.  i:.ii!      n;:'. 

„r  so.  proviil.'d  tiu'  t.-mperiiture  is  iiorinal  and  tlietc  is  no  stain  thn.iijili 
tl.c  dressings.  .Xftt-r  the  first  dressing,  the  wound  sl.ould  he  dressed 
daily,  with  or  without  syringing.  If  lewder  is  used,  hone  aeid  shouhl 
now  be  sul)stituteil  for  iodoform  to  avoid  iodoforinisni.  Ihe  i.iitient 
sliould  he  Itept  in  hed  for  from  fo  r  to  six  weeks  and  on  a  milk  or 
fluid  diet  for  two  or  three-  weeks.  If  the  bowels  have  not  moved 
spontaneously  hv  the  end  of  a  w<>ek  a  mild  purgative  shor.ld  he  given. 
The  patient  should  not  be  permitted  to  leave  the  recumbent  posture 
until  the  wound  is  well  on  the  road  to  healing. 

After  ev'icuation.  the  absn-ss  walls  sink  into  iipiK.sitioii  and  the 
eavitv  becomes  .(uicklv  obliterated,  as  a  rule.  Often  adhesions  form 
between  the  brain  and  dura  or  fibrous  tissue  at  the  «/pening  m  the 
bone;  sudden  movement  is  then  apt  to  cause  shock,  with  faintncss  or 
transitory  unconsciousness. 

Otic  Cerebellar  Abscess,  .\bscess  of  the  cerebellum  occurs  usually 
in  one  hemisi.here,  generally  in  the  anterior  portion  The  majority 
are  in  more  or  less  direct  contact  with  the  sigmoid  sulcus  Kocli 
believes  many  of  the  abscesses  occurring  in  connection  with  chronic 
middle-ear  supjxiration  are  acute  abscesses  caused  by  a  rtmidescence 
of  the  trouble.  , 

The  general,  brain,  and  brain  pressure  symptoms  are  much  tne 
same  as  in  cerebral  abscess.  Localizing  symptoms  may  be  altogether 
wanting,  and  frequently  are.  ,      ,    .     • 

Excessive  vomiting  is  more  apt  to  be  pn-seut;  headache  is  never 
wanting  and  is  usuallv  occipital,  but  may  he  referred  to  other  parts; 
the  speech  is  sometimes  jerkv  and  syllabic:  optic  neuritis  may  be 
present,  but  is  of  n.)  special  significance.     Marked  dizziness  is  present 
in  about  one-third  of  the  Ciuses.     Macewen  attaches  significance  to 
rigidity  of  the  masseters.     There  are  disturbances  m  eqmlibnum,  in 
eait,  in  breathing,  and  ii.  motor  speech.     Amaurosis,  without  atrophy 
of  the  optic  nerve,  mav  be  i)resent.     "There  may  be  total  blm.lness, 
prohablv  attributable  to  severe  hydrocephalus  mternus.     .\.s  no  case 
of  temporal  abscess  has,  as  vet,  been  accompanied  by  double  amau- 
rosis, this  coPU)lication  is  of  diagnostic  value"  (Koch).     Convulsions 
occur  esijcciallv  m  children,  and  probably  indicate  the  presence  ot 
internal  hvdrocephalus.     Paresis  of  the  facial  nerve  of  the  same  side 
mav  occur     .Vs  meningitis  develops,  retraction  of  the  head  and  neck 
makes  its  ai.ix-arance.     Heri)es  facialis  was  present  in  Ca.se  Xl>.  ot 
Macewen's;  the  patient   died.     Macewen  notes  that   patients  often 
vomit    when  raised   from   the   recumbent    posture.     Weakening  or 
paralvsis  of  the  bladder  and  rectum  are  more  apt  to  occur  than  in 
cerebral  abscess.     (Vrehellar  abscess  only  occasionally  involves  the 
motor  oculi.     1  )ouble-sided  involvement  of  the  cranial  nerves  is  rare : 
rarer  still  is  crossed  affection  ..f  the  nerves.     The  nearer  a  cerebellar 
abscess  reaches  to  the  middle  line,  the  more  it  is  ai)t  to  produce  f<ical 

symptoms. 

"  If  the  abscess  occurs  in  the  pons,  localizing  symptoms  may  nut 
appear  unless  the  abscess  is  large,  in  which  case  crossed  hemiplegia. 


1174 


Tilt:  EMI. 


(louhU!  hoiniplcKiii.  t>r  other  liiU-ra!,  hiliitcnil,  or  shifting  palsien  may 
1*0  prospnt,  apcdrding  t(i  Derciini.  OculoinDtor  symptoiiiM  may  aluo 
exist.  In  come  cases  the  syinptonus  present  arc  referable  to  the  over- 
lying meningitis,  the  abscess  itself  producing  no  symptoms,  or  the 
abscess  symptoms  are  masked  and  ovcrsluulowed  by  those  of  a  coex- 
isting sigmoid  sinus  thrombosis. 

Koch  noted  a  clo.se  following  of  the  al>8cess  u|)on  the  ear  affection 
in  one-half  of  the  cases.  In  others  the  interval  may  vary  from  sev- 
eral weeks  to  .several  months.  The  length  of  the  terminal  stage  varies 
from  three  days  to  two  and  one-half  months,  the  average  being  two 
weeks.  Macewen  observed  one  case  in  which  abscess  symptoms  had 
l)een  present  for  eleven  months. 

In  one-half  of  the  cases  the  final  cause  of  death  Wius  not  determined ; 
meningitis  caused  death  in  one  (juarter,  progressive  encephalitis  in 
some,  rupture  into  the  fourth  ventricle,  hydrocephalus  interims, 
sinus  phlebitis,  or  some  other  complication  in  others  Death  .sonu"- 
times  results  from  the  encroachment  of  the  abscess  uiion  important 
centres,  such  as  exist  in  the  medulla. 

As  with  cerebral  abscess  so  with  cerebellar,  the  diagnosis  is  usually 
only  determined  with  certainty  by  operative  investigation. 

The  natural  termination  is  in  death;  by  means  of  operative  inter- 
ference about  50  ])er  cent,  of  the  cases  may  be  saved. 

The  treatment  consists  in  operation.  Tlie  horizontal  incision  jiom 
the  mastoid  incision  is  carried  backward,  so  as  to  uncover  the  occip- 
ital bone  over  the  situation  of  the  cerebellum.  The  sigmoid  simis 
is  then  uncovered  for  investigation  and  the  Iwne  wound  continued 
backward  over  the  cerel)ellum  by  the  use  of  the  bone  fcjrceps.  As 
most  cerebellar  absces.ses  are  .situated  in  the  inmiediate  neighborhood 
of  the  sigmoid  groove,  the  operation  through  the  mastoid  has  great 
advantage  over  the  method  of  trephinirg  behind  the  process;  it  also 
enables  us  to  examine  the  sigmoid  sinus  at  the  same  time.  The 
remarks  made  as  to  locating,  evacuating,  and  dressing  cerebral  i  bscess 
also  apply  to  cerebellar.  In  the  latter  large  sloughs  of  brair  tissue 
in  the  abscess  cavity  are  rare. 

In  operating,  sometimes  suspension  of  breathing  suddenly  occurs, 
due  to  the  ana'sthetic  increasing  the  cedematous  condition  of  the 
brain.  When  this  hai)pens.  the  operation  should  be  quickly  pro- 
ceeded with  to  evacuate  the  abscess  and  relieve  the  pressure  exerted 
on  the  respiratorv  centre,  meanwhile  using  artificial  respiration.  If 
the  period  of  anaesthesia  is  shortened  by  the  preliminary  adminis- 
tration of  nitrous  oxide  gas  this  unfortunate  occurrence  is  less  apt 
to  manifest  itself. 

Differential  Diagnosis.  The  fact  of  the  existence  of  suppurative 
])rocess  in  the  middle  ear  is  of  great  help. 

In  ieyitomcningitis  there  are  hiph  temi>eraturf'  and  rapid  pulse 
without  marked  remissions,  irritability,  general  excitement,  restless- 
ness, and  hvperresthesia  of  the  sensorium. 

In  inf(>ctive  sinus  thrombosis  there  are  mental  depression,  rigors, 


iTiiri.Hsr  i.\hi..niMMii>.\  of  int.  Minin.t:  h:.\H      uto 

coiistiiniti.;..,  iruiik...lly  HucUmting  fcbrili-  inuvf.nont .  an.l  in      ilur 

freniicnt  pulse.  .     .  ,  i        ,  , 

It  t  e  tl'mi.(.roai)hcM..i.lal  abscess  W  large  we  may  liuvc  oculo.   .,tor 

an.l  uupillarv  eha.iges.  weakness  and  convulsions  of  the  opi   -site 

side  of  the  r)o<ly.  perhaps  various  forms  of  aphasia,  and.  pos^  hlv, 

"'Tn  mehenar  .l.scess  there  arr  exces.-ive  vomiting,  rigi.lily  ol  he 
back  of  the  neck.  9t:iggering  gait,  "cerebellar  sper.h.  and  vert  -o. 
In  both  brain  abscesses  there  are  slow  pulse  and  low  fever  sonte- 
times  subnormal  temperature,  slow  cerebration,  apathy,  and  droxysi- 
„ess'  but  the  fact  that  more  than  one  intracranial  patlu.logic«l 
o^idition  often  coexists  in  th^  same  patient  should  n-  ver  be  oyer 
locked,  and  we  shoulo  Ije  guided  in  our  u.agn.  '  uper.Un 

interference  by  the  remembrance  of  this  fact. 


CIIAI'TKW     XXVIII. 

(  llltoNK    N(»N-SIIMMI!.\riVK  \i!l>l>l,K  KAII  lUSKASK. 

Bv  AHTmii  II.  CmiATLi:.  F.K.C.S.  Km; 

Kzamination  of  the  Patient.  riii!<  .should  Im>  cairicii  out  with 
gri'iit  ciin-  anil  lliiirdunhiicj^s  in  iinlcr  that  a  proiHT  (liajjnosis  ran  U' 
made,  anil  al.>*t)  that  the  surnt-oii  should  he  ahlc  to  jfivc  a  |)roKnosis, 
which  is  often  of  ^n-at  nioiiiciit. 

The  family  history  siiould  Ih'  hist  in(|uircil  into  for  evidence  of 
heredity.  The  life-history  of  the  patient  liiinself  must  then  Ix-  inves- 
tigated from  a  ^reneral  point  of  view.  Then  will  follow  the  hi.story 
of  the  mode  of  on.set  and  |)rojtress  of  the  annd  trouhli'. 

.\ll  thes<>  things  haviiiK  In-en  noted,  the  examination  of  the  patient 
can  l)e  maiie.  This  is  never  complete  unles.s  both  i-ars,  the  no.se, 
the  pharynx,  the  nasopharynx,  tojjether  with  the  jjeneral  health  and 
surroundinjts  have  t)f>en  minutely  in.spectod  and  in(|uired  into.  It 
i.s  always  wise  to  make  careful  notes  and  drawinir-s  as  Jie  examina- 
tion proceed.^. 

The  lliiirinij  I'ouir  Must  hr  Mmniina.  l'"or  this  various  methods 
are  used,  the  most  useful  Iwinj;: 

1.  The  Watch.  It  is  useful  to  have  two.  one  with  a  very  loud  and 
the  other  with  an  ordinary  tick;  both  must   have  \tovu   carefully 

ineasjired  with  normal  hearing 
in  order  that  eacl.  ,  ay  have  its 
standard.  In  t(s,mK  with  the 
watch  (or  in  any  other  test) 
the  eye.s  and  the  ear  not  under 
examination  should  1h>  closed, 
.iiid  the  w;itch  liaviii^  been 
placed  close  to  the  ear  for  the 
patient  to  :i|ipreciMte  what  he 
is(>xj)ected  to  hear,  should  then 
1h>  taken  to  the  extreme  ranjte 
and  slowly  approacheil  until  it 
A'lNiiniUT  is   heard,    the   <listance    being 

measured  l)y  a  tape  measure. 

2.  The  Voice.  The  whisper  and  ordinary  conversational  voice  and. 
if  n(!ce.s.sary,  shoiiting  should  be  u.sed.  "'Ms  method  is  a  u.seful  but 
rough  one,  a.«  it  is  almost  iiiip(i,<sil)Ie  to  liuuge  the  voice  acour.ately 
lor  each  exammation. 

.'^  The  Acoumeter.  I  Fig.  ().^'i.  I  Th.s  little  iustrumc  .  invented  by 
Pulitzer,  is  of  great  value,  as  the  note  struck  is  alwavs  of  the  same 

iIITli) 


riii:i>\ir  \'i\  sii-i'i  i;.\rni:  Mihin.nh.Mi  hi>i:A^h:    |I77 


•t'  iiliuut   fully  tVct   ill  a  i|iiiet  roi 


Thr 


vuliir.     It   lias  a  lanp-  nt   aMuu  . 

iiiohilityiif  tin-  iiii-mbrai.a  tyiiip'iii  aiul  iiiallciis  should  hr  li-stcd  liy 
usinj!  SicRlcV  piiciiniatic  spcculimi  {\'\n.  M\).  with  whicli  the  Ih'- 
havicir  of  llic  incinliram-  when  thi'  cohimii  of  air  in  the  iih'o'is  is 
cxhaiistnl  or  coiiiiirrsscil  rail  Iw  cxainimMl. 


Sleglc'n  pneumgtlc  «jieciiliim 

The  heuriiig  power  in  these  several  ways  having  In-en  tested  it 
is  neeessary  to  establish  the  diagnosis  of  middle-ear  from  internal- 
ear  disease.  The  history  of  the  onset  and  eause  of  the  d  less  will 
aid  considerably. 

1.  In  middle-ear  disease  definite  changes  in  the  membrane  are 
sometimes  seen.  Internal-ear  disease  is  often  marked  by  attacks 
of  vertigo  and  vomiting,  the  special  f)oint  regarding  true  labyrinthine 
-.ertigo  lieing  fh'it  objects  appear  to  move  in  one  direction  or  another. 
Vertigo  is  not  found  in  uncomplicated  middle-ear  diseases.  In  middle- 
ear  disease  the  deaf'ii'ss  is  markedly  aorse  during  a  cold,  in  internal 
little  or  no  increase  is  noted.  Paracusis,  or  hearing  better  in  a  noise, 
is  pathognomonic  of  middle-e;<r  affections  in  their  later  stages;  in 
internal  the  hearing  is  betli-r  in  a  quiet  room,  a  noise  confusing  the 
patient.  H  )Ughlv  speaking,  in  middle-i-ar  troubles  low  tones  are 
badly  heartl,  while  the  convf  ise  holds  in  internal:  in  comi)anng  the 
hearing  distance  for  the  watch  and  voice  this  sign  is  often  of  value 
in  the  difT(>rential  iliagnosis.  In  order  that  this  may  be  more  accu- 
rately tested  the  following  may  be  used: 


limit 


i-t|:    (Fig.  ();io)  is  u.sed   for  testing  the  ui)pei- 
•^  -"V  of  value  if  the  deafness  is  extreme.     It 


117H 


■/•///•,'  /•;.i/.'. 


has  a  range  from  tlie  liighe.st  appreciable  pitch  to  near  the  rnediuii], 
Th(>  whistle  is  made  by  comi)ressing  the  rubber  ball,  the  pitch  being 
varied  and  measured  by  turning  the  cylinder. 

.4  seric!'  of  tuning-forks,  such  as  Bezoid's  or  Hartmann's,  for  testing 
the  lower  and  middle  ranges.  Hartmann  ha.s  a  set  of  five  fork's- 
V.  r  +  1,  C  +  2c,  C  +  3,  C  +  4. 

In  middle-ear  disease  the  deafness  never  becomes  absolute  as  in 
internal.  As  a  rule,  the  patient's  own  voice  is  heard  loudly  in 
middle,  while  in  internal  it  may  not  be  heard  at  all,  so  that  if  it  is 
of  long  standing  and  bilateral  the  voice  becomes  monotonous;  again 
if  one  ear  is  affected  with  internal-car  disease  the  voice  will  not 
be  heard  at  all  on  that  side,  but  will  seem  to  travel  over  to  the 
other. 

On  gently  scraping  the  membrane  in  advanced  internal-(;ar  disease 
The  action  will  be  felt,  but  not  heard.  Inflation  of  the  middle  ear 
lenders  the  hearing  vorse  when  the  internal  ear  is  affected. 

In  the  normal  ear  nir  is  better  than  bone  conduction.  In  middle- 
tar  disease  the  bone  conduction  is  increased  and  is  better  than  the 
aerial,  while  in  internal  bone  conduction  is  diminished  and  the  aerial 
is  better  than  the  b(  ny. 

These  phenomena  are  tested  in  various  ways  by  means  of  the 
tuning-fork,  a  C2  being  the  best  to  u.se  for  the  purpose,  as  it  is  free 
from  overtones. 

1.  Schwabachs  Test.  In  this  method  the  length  of  time  the  tuning 
fork  is  heard  on  the  mastoid  of  the  pati.'iit  is  comjiared  with  that 
of  the  observer,  whose  hearing  must  be  normal. 

If  the  tuning-fork  is  heard  on  the  surgeon's  mastoid  after  it  has 
cea.sed  to  be  heard  on  tliat  of  the  patient  it  demonstrates  that  bone 
londuction  is  diminished  and  that  internal-ear  trouble  e.xists.  while 
if  the  patient  can  hear  it  after  the  surgeon,  bone  conduction  is  in- 
creased and  indicates  middle-ear  disease. 

The  number  of  seconds  of  increa.se  or  diminution  arc  counted  and 
noted. 

2.  Weber  8  Test.  In  tiiis  test  the  vilnating  tuning-fork  is  ])laced  on 
the  middle  line  of  tlie  skull,  vertex,  bridge  of  no.se.  or  incisor  teeth. 
Tf  one  ear  is  affected  witli  middle-ear  di.sease  the  sound  will  be  heard 
l)rincipally  in  th.at  ear.  wliile  if  botii  are  affected  an-!  one  is  markedly 
worse  than  the  other,  the  .sound  will  be  heai'd  better  in  that  which  is 
more  affected.  If  the  internal  apparatus  of  uiw  ear  is  affected  the 
sound  will  be  heard  lou<ler  than  in  the  normal,  while  if  both  are 
atfected  with  internal-ear  disease,  and  one  is  much  worse  than  the 
other,  the  sound  will  he  louder  in  the  less  affected  ear. 

If  confusion  should  ever  arise  in  the  mind  of  the  student  in  con- 
nection with  this  test,  or,  indeed,  in  any  of  the  others,  the  clue  can 
readily  be  found  if  the  student  closes  one  of  his  own  ears  with  the 
finger,  thus  imitatins:  middle-ear  deafness,  and,  on  placing  the  vibrat- 
ing fork  on  the  middle  line  of  the  cianium,  finding  that  the  .sound  is 
louder  in  the  closed  ear. 


ciiHosic  .\<>.\.srri'ri!ATi\i-:  miodle-eah  i>ise.\sf..    nvii 


p  ■ 


3.  Einne'8  Test.  With  tliis  the  air  aiul  bono  conduction  are  com- 
pared. If,  in  the  normal,  when  the  fork  has  cea-sed  to  be  heard  in 
the  mastoid,  it  be  removed  and  the  pronps  are  placed  in  the  air  close 
to  the  meatus  the  sound  will  be  heard  again,  showing  that  the  air 
is  better  than  the  hone  conduction.  This  is  called  positive  Rinne, 
;ind  indicates  either  a  normal  ear  or.  if  deafness  is  present,  some  affec- 
tion of  the  internal  ear.  while  if  it  be  heard  on  the  ma.stoi(l  after  it 
has  ceased,  when  placed  in  the  air  close  to  the  (>ar  {negatire  Rinne) 
b(ine  conduction  is  increased,  thus  indicating  a  middle-ear  affection. 

4.  Gardiner  Brown's  Test.  This  test  is  based  u])on  the  fact  thai, 
given  trained  fingers,  the  vibration  of  a  middle  C  timing-fork  placed 


■  .aMiner  Bniwn's  t\inin(;-fnrk  ;  mliidle  C,  of  r>12  vlbratioiu  per  stoind  lone-third  imlural  sizei. 

un  the  mastoid  in  a  normal  case  can  be  jell  by  the  surgeon  for  pre- 
cisely the  same  length  of  time  as  they  can  bo  heard  by  the  person 
under  observation. 

In  the  middle-ear  .affection  the  sound  will  be  heard  longer  than 
the  vibraticins  can  be  felt,  while  in  internal  the  vibrations  can  be 
felt  for  a  more  or  less  period  after  the  sound  has  ceased.  This  plus 
or  minus  should  be  counted  in  seconds  and  noted. 


Fl,i.  iMT. 


Anwultntinll  ,JiHKil,)Vli,'  till,,'. 

A  diagnosis  of  middle-i'ar  disease  hav- 
ing been  iiuido  the  middle  ear  should  be 
inflated  through  the  Eustachian  tube  by 
me.-iiis  of  I'olitzer's  bag  or  a  Kustachian 
catheter.  During  inflation  a  diagnostic 
tuU'  should  be  used,  passing  from  the 
patient's  to  the  surgeon's  ear,  in  order  that  it  may  be  certain  that 
the  inflation  is  efficient,  that  any  obstuction  can  lie  not«d,  or  that 
fluid  in  the  tube  or  middle  oar  can  be  diagnosed. 


IIMO 


/■///•:  i:ai;. 


Politzers  Bag.  Tlic  most  iisct'iil  is  ;ni  ci^jlit-ouncc  one  witli  Prii- 
chanl's  nosc-picrc  wliicli  is  mjidc  of  vulcanite  and  coiiiicctcd  witli 
the  nozzle  of  tlic  liag  hy  means  of  a  i)iccc  of  i  Mlia-nihticr  tul)in)r. 

Tlie  iiictlioii  of  lioiiiinj;  the  haj;  is  well  sliown  in  the  acfompanyiiiu 
cut.  Tlic  haj;  is  (•omprcs.<('(|  wliilc  a  sip  of  water  is  l)einji  .'swalloweil, 
or  when  tlie  cliei'ks  are  blown  out.  or  on  saving  "liic;"  all  thre(' 
methods,  hy  (>levatiiiK  the  .soft  palate  and  tluii  shutting  off  the  na.so- 
pharynx  from  the  i.harynx,  compel  the  air  to  enter  the  Ilustaehian 
tuhes. 

If  one  ear  only  is  to  he  inflated  hy  this  method  the  j)atients  hea.i 
siiould  !)(>  turned  on  one  side  with  the  affected  ear  uppermo.st  and. 
with  the  finger  closinji  the  sound  ear.  inflation  should  he  practised 
through  the  nostril  corresponding  to  the  affi-cted  side. 

Eustachian  Catheter.  The  most  useful  catheter  is  a  short  silver 
one  whicli  caji  he  hoih'd. 


Km.  ii:i«». 


KuMui'hiuii  rathi'ler 

The  most  certain  way  of  intro(hicing  it  is  Loewenbeig's.  .Uter 
tilting  up  the  jwint  of  the  no.se,  the  instrument  with  the  point  hori- 
zontal is  passe<l  over  the  elevation  of  the  ticjor  of  the  vestil)ule  to 
reach  the  floor  of  the  nose,  the  outer  end  is  then  brought  up  hori- 
zontally and  the  instrument  pa.ssed  liglitlv  along  to  th<>  p().sterior 
tiasopfiaryngeal  wall,  when  the  beak  is  turned  horiz(jntallv  inward 
and  gently  withdrawn  until  the  back  of  the  .sep'r-u  is  fi-lt.  The 
beak  is  then  rotated  downward,  outward,  and  upv.  i  .  until  the  ring 
on  the  outer  end.  whicli  corresponds  to  the  beak,  ixiints  to  the  outer 
canthus  of  the  con-esponding  eye.  .\ir  is  then  blown  through  the 
catheter  by  means  of  a  suitable  bag. 

If  the  tube  is  found  to  be  much  obstrm'ted  it  may  be  necc.-^sarv 
to  intro(hrce  fluids  or  a  hoiif/if  through  the  catheter. 

Before  introducing  the  latter  accurate  measurements  nmst  be  made 
m  the  following  way  before  passing  the  catheter.  The  bougie  should 
l)e  pa.ssed  down  the  cathet<-r  until  the  point  just  ajipears  at  the  imier 
or  tube  end:  rm  ink  mark  is  then  made  uii  the  bougie  at  the  point 
corres|)onding  to  the  entrance  of  the  outer  end.  and  frotu  this  ink 
mark  the  length  CM  t(j  :iii  mm.)  of  tiie  llu.stachian  tube  is  m.'asured 
off  and  again  marked.  In  this  way  can  be  told  (n)  that  the  bougie 
IS  at  the  month  of  the  Eustachian  tube,  i/l)  how  far  uj)  the  tulte  the 
bougie  has  i)a.>;sed,  and  (c)  at  whicli  part  of  the  lube  ob.stniction  is 
most  marked.  The  passing  of  the  bougie  shoiiM  he  doii''  gentlv  .Mnd 
111  a  rotatory  manner  when  passing  through  the  tube.  Lubricating 
the  bougie  with  paroieine  before  intro.liiction  will  be  found  uscfuL 


f///.'o.v/r  so.\-siri'ii!.\Ti\h:  Minnr.KiiMi  disi-.ask.    hm 

AtttT  inflation  lias  Ijccii  effected  tlie  rostilts  on  the  membrane  must 
he  inspected  and  tlie  liearinp  jiower  ajiaiii  measured  and  noted.  Th(! 
effeet  on  tinnitus,  if  |)resent,  should  lie  iiKjuired  into. 


ViTtiiai  Mitioii  ot  the  imsoplmryiix,  «iih  tin-  iiitheler  intrixluiiil  liUo  tlic  Kustachmn  lube.  A 
Inleri.T  t\irl.i.i..te<l  hone  II.  Mi'Mli'  tiirhiiwH'il  bciiu'.  C.  l^tlperior  turhilialeil  hone.  P.  Hani 
palate  E.  Vtliini  paiali.  F.  I'DMerlor  phnrj-HK™' ««"•  u  l<nscniii(lller'sf.)«sa.  U  Posterior  lip 
•  f  ilit'oritii'i'  (it  the  Kustnchiaii  t\il>e     .Phi.itzki:  i 

The  effeet  of  massnur.  of  tiie  membrane  by  means  of  Siegie's  specu- 
lum or  D(l>tanclie's  masseur  jiently  npplieil  on  hearing  and  tinnitus 
-sliouhl  be  inve.stigated. 

Ki(i.  mi. 


Itelstanche's  masseur. 


Jl 


\IH2 


/'///■;  EAH. 


Massafte  may  be  api)lie(l  under  two  conditions 
1.   With  Ihc  vieaial  air  exhamlcd,   \vl 


ind  in 


fus  will  he  niostiv  affected. 


len   liie  niembrane,  in: '1 


eu- 


2.  With  the  mcatal  air  compressed,  when  the  stapes  is  thuiirht  u 
i)e  reached.' 

Classification.  Difiieuitv  is  always  experienced  in  chissifvingiu,ii- 
supjmrated  nii<idle-ear  di.sea.ses  on  a  patholo<;ical  basis,  as.'aithou.'ii 
p-eat  advance  lias  been  made  of  late  years,  tiie  ojjportunitv  for  inves- 
tigation m  their  earlier  stages  is  neces.sarily  rare.  The  followiiii; 
must  therefore  be  acceftted  tentatively  and  tor  purposes  of  descri]" 
tion.  Clhiically,  it  is  often  difficult  or  impo.ssiblc  to  draw  haiil-;tii,|- 
fast  lines  between  them: 

A.  Hypr-rtroijliie  catarrh. 

1.  Chronic  catarrh  of  the  Kustachian  tube. 

2.  Cliroidc  catarrh  of  the  middle-ear  tract. 

B.  Atrophic  catarrh  or  sclerosis. 

C.  Changes  in  the  lining  membrane  due  to  variations  in  pressun-. 

D.  Changes  in  the  lining  membrane  due  to  deficient  blood  su|)ply. 
A.  Hypertrophic  Catarrh.     This  is  a  di.sea.se  which  has  its  ori<'iii 

prmcipaliy  in  early  life,  having  for  its  chief  characteristics  deafnT— 
a.ssociated  with  definite  changes  in  the  membrana  tvmpani.  and  sonn 
pathological  conditions  in  the  nose  or  nasopharynx. 
Causation,     The  causes  must  Ix'  any  condition  which  will 

1.  Predispose  to  attacks  of  acute  catarrh. 

2.  Teiid  to  make  acute  catarrh  become  chronic. 
'.i.  Maintain  a  chronic  catarrh. 

The.se  cau.ses  may  be  local  or  general:  the  local  condition  abov. 
all  others  is  chronic  liyi)ertrophy  of  the  iia.sopharvngeal  tonsil  (aden- 
oids), a  disease  chieHy  of  childhood  ami  earlv  life,  although  not 
uncommon  in  middle  life,  and  occasionally  met  with  at  a  much  later 
period.  Hypertrophied  tonsils  (although  often  associated  with  aden- 
oids), if  they  are  present  alone,  will  help  to  maintain  a  chronic  catarrh. 
Other  local  causes  are  secondary  syphilis,  true  or  false  hypertro])h\- 
of  the  turbinal  bodies,  suppuration  in  accessory  cavities  df  the  nose, 
atrophic  rhinitis,  nasal  polypi,  irritation  due  "to  noxious  fumes,  to- 
bacco, etc.  The  general  causes  are  exixisuie  to  wet  and  cold,  aiuemia. 
tubercle,  in  fact  any  disease  which  lowers  the  vitality  of  the  organism, 
rendering  infection  ea.sy  and  hindering  return  to  a  iiormal  condition. 

Pathology.  In  considering  the  pathology  ,,i  this  disease  we  will 
consider  shortly  what  a  catarrh  is  and  what  changes  are  produced 
by  it:  but  liefore  doing  .«o  the  reader  may  be  reminded  that  tin 
lining  membrane  of  the  niiddle  ear  consists  of  three  lavers- 

1.  I';pithelial. 

2,  Subepithelial,  containinj;  lymphatics,  nerves,  and.  comparatively 
speaking,  large  bloodvessels. 

.'{.  Fibrous,  which  is  adherent  to  the  hones. 


TrHllsiicf.n^^  of  ill.ilngicii'  ConKri'ss,  l.^M, 


ciuioMc  .vo.v-.s/'/'/t/my/ia;  Minin.K-H.m  inshAsH.    iih;{ 


All  aculo  i-atarrh  is  an  acute  iiiliaininat;.yii  of  a  mucous  membraue 
due  to  either  injury  or  infection.  At  present  we  are  unable  to  say 
(Jefiniteiy  wiial  niicro-orsiuiism  will  produce  catarrh:  but,  as  far  as  is 
known,  any  pathogenic  organism  has  the  power. 

Th(!  immediate  result  of  infection  is  acute  swelling  and  reddening  of 
tht;  membraue,  due  to  the  engorgement  of  vessels  and  the  presence 
of  exudation,  especially  in  the  subepithelial  laye.-.  Exudation  is  also 
poured  out  from  thesurface,  being  serous,  s'romucoid,  or  chieHy 
nmcoid.  At  this  point  resolution  may  take  place,  leaving  ik  trace, 
the  I'xuilation  in  the  subepithelial  layers  being  carried  off  by  the 
lymi)hatics,  and  t!ie  vessels  returning  to  their  normal  size.  But  if. 
from  some  local  or  general  cause,  resolution  does  not  occur,  the 
engorgement  of  vessels  continues,  a'ld  more  or  less  exudation  per- 
sists, that  which  is  poured  out  from  the  surface  being  a  marked 
clinical  feature  in  some  ca.ses. 

The  chronic  engorgement  of  vessels  leads  to  local  proliferation, 
especially  of  the  hbrous  tissue  in  the  subepithelial  layer:  this  fibrous- 
tissue  proliferation  undergoes  contraction,  the  exudation  ceases,  the 
epithelial  layer  by  stretching  becomes  atrophied,  and  the  whole  lining 
m.embrane  Incomes  ultimately  converted  into  a  layer  of  thick  fibrous 
tissue. 

There  ari'.  therefore,  four  stages  which  run  one  into  another  when 
the  acute  period  is  past: 

1.  Chronic  engorgemcMit  of  vessels  with  exudation. 

2.  Resulting  proliferation,  especially  of  the  fibrous  tis.sue. 

3.  Contraction  of  the  proliferated  fibrous  tissue. 

■^.  The  ultimate  .stage  of  cicatricial  condition  which  may  be  called 
post  catarrhal. 

The  results  of  such  changes  in  the  middle  ear  can  be  easily  imagined 
when  it  is  remembered  that  the  lining  membrane,  besides  clothing 
the  bony  walls  and  inner  .aspect  of  the  membrane,  forms  folds  and 
pocket /around  the  ossicles,  their  joints,  ligaments,  and  muscles. 

At  first  the  ossicles  and  membrana  tympani  are  hampered  by  the 
swollen  membrane  and  the  exudation.  Later  the  contraction  of  the 
proliferated  fibrous  tis.sue  causes  further  and  permanent  fixation. 

Th((  membrana  tympani  is  drawn  in  by  the  same  cause,  aided  by 
the  non-aeration  of  the  cavity  through  the  Kustachian  tube,  allowing 
external  atmospheric  pressure  to  exert  its  influence.  The  folds  of 
lining  membrane  are  converted  uito  fibrous  bands,  binding  down 
the  ossicles  to  the  neighboring  walls,  the  incus  to  the  outer  attic 
wall,  and  the  stapes  to  its  niche. 

The  tip  of  the  handle  of  the  malleus  coming  in  apposition  to  the 
promontory,  the  opirosing  epithelial  layers  become  rubbeif  off,  and 
allovv  of  adhesion  at  this  point.  The  os.sicular  joints  become  anky- 
losed,  the  muscles  fixed.  The  exudation  becomes  inspissate"  r 
confiiici  in  pockets  of  the  lining  membrane.  The  Kustachian  ml^c, 
sharing  the  same  changes,  l)ecomcs  narrowed,  so  that  an  originally 
pink,   moist,  thin,   somewhat   movable,   lining  membrane   becomes 


IIM.J 


THE  i:.\i!. 


smooth,  wliiU',  dry,  mii.I  tliick.  Fiirtlipr  fliaiijics  df  the  liiiiii^;  iiitim- 
l)raii(>  sometimes  oeciir,  such  as  eah-Uicatioii,  fatty  deKeiioration,  ete. 
The  tensor  tynipaiii  atul  stapedius  muscles  (indorgo  atrophic  depen- 
< Tat  ion. 


Aiikyliisis  (if  ihi-  |,liil.-..f  till' -luiic-s  will,  the  fem'slra  ovHli«.  .MiiT(i.s(.|i|,lc  -eolioii  lhniU({h  ihi- 
.taiv.lUn-.'slihularw.iiiircll.ui.  ./,  IloH.l  ..f  the  Ma|t->.  ',.  liase  ..r  Ihc  stapes.  ;,.  rroiiinnlnry  .. 
■ipuriims  a(lhi-si..ii  i.f  the  Ix.rdtT  ol  Ilie  stain's  with  the  fenestra  nvalls.  *•.  Adhesio.i  ,if  the  anierl-ir 
tninler.  the  e<l(;e  ln'iin;  -liil  llotieealjle  liy  the  iliirk  line.     ■  l'.)i.n/KK.! 


As  the  trouble  may  be  limited  to  the  Eustachian  tube  or  may 
involve  the  whole  iniddle-ear  tract,  each  will  lie  con.sidered  sepaiately, 
with  their  symptoms,  sijins,  prognosis,  iliapnosis,  and 
treatment,  as  far  as  possible  in  their  difTerent  stages. 

(I.  Chronic  Eustachian  Catarrh.  This  may  be  limited 
to  the  orifice  of  tiie  tube  or  extend  some  distance 
up  the  cartihiftinous  portion.  If  loiif,'  continued, 
chancres  may  take  place  in  the  whole  tract;  these 
will  be  considered  under  the  chanpes  produced  by 
variations  in  jires.surc. 

Sv.\ipt:)Ms  and  Sions.  One  or  both  ears  may  \w 
aflected:  if  both,  one  is  often  worse  than  the  other. 
Deafness  is  marked,  but  m.ay  \  .try  from  time  to 
time,  improving  sometimes  on  swallownig  or  on 
blowing  the  I  lose:  but  the  im|>rovement  soon  dis- 
ai)i)eais,  or,  if  permanent  changes  havi,  not  occurred, 
the  patient,  after  suffering  for  some  tim(>.  may  feel 
a  crack  in  the  ears,  with  ,subse,|uent  complete  res- 
( oration  of  hearing. 
()n  inflation  with  Politzer's  bag  or  the  Kustachian  catheter  imme- 
diate and   [lermanent  improvement  may  occur  in  the  limited  early 


*:ircumseri!x'il  aiihe 
sioii  of  the  niembrana 
tyni|iAiii  to  the  pri>- 
nmtilory  iniilertieath 
the  haliclte  t>t  the 
malleus,  n.  I'laee  nl 
adhe.sioTi  on  the  pni- 
inontory.  (.Mieraiire- 
paratiotiol  iiilne.  itow 
in  the  rnil^eniii  of  the 
f'olk'K*.'  of  Chysieians, 
in  I'hiladeli'hia. '  'l'<i 

l.IT.'.KH. : 


riiiioxic  \o\-srri'cnATivi-:  mu)I>lk-e.{r  disease,    hso 


stage,  or,  if  thp  discaso  is  of  long  standinp.  pspociaily  if  it  has  pxtended 
some  nay  along  llio  tul)o,  difficulty  may  l)0  oxpcrienrod  in  getting 
the  1ul)0  open,  and  the  resulting  improvement,  although  great  at  the 
time,  sooner  or  later  disappears.     On  listening  with  the  auscultation 
tube  during  inflation  the  air  can  1)0  heard  at  first  in  the  distance, 
entering  with  difficulty  l)efore  clearly  entering  the  cavity  of  the 
tympanmn.     In  the  exudation  stage  distant  bubbling  may  Iw  at 
first  heard.     The  patient  complains  of  a  distinct  feeling  of  oppression 
of  the  head  on  tlie  side  affected,  and  mental  dulne.ss  may  be  felt, 
especially  if  both  tubes  are  blocked.     Titmitus  of  a  rushing  character 
is  heard.     The  patient's  own  voice  sounds  to  him  louder  on  the 
affected  side,  and  if  both  ears  are  implicated  it  seems  as  if  he  were 
talking  into  a  hollow  ves.sel.     The  auricle  and  surrounding  parts  feel 
numb  when  lightly  touched.     On  looking  at  the  mcmbrana  tympani 
all  the  signs  of  (lepression  will  be  seen.     If  permanent  changes  in 
the  midt'Je  ear  have  not  been  produced  the  pink  lining  membrane 
may  show  through,  unle.'^s  any  opacity  be  present.     The  white  short 
process  of  the  malleus  is  prominent,  and  the  handle  foreshortened 
and  drawn  somewhat  backward.     The  folds  running  forward  and 
backwanl  from  the  slu^-t  process  to  t!ie  iKriphery  are  marked,  the 
latter  especially.     The  triangular  light  reflection  from  the  tip  of  the 
handle  of  the  inalleus  is  internipt<>d,  shortened,  or  absent,  depending 
upon  the  amount  of  depression.     The  structures  hi  the  middle  ear 
and  the  inner  wall  may  be  clearly  visible.     In  the  posterior  and 
superior  segment  the  descending  process  of  the  incus,  with  the  sta- 
pedius muscle  running  backward  from  close  to  its  tip,  and  the  chorda 
tympani  nerve  running  from  behind  upward  and  forward  across  the 
descending  process  of  the  incus,  may  Ik-  seen.     The  smooth  curve  of 
the  promontory  in  the  inferior  segment  is  well  marked,  and  below 
and  behind  it  the  round  window  appears  as  a  dark  patch.     On  looking 
at  the  nasopharynx  a  catarrhal  comlition  of  the  lining  membrane 
may  lye  seen,  it  being  red  and  swollen,  with  exudation  lying  on  its 
surface.     Sometimes  this  can  be  seen  involving  the  lips  and  orifice 
of  the  Eustachian  tube  and  rarely  a  plug  of  exudation  may  be  seen 
Iving  in  the  orifice. 

Proc.nosis.  In  the  early  stages  this  is  very  good;  in  the  later  it 
will  depenfl  on  the  amount  of  constriction  produced  and  whether 
the  tvmpammi  is  also  involved. 

Di.\GNOsis.  Simple  chronic  Eustachian  catarrh  will  be  diagnosed 
by  the  marked  improvement  of  hearing,  by  inflation,  and  the  absence 
of  permanent  changes  in  the  membrane. 

Trf:.\t.mkn  r.  Any  cau^es  in  the  nose  or  nasopharynx  must  be 
removed,  and  treatment  directed  to  improving  the  patient's  general 
condition  adojjted,  especially  change  of  air  and  tonics.  In  the  early 
stages  a  single  inflation  may  be  all  that  is  necessary  to  open  a  tube 
which  has  been  perhaps  blocked  by  a  plug  of  mucus,  or  the  sides 
of  which  have  stuck  together.  If  the  trouble  has  extended  some 
distance  up  the  tube,  inflation  will  have  to  he  repeated,  the  intervals 


u 


wmm 


118t> 


riih:  EAH. 


betHccii  tli(>  proccoditig  ilc|K'n<liiiK  on  the  <-tTcct  produced  and  tl 


i 


lenjith  of  t 


imc  iriiprovctiH'iit  in  hoarinK  remains 


In  the  later  .staues,  when  eontraction  api)ears  to  heeonie  a  definit. 
feature,  e.siM'eiaily  if  tlie  eartilajiinous  portion  is  affeeted,  inject 


I  alkalnie  solution  or  of  paroienie.  or  the  jjassage  of  a  houRie  throupli 
the  Eustachian  catheter  may  Im"  necessarj-.  Combined  with  this 
treatment  the  chloride  of  ammonium  vapor,  obtained  by  means  of 
Godfrey's  or  Hasdon's  inhaler,  drawn  into  the  mouth  and  blown 
through  the  nose  for  ten  minutes  niRht  and  morniiiR,  with  a  few 
autoiiiHations  into  the  middle  ear  by  means  of  Valsalva's  method 
when  the  mouth  and  nose  are  full  of  vapor,  is  often  of  grer.t  use. 

An  alkaline  and  astringent  solution  gentlv  syringed  down  the  nose 
after  the  inhaler  is  often  useful.  In  the  la.st  stage  it  will  Im«  u.sually 
found  that  further  changes  in  the  upper  mid(lle-<'ar  tract  have  occurred 
either  by  extension  of  the  catarrh  or  l.v  changes  produced  by  the 
variation  in  pres-sure.  The  treatment  ii  the.se  ca.ses  will  be  consid- 
ered later. 

A  useful  i)oint  when  .lithculty  of  oj^ening  the  luL-'tachian  tube 
by  ordinary  inflation  is  ex[)erienced,  is  to  place  a  few  drops  of  pure 
chloroform  into  the  bag  before  inflaticm. 

h.  Chronic  Hypertrophic  Catarrh  in  the  Whole  Middle-ear  Tract. 
Symptoms  and  Signs.  These  will  depend  on  how  far  the  disea.s«»  has 
prf)gro.ssed. 

1.  Stage  of  Chronic  Engorgement  of  Vessels,  with  Exudation.  Although 
a  certain  amount  of  exudation  from  the  surface  is  present  in  all  cases 
yet  in  some  it  forms  a  very  prominent  clinical  feature  demanding 
special  description.  It  must  be  stated  that  ca.ses  of  this  variety  are 
undoubtedly  rare  in  Creat  Britain.  It  is  impossible  to  .siiy  what 
determines  this  excess  of  exudation;  undoubtedly  in  .some  cases  the 
excess  is  more  apparent  than  real,  being  due  to  the  collection  of 
exudation  ;n  tlie  tympanum  owing  to  coexisting  Eustachian  ob-struc- 
tion.  The  character  of  the  exudation  varies,  b-ing  .^erous,  sero- 
mucoid.  or  mucoid:  and  here  also  it  is  impossible  to  .say  definitely 
on  what  the  varying  characters  of  the  exudation  depends. 

The  history  of  these  ca.ses  in  which  exudation  is  marked  usually  is 
that,  after  an  acute  catarrh  of  the  nasopharynx,  deafness  in  one  or 
both  ears  persists.  The  exudation  form  may  be  present  on  the  one 
side,  with  sim])le  I'iustacliian  ob.struction  on  the  other.  There  is  a 
feeling  of  fulness  in  the  ear,  stopping  short  of  actual  pain,  and  a 
sensation  of  something  moving,  especially  if  the  exudation  is  serous, 
with  occasional  bubbling,  especially  after  blowing  the  no.se.  Im- 
provement in  hearing  occurs  temfyorarily,  but  is  onlv  of  short  dura- 
tion, and  may  vary  with  the  position  of  the  head,  the  patient  may 
hear  bubbles  bursting,  especially  after  inflaiion.  Hushing  and  occa- 
sional piil.xating  tinnitus  is  })re.sent.  The  head  on  the  affected  side 
Icels  heavy,  and  numliness  of  the  auricle  and  .surrounding  parts  is 
experifiKed.  The  patient's  own  voice  .sounds  unusually  loud.  In- 
ability to  do  mental  work  is  often  complained  of,  and  sleep  may  be 


rillloMC  .VO.V-.Sf/'/T/M77rA'  MIIHH.E-EAH  hlsEAsi'.      HhT 


¥\r,    (A\. 


ili.stiiii)0(l  o\viii)i  to  tlip  l)iil)hlirij;  ami  cracking  wliicli  goes  on  in  tlio 
car.  When  tin-  mucoid  cicnH'iit  predominates  l)ut)l)ling  on  variations 
of  posture  are  not  marked. 

Sometimes,  especially  in  olti  people,  the  membrane  may  rupture 
on  blowing  the  no.sc  or  on  inflation,  producing  perhaps  a  suppurative 
process  resulting  from  septic  infection  from  the  meatus.  In  infancy 
and  early  childhood  rupture  seems  to  readily  take  place  in  the  early 
stages. 

On  examination  the  apijoarance  of  the  membrane  varies  according 
to  the  character  and  amount  of  the  exudation,  to  the  length  of  time 
it  has  been  present,  and  to  the  degree  of  clearness  of  the  membrane. 

If  the  exudation  is  slight  and  serous  the  malleal  ve.><.sels  are  some- 
what injected,  and  the  fluid  can  Ih'  seen  occupying  the  lower  part, 
its  upper  level,  which  appears  as  a  thin  line,  vary- 
ing with  the  position  of  tlic  head,  or,  if  greater  in 
amount,  marked  bulging,  u.>iually  in  the  post<'rior 
segment,  is  seen,  j)erhai)s  completely  hiding  the 
handle  of  the  malleus.  On  inflation  a  distur- 
bance of  the  Huid  can  Ih-  seen  with  the  forma- 
tion of  bubbles,  or  if  the  auscultation  tube  l)e 
used,  clear  bubbling  can  be  heard.  If  the  mucoid 
element  j)rep(inderates  a  whitish-yellow  appear- 
ance of  a  more  or  less  bulging  membrane  is  seen 
with  dilated  vessels  coursing  over  it :  there  is  little 
or  no  movement  ob.><ervable  on  posture,  and  on 
inflation  through  the  catheter,  as  t!ie  bag  is 
often  not  effective,  the  air  can  be  heard  at  first 
in  the  distance,  and  then  to  gradually  enter  the  tympanum  with 
sticky  rales. 

In  the  later  period  of  the  exudative  stage  the  exudation  partly 
escapes  from  the  Eustachian  tube,  while  some  becomes  inspi.ssated, 
the  membrane  in  the  meanwhile  becoming  pale  and  depressed,  with 
perhaps  localized  collections  of  exudation. 

In  tho.se  ca.ses  in  which  exudation  is  not  a  mnrkvd  clinical  feature 
the  symptoms  and  signs  are  not  so  aggressive.  Deafness,  improving 
on  blowing  the  nose,  with  gradual  return  to  the  former  condition, 
and  tinnit.is  of  a  rushing  an<l  pulsating  character,  are  complained  ci". 
The  membrane  is  somewhat  depressed,  the  lining  membrane  s«>en 
through  being  dark  pink  in  color.  On  inflation  slight  bubbling  may 
be  heard,  the  improvement  in  hearing  produced  being  greater  and 
more  lasting  than  in  the  cases  of  marked  exuilation. 

Phoonosis.  This,  if  the  case  h?  pre  )erly  taken  in  hand,  is.  as  a 
rule,  excellent:  but  if  long  contimu..  "  untreated,  resulting  in 
further  changes  in  the  lining  membrane,  as  den.,instrated  chiefly  by 
the  amount  of  itiipruvfur'iit  in  iir-aring  jmiduced  by  efficient  inflation, 
renders  it  proportionately  worse:  tlu>refore,  liefore  giving  a  definite 
opinion  in  long-standing  cas(>s,  it  is  well  to  await  the  effect  of  treat- 
nie!it. 


Ai'c'iiinulation  of  Huid 
effusion  in  the  Inferior 
portion  of  the  tympanic 
lavlly, marked  byabright 

line.      (POLITZER.l 


WHH 


I  in:  h.Mi. 


(■uses  (if  iimrkod  cxuihttion  jtivc  (Icfinifc  8i>ji».< 


|)lA<iNKSI.H.      'I'' 

From  a  collt .  if  pus  tlicy  arc  diajftioscd  hy  llio  ;il)sciico  of  anitc 

rctl'.css  of  fl't"  iiifiiihrauc,  ciironicity,  ami  IIh"  ahscticc  of  pain  ami 
fi'Vf,-,  If  the  cxticlatioti  is  mucoid  a  general  whitish  api^carance  i> 
seen,  instead  of  a  yellow  or  greenish  yellow,  which  is  s«'en  when  the 
c(>ntents  of  the  tympanum  are  pmiilent.  The  effect  of  tn-atnicnt 
will  also  help.  In  tho.se  cases  in  which  exudation  is  not  a  marked 
clinical  feature  lnihl.ling  is  sometimes  heard,  and  Ili(>  umisually  dark 
and  swollen  lining  memhrane  seen  through  the  membrana  tvtnpani. 
together  with  the  |K'rsistency  of  the  symptoms  and  effects  of  inflation, 
mark  them  from  simple  liustachian  obstruction. 

TiiKATMK.vr.  .Vt  this  stage,  a.s  we  have  w-on,  it  i.s  poHrtibie  for  the 
disea.se  to  Ik'  completely  arrested,  and  no  means  should  l)e  spared 
to  prevent  fuHher  progress.  The  treatment  is  local  and  general. 
Tnose  ca.ses  in  which  ixiidntiini  is  m.-irked  will  In-  first  '-onsidered. 

If  this  is  slight  ;ind  .serous  the  tr-atment  adopted  for  simple  I'lusta- 
chian  catarrh  will  suflice.  ,\s  ix'fore  stated,  it  is  impo,<sil»le  at  first 
to  say  how  much  Kastachian  ohstnK'tion  is  responsible  for  the  collec- 
tion of  exudation  in  the  tympanum:  .s(,metimes  cji.ses  which  at  first 
apiM'ar  to  demand  more  radicid  measures  yiel.l  to  simple  treatment. 
In  the  ca.^^es  in  which  simple  remedies  ('',  not  effect  a  cure  a  collection 
of  exudation  (KTsisting.  and  especially  when  the  nmcoid  el<>meiit 
liredominates,  ihey  nmst  U'  suppli'inenfed  by  intratvmpanic  injec- 
tions of  warm  sterile  alkalie  ilutions,  such  as  bicarbonate  of  .soda, 
five  grains  to  the  ounce,  or  of  jiandeini'.  ("oiinter-irritation  behind 
the  car,  or  ma.s.sage  from  ;d)ove  downwjird  behind  the  ear  and  up|K'r 
part  of  the  neck,  may  al.«;o  U'  used.  If  these  niea.sures  do  not  .suffice 
the  membrane  nmst  be  opened,  perhaps  more  than  once,  as  the  inci- 
sion spee(lily  closes  in  sjiite  of  inllalion.  The  inci.sion  nmst  Im-  made 
und(T  strict  antiseptic  precautions  thn.ugh  the  jiarl  in  which  tiic 
bulging  is  most  marked,  or.  if  no  bulging  is  present,  in  the  po.'^terior 
and  inferior  segment;  it  should  Iw  free  and  parallel  '  .  the  handle 
of  the  malleus.  .\t  the  time  of  incision  inflation  slioi  ,  Ik-  practised 
to  clear  the  middl(>  ear.  the  exudation  being  then  gently  niopjx'd 
out.  The  meatus  should  then  be  lightly  |)luggeil  with  the  "antiseptic 
dressing.  The  simple  treatment  of  the  nose  ami  naso|)harynx  with 
the  chlori<|e  of  ammonium  iidialer  and  nasal  solution  should"  be  con- 
timied  meanwhile.  Massage  by  means  of  Siegle's  .speculum  will  Im- 
found  useful  in  hastening  absorption  and  preventing  adhesions. 
Change  of  air  to  a  high  and  dry  climate  with  tonics  ;:re  esp(>ciallv 
benehcial. 

In  those  cases  in  which  isititnliim  is  not  warmer/ simple  treatment, 
regular  infl.-ition,  ma.s.sag«>  of  the  membrane,  together  with  tonics  and 
change  of  air,  will  u.sually  be  found  .sufficient.  In  the.se  cases,  again. 
'oral  trouble  in  the  nu?e  or  irasopliarynx  must  al.-o  be  removed. 

2.  Stages  of  Proliferation  and  Contraction.  In  discussing  the  following 
stages,  they  mi'rge  .so  gradually  one  into  the  other  that  it  is  impos- 
sibh'  to  separate  them  completely,  the  ])r(igre.ss  of  the  cases  being 


ciiiiosif  M)s-.si-rrci!.triyi-:  Miinn.t:  i:.\u  i>tsE.\sh:    |]s<i 


juilKfMl  accunliiij;  to  tin-  amount  of  iniprovi'iiu-iil  <)l)liiiinM|  l»y  tn-at- 
iiiciit  and  flu-  cliaiiKt's  [iri'si'iit  in  flic  iiu'tiihrano.  \\V  may  ili<cu.xrt 
till'  stajtcH  of  proliffratiun  ami  coiitrartinn  tonctlicr.  This  is  a  com- 
mon iH'iiod  for  patients  to  pnscnt  tlicmsclvi-s  for  treatment,  as  tluv 
liml  tliat  the  deafness,  whicli  tliey  tliouRlit  would  pass  otT  in  tim<', 
has  not  only  fjorsisted,  hut  is  jiradually  getting  \vors<'. 

Sv.MlTuMs  AND  Sic.Ns.  The  history  of  these  patients,  usually  younp 
ailults,  is  that  deafness  has  persisti  d  after  a  eold  or  s<'ries  of  colds, 
or  has  ttradually  come  on  since,  or  that  in  childhood  occasional  deaf- 
ness was  noticed,  with  a  history  that  points  .stronitiy  to  the  fact  that 
adenoids  were  pn'sent  at  that  period.  In  fact,  they  often  jireseiit 
the  appi-arance  due  to  chronic  nasal  ohstrudion.  They  also  state 
that  they  are  worse  with  every  cohl,  with  perlKi|>s  marked  permanent 
deterioration.  In  tiie  later  siiipv,  when  far  advanced,  the  .-symptom 
of  hearing  iH'tter  in  a  noi.se  may  henin  to  show  itself,  indicatiiift  the 
j;radu:il  onset  of  the  (ix:ition  staitc  Deafness  is  well  marked,  both 
ears,  as  a  rule  heinj:  alTected.  one.  often  tlx-  left,  heinjr  the  worse. 
The  fact  that  the  patient  cannot  hear  peneral  conversation,  or,  when 
at  a  dinner  ]>arty.  he  camiot  hear  conversation  distinct'y  on  one  side, 
may  Ik-  the  sympt<im  which  comix'ls  him  to  come  for  troatmetit. 
Tinnitus,  rushinj;.  roarinn.  clanjiinn.  or  machinery-like  in  character, 
is  often  a  source  of  jireat  trouble,  heinn  worse 
when  the  patient  is  (|uiet.  especially  at  nifjht, 
sometimes  jireventinn  sleej). 

Diplacusis,  usu.ally  ilisharmonic,  is  sometimes 
com|)lainetl  of.  On  examination  the  membrane 
is  pale,  often  opiuiue.  with  perha])S  i)atches  of 
chalky  de|(osit  (phosph.ale  of  lime),  the  signs  of 
depn'ssion  beinji  marked,  and  in  the  latter  stage 
the  i)ink  lining  membrane  cannot  1)0  seen,  even 
if  the  drum  is  ck  ar. 

On  applying  Siegle's  speculum  it  will  Im>  found 
that  tlie  membrane  and  malleus  do  not  move 
freely,  or  perhaps  the  posterior  segment  will  alone 
Iw  freely  movable.  On  inflation  through  the 
catheter  the  air  will  be  heard  to  enter  with  ditii- 
culty  and  dryly,  with  perhaps  a  whistling  sound. 
The  amount  of  imjirovement  in  hearing  produced 
will  vary  according  to  how  the  j)athological  changes  have  jirogressed. 
On  examining  the  membrane  after  inflation  little  'ir  no  alteration  is 
seen.  The  no.-^e  or  nasopharynx  may  present  some  pathological  con- 
dition, and  it  is  often  possible  to  detect,  even  in  middle  life,  remains 
of  adenoids,  which,  if  seen  during  a  cold,  may  be  considerable  in 
size. 

PitO(i\()sis.  For  this  we  rely  upon  the  progressive  character  ot  the 
deafness,  which  i.-  wor.^e  with  each  rold,  and  the  alisiiii-e  of  iiiternal- 
ear  trouble,  as  sho\..-.  by  the  tuning-fork.  etc.  From  the  exudation 
stage,  by  the  absence  of  moist  .sounds  on  inflation,  the  depression, 


Ihirseslioe  chalky  de 
lKH.it  ill  the  mombraiia 
lympHiii  of  a  woman 
llilrly  ycaniol  age.  Hum- 
liitiioftiio  fflrdiwcaR'.  tun 
yearn.  Tiiiiiluis  wldoin. 
.^eoiiineter  M    era. 

S|«'eeli        3  in       ilNiLir- 

/KK.t 


ll!Mt 


77/ a;  Htlt 


Jix.iliiiri.  and  opacity  of  the  incnil 


iraiM',  ami  llir  aiiioiint  of  iiii|)i 


OVC 


iiiciit  producMl  l,y  iiitlalioii.  From  tlu'  last  sUinv.  hv  the  aiiioiint  of 
irnf.rov.iM..nt  pr.Mlu.i'il  \,y  inll;.';..ii,  the  ahM-iicc  of  faranisis,  whirli 
thoiijfli  i-riMiit  ill  th.-  later  slap-s  of  rontraction,  ap|H'ars  to  iiulicat.- 
that  the  tinal  stajr«'  i"  Iwinj;  icaclicd. 

I  lu; ATMiA  r.  If,  on  inflati<»n.  the  iiiij)rovcini'?it  in  licarinjt  is  marltc.l 
\vc  Katli.'f  that  thf  contraclioii  stap'  ha.«  not  advanced  far.  .in.l  w.- 
nuist  ado|.t  tr.-atnicnt  which  will,  as  much  as  po.^sil.jc.  cut  short  the 
prolilcraiion  or  limit  the  amount  of  contraction.  In  order  to  do 
tlii>  defmite  local  troiiMes  in  the  nasopharynx  or  nose  must  U"  iv- 
movi'd.  followed  liy  rejjnlar  inflation  hy  means  of  the  hag  or  Kusta- 
chiaii  c.-itheter,  the  intervals  l)etween  the  inflations  iM'inp  judged  hy 
llie  leiijith  of  time  improvement  in  heariti);  la.sts.  .Ma.ssa^te  hy  ineiins 
of  Siejile's  speculum  or  Delstanclie's  mas.seur  is  also  useful.  The 
chhiridf  of  ammonium  inhaler  and  the  nasal  solution,  with  tonics 
and  clijintre  of  air  to  a  hi>jli  ami  dry  climate,  should  Ix'  comliinrd 
with  the  other  treatment. 

If  the  Kustachian  ohstructioii  is  a  prominent  feature  a  l>ouj{ie  may 
lie  jia.ssed  u[)  the  tulx',  or  paroleine  may  l«>  injected  through  the 
catheter.  If  the  results  pn.duced  hy  this  treatment  are  not  great 
we  must  mfer  that  contraction  is  well  advanced,  and  we  may  have 
1o  consider,  if  the  deafness  is  extreme,  the  (piestion  of  operative 
tri'atment.  which  will  he  presently  dealt  with  in  considering  the 
treattnent  of  the  po.stcat.arrhal  stage. 

Sometimes  iodide  of  pota.s.siuni  in  small  do.ses,  combined  with 
anmionia,  given  in  hot  wafer  twice  a  day  for  a  fortnight  or  three  wi-eks. 
jiroduces  good  results.  With  regard  "to  tinnitus,  the  treatment  wo 
have  indicated  will  usually  do  as  much  good  as  is  po.ssihle.  as  it  is 
mecli:inic.,ll_»  produc<'il.  an. I  depemi- on  the  h.cal  changes.  Tonics 
are  useful  in  rendering  the  patient  more  ahle  to  stand  the  noises: 
bromide  of  pota.ssium  and  diluted  hydrobromic  acid  are  soinetimos 
useful  as  .sedatives,  Klectricity  may  be  tried;  if.  at  the  first  sitting, 
neither  the  anoile  nor  cathode  alters  the  sound  the  ca.se  is  unfavor- 
able: but  if  the  noises  ;ire  diminished  during  the  pa.s.sage  of  the  anodal 
current  the  tie;itnient  is  more  hopeful.  ;ind  shoulil  be  continued.' 

.{.  Cicatricial  or  Postcatarrhal  Stage.  This  may  \>e  looked  upon  as 
the  ultimate  condition  resulting  from  the  unchecked  progress  of  the 
di.se.'ise,  which  may  have  occu|)ie(|  ;i  longer  or  shorter  lengili  of  time. 

Symptoms  .wd  Sicns.  .\  history  of  gnidual  increasing  deafness 
of  cat;irrhal  (irigin,  ilistinctly  worse  on  colds,  until  »  pitch  of  deaf- 
ness h;is  .•irrive.l.  which,  although  never  ab.solute.  neccssiiates  a  loud 
voici'  close  to  the  e;ir.  Paracusis  Willisii,  or  hearing  better  in  a  noist>. 
i-^  a  pniminent  symptom:  this  phenomenon  is  suppo.sed  to  be  due 
to  vibration  produced  by  jolting  or  loud  noi.ses,  enabling  tlie  rigid 
ossicular  chain  to  more  readily  transfer  .sound  waves.     ( iccasionally 

l!i'-  i'Mtif^iiN  will  -t;itr  fh.-it  Ihey  ,i.<rft  ((.  iicar  iif-Tter  ill  a  noise.      Tlii- 
I  l.fwts  Jones,  Arthlvcs  ol  oiolnity.  vnl.  .\.\lv. 


rminSir  MtSSll'I'lllATiyh:  Mlhhl.K  KMt  DISEASE,     iitii 


iiitiis  !■<  i)ft(ii  \iry  iliMlrcsMiiijj,  somctiriH's  n'lnltTidjf  life  !ilin(»Ml  iiiilM-ar- 
mIiIc,  itml  in  ;i  IVm  even  suicidal  fciKli'iicit's  may  Ix-  pn'scnt.  Tin- 
palifiits  arc  iiionisc,  intr(>s|M'ctivc,  Im-Iiik,  to  a  large  extent,  cut  otT 
from  the  outside  world.  Many  actinii'c  in  some  deurcc  the  power 
of  lip-rcadiuK.  unil  tliey  will  <'oiisc(|iiently  hear  Ixtter  when  the 
sp<'aker  is  facing  tiieni.  A  low  hut  clear  voice  is  lieard  iH-tter  than 
shoutitig.  Iligli  tones  will  Im-  distinctly  heard  letter  than  low;  for 
instance,  a  watch  will  Ix'  heard  coinp.irativcly  hetter  than  the  human 
voice.  On  looking  :tt  the  menilirant  it  will  appear  markedly  de- 
jjressi  d  ami  oita<|ue.  Hy  means  of  Siegle's  speculum  thi'  malleus 
nuiy  Ih'  seen  to  Im'  firmly  adherent  to  the  promontory,  the  membrane 
perhaps  ti.xed  to  the  descending  process  of  the  incus  and  around  the 
malleus  to  the  promontory.  On  inflation  the  air  enters  witli  diflioulty, 
and  produces  no  change  in  the  position  of  the  malleus  or  niemhrai.e. 
Improvement  in  hearing  is  either  absent,  or,  if  slight,  is  of  short 
duration.     Dimiimtion  of  the  iioi.so  is  sometimes  produced. 

I'HtXiNosis  is  extremely  had  as  regards  hearing  and  tinnitus;  deaf- 
ness is  never  ah.sohite,  and  the  j)atient  may  Iwcome  mon>  <tr  less  used 
to  the  noises,  which  may  vary  with  the  state  of  the  health.  Opera- 
tive measun-s  may  produce  improvement,  if  not  in  hearing,  in  tinnitus. 

Di.viiNosis.  From  the  previous  stages  it  maylx'  diagnosed  i)ytiip 
fixation  of  the  memhrane,  th;'  ohstruction  of  the  tul)o,  the  paracusis, 
and  the  slight  improvement  on  inflation.  The  tuning-fork  and  tone- 
hearing  tests  will  distinguish  it  from  intern.'d-ear  disease;  but  we 
occasi'iUally  find  that  the  tuning-fork  in  these  cases  itidicates  a  certain 
amount  of  internaU'ar  implication:  the  history  of  j)aracusis  will  lx> 
sufficient  to  stamp  the  case  as  having  originated  in  the  middle  ear, 
esjM'cially  if  other  symptoms  of  internal-«'ar  di.sea.-ios  are  absent.  Tnie 
auditory  vertigo  does  not  occur. 

Tkk.vtmknt.  It  follows  fromthe|)athological  condition  that  ordinary 
local  and  general  tieatment  is  useless  in  efTecling  useful  or  any  per- 
manent improvement  in  hearing  or  tinni'.us.  The  treatment,  however, 
descrilM'd  under  tlu-  [nevious  stage  should  he  given  a  fair  trial.  If  the 
})atient  is  satisfied  with  the  temporary  and  slight  improveni'i  i  which 
may  l)e  effected,  especially  if  li|i-reading  lessons  are  taken,  oiiihuiry 
methotls  of  treatment  should  he  from  time  to  time  etiijjloyt  d. 

Hefore  undertaking  openitive  measures  care  must  Ix'  taken  that 
the  internal  ear  is  intact,  and  it  must  !«'  pointed  out  to  the  p.itient 
that  they  are  more  or  h'ss  of  an  experimental  nature.  It  is  well  to 
fully  explain  to  the  patient  the  true  condition  of  tilings,  and  leave 
it  to  him  to  decide  as  to  whether  they  should  be  undertaken.  It  is 
V  ise  to  first  operate  nn  the  ear  wiiich  is  more  afleeted.  These  oj)era- 
tions  fall  under  four  headings: 

1.  Those  undertaken  to  relieve  tension. 

2.  Those  undertaken  to  diminish  undue  fiaecidity. 

,3.  Those  undertaken  to  allow  sound-waves  to  reach  the  lene.-tra} 
direct. 

4    Removal  of  some  part  of  the  i)ony  labyrinthine  wall. 


11!»2 


77/ a;  i:.ii{. 


K 


cautions 


ono   )f  tlicni  should  l)o  undertaken  witliout  strict  antiseptic  p 


I.  T/)i)sr  Vmhrtdkcn  to  HvHnr  Tcnxinn.  These  romprise  division 
of  adhesions,  section  tlir -usrh  the  posterior  fold,  tenotomy  of  tiie 
tensor  tyini)ani,  an<l  <!;,•< ;„'  l^t'aments.     These  have  not  realized 


■\  is  i)roduoed  speedily  disap- 
;iiK  takes  jjlacc:  therefore  they 


expectations,  any  n.  j ■•■(,v.'in(  nt  »,li 
pearing  as  soon  as  t  ■■  ii  ■•iltahic  he 
may  he  j)laced  on  o,  .>  f'^U\ 

2.  Those  Un(hrt(ik(.  .  ■/ ' '  -v  ,, ,./  /',),/,/(.  Flaccidili/.  'When  the  mem- 
brane or  some  part  of  the  niemluane  is  seen  by  inflation  or  the  Siegle 
speculum  to  i)e  unduly  flaccid,  due  to  atrojdiy  or  too  energetic  infla- 
tions, or  the  result  of  .•(  cicatrix,  especially  if  marked  improvement 
in  hearing  occurs  when  it  is  i)ut  ou  the  stretch,  multiple  incisions 
made  through  the  flaccid  j)art  with  the  idea  of  producing  cicatricial 
contraction  m.'iy  he  undertaken ;  hut  the  result  is  often  disappointing. 
Collodion  painted  over  the  fl;iccid  portion  and  adjacent  meatal  wall 
may  he  of  henelit. 

:].  Thiisf  ('nilriidkcn  to  Allow  of  Sound  Wores  Reachinci  tlw  Fcucs- 
tnr  Dincl.  It  has  long  been  known  that  the  artificial  perforation 
of  the  memhrane  will,  in  some  cases,  produce  great  improvement  hi 
hearing:  hut.  ;is  healing  always  takes  place,  and  no  method  of  keephig 
the  perforation  open  has  yet  been  devised, 
some  further  procedure  heconies  necessary.  As 
to  wheth(;r  further  proceedings  should  be 
adopted,  exploratory  tympanotomy  is  a  useful 
guide,  for  if  it  produces  improvement  in  hearing 
or  tinnitus,  w;-  are  encouraged  to  proceed  to 
more  radical  measures;  but,  even  if  it  does 
not,  and  given  that  the  internal  ear  is  intact, 
and  the  case  is  not  one  of  atrophy,  we  may,  if 
the  pjitient  so  desires,  adojit  the  more  radical 
measures,  as  it  may  me:in  that  the  absence  of 
improvement  is  due  to  fixation  of  the  stapes,  or 
the  blocking  of  the  round  window  to  a  cicatricial 
tissue. 

Erplornlori/  Tj/mpaitolotn)/.  This  little  operation  is  best  performed 
under  gas  ana'Stliesia  by  cutting  ;i  flap  with  its  apox  uppermost  in  the 
posterior  and  suiierior  segment,  by  means  of  a  sharp-pointed  knife 
under  a  good  reflected  light.  Preliminary  inflation  of  the  middle  ear 
I'  be  useful  ill  separating  the  membrane  as  far  as  possible  from  the 
IK.  .die-ear  wall.  Further  procedures  can  be  divided  into  two  stages: 
a.  Removal  of  the  membrane,  malleus,  and  incus,  which,  if  not 
l>roductiv(>  of  improvement,  even  after  an  artificial  membrane  has 
been  tried,  may  he  followed  by 

6.  Mobilization  or  removal  of  the  stapes  and  reniov.-il  of  cicatricial 
tissue  from  over  tlie  munrl  window. 

o.   Tlir  liiinovul  oj  tlw  Mcmhrnnr,  Mnlhiis,  and  hiriis.     This  should 
he  jierformed  under  a  general  anar-sthetic,  the  head  being  slightly 


Tria!)Kiilt*r  itx-isinn  in  iIr> 
|x)storiifr->.iJiK.'rli»rtiimilratit 
fur  ex[xtsii)g  the  ftrticiila- 
tioiioftlieiiu'iisHipl  sta)>i'«> 

(E'oI.I1ZKR.  1 


H 


ciinoMc  \o.\-.sci'i'n!ATiyi-:  miihhj:  f:.\n  ihshas/:.    mcj 

raised  on  a  pillow  and  turned  three-quarters  over  to  tlie  opposite  side. 
A  good  reflected  light  is  necessary.  An  incision  is  made  with  a  sharp- 
pointed  knife,  starting  from  immediately  behind  the  short  process 
of  the  malleus,  sweeping  around  as  close  to  the  i)eriphery  as  possible 
to  a  corresponding  point  on  the  anterior  aspect  of  the  sh..it  process. 
The  handle  is  then  freed  from  adhesions  which  may  be  |)resent  l.>e- 
tween  the  membrane  or  malleus  and  the  promontory.     The  tensor 

Fig.  cat. 


Sexton's  fmx'c'iw  hikI  knives  (m  ivm>i\\u«  the  meiiibrane  unil  dcsicles. 


tympani  is  then  divided,  either  l)y  DelstanclieV  extractor  or  by  a  small 
curved  knife.  The  malleus  is  then  .seized  as  high  up  as  possible  with 
a  pair  of  strong  curved  forceps,  being  pulled  first  downward  to  free 
it  from  the  attic,  and  then  outward.  The  incus  nmst  then  be  turned 
out  from  the  attic  by  means  of  an  incus  hook,  which,  being  intro- 
duced into  the  interior  part  of  the  cavity,  is  rotated  downward 
and  backward,  pu.shing  the  ossicle  into  the  1o\v»t  middle  ear,  when 
it  may  be  removed  by  forceps  or  by  syringing.  Numerous  incus 
hooks  are  made,  the  most  useful  being  either  Delstanche's,  Lake's,  or 
Fvudwig's. 

The  middle  ear  should  then  be  gently  mopped  out,  a  gauze  dressing 
should  l)e  lightly  introduced  into  the  meatus,  and  a  general  dressing 
and  bandage  applied.  If  antiseptic  precautions  have  been  eflicient 
dressing  will  not  be  required  for  a  week  or  ten  days.  At  the  end  of 
;,  fortnight  or  three  weeks  the  hoarinsr  power  should  be  t(>sted  again 
and  the  amount  of  tinnitus  noted.  The  dressing  should  not  be  l(>ft 
out  until  healing  is  complete,  when  an  artificial  membrane  may  be 


it 


11!»4 


77/ A,'  HAK. 


triod  if  no  in  lovrinciit  rosulfs.  SoiiiPtiiiips  an  advontitious  mem- 
brane forms  .ii'riiss,  annulling;  any  gooil  effect,  and  may  reiiuirc 
removal  more  than  onee. 

b.  Mubilizntion  and  the  Rntimal  of  the  Stapes  ojid  the  Removal  of 
Cicatn'eial  Tistme  from  onr  the  Round  Window.  Before  tfiese  opera- 
tions are  performed  t'  r  should  Ix-  allowed  to  heal  soundly,  allow- 
"ng  the  condition  of  tni:  inner  middle  wall  to  be  plainly  seen.  Adhe- 
sions binding  down  the  head  and  crura  of  the  stapes  should  be  divided 
with  a  fine,  sharp,  shouldered  knife,  such  as  Politzer's,  as  close  to 
the  ossicle  a.s  possible  under  eueaine  or  cocaine,  the  stapedius  muscle 
being  also  divided  and  the  stapes  mobilized  by  means  of  a  suitable 


Kl(i.  649. 


Pelstanche's  malleus  exlractnr 


Fill.  ilV), 


1 
i 


lAki''s  attic  iiiri'ttt  aiiii  iiict:s  liiiok. 


probe.  If  im])rovemenl  occurs  nothing  more  should  be  done;  if  it 
does  not,  we  may  again  try  an  artificial  meml)rane:  if  tins  Is  in- 
effective we  shoulii  remove  adhesions  obscuring  the  round  window 
as  far  as  possible,  a  rather  difficult  procedure,  on  account  of  the 
anatomy  of  the  part.  If  this  is  insufficient  we  must  infer  fixation  ol 
the  base  of  the  sta{)es. 

With  regard  to  removal  of  the  stapes  more  exi)erience  and  inves- 
tigation are  necessary. 

If  niol)iliz;ition  has  not  been  possible  attempted  remov.a!  will,  m 
all  probability,  result  in  fracture  of  the  crura,  leaving  the  foot-plate 
still  in  position.     The  attempted  removal  should  be  m!;d(>  by  means 


u 

W- 


( iinnsic  .\ti.\  sii'i'i'iiATivi-:  Mn>i>i.h:~i:.\n  ihsease.    ii{),j 


of  a  tine  hiiok  iiitrodiict'd  hctwi'cn  tlic  crura  from  al)()vc,  and  with  a 
>;ciill<' side  t(i-sidc  iiiovciiiciit.  It  may  he  that,  in  t!ic  futiirf,  opfia- 
ti(.;is  (HI  till'  ifiiKT  middle-car  wall  may  he  of  hcneht.  A  more  radical 
methiid  has  lieen  proposed  ami  carried  out  hy  .Malherhc,'  who  opens 
the  anirnm  from  hchind,  divides  the  adhesions  in  the  middle  ear, 
and  introduces  a  celluloid  tuhe  throufiii  the  meatus  into  the  antrum. 
The  results  have  not  been  lirilliaiit,  and  until  further  experience  has 
hi'cn  obtained  it  may  he  fairly  stated  that  operations  throufrh  the 
meatus,  as  described,  are  e(|ually  I'tficieiit. 

4.  liiiHoidl of  Simii-  I'nrt  i>j Ihc  ii»n)/  Lnhi/riiithhie  Wall.  Mr.  Charles 
Hallance  broufjlit  forward  a  case  at  the  '  Hological  Society  of  the 
I'nited  Kinjrdonr  in  which,  in  the  course  of  ope-ating  for  .supjmrativo 
extension  from  the  middle  ear,  he  found  it  necessary  to  open  the 
vestibule  from  behind.  After  the  sui)se(|uent  skin  jirafting  tlic 
hearinjr,  which  had  been  lost,  returneij  in  a  .surprising  degree,  and 
tlie  giddiness  ami  stafrjrerinp  which  had  been  extreme,  totally  disap- 
peared. Following  this  ca.«e  Milligan  and  Hallance  have  operated  on 
non-sup|)inative  middle-ear  disease  in  the  latest  .stage''  by — after 
opening  the  antrum  and  laying  it  open  into  the  middle  ear,  as  in  the 
complete  mastoid  0{)erat  ion  -removing  a  ]>ortion  of  the  promontory 
anil  immediately  applying  a  skin  graft.  The  results  in  some  cases 
were  somewhat  encouraging,  especially  as  regards  tinnitus:  but  a 
verdict  cannot  at  present  be  gi\-en. 

11  Atrophic  Catarrh.  Fixation  of  Stapes.  The  chief  character- 
istics of  this  form  are  the  very  gradual  and  insidious  oTiset  of  the 
deafness,  with  little  or  no  change  in  the  membrane,  and  no  obvious 
cause  in  the  nose  or  na.soph.-irynx,  the  majority  of  cases  occu-ring 
in  women  between  the  ages  of  twenty  a!id  forty  years. 

Causation.  The  causes  are  obscure  in  the  highest  degree.  Heredity 
is  certainly  an  important  factor.  Occasionally  a  vague  history  of  a 
bad  cold  or  .series  of  colds  is  obtained  as  a  .;arting  point  Some 
severe  illness,  such  as  rheumatic  fever,  is  thought  sdmetiines  by  the 
])atient  to  lie  the  origin,  and  <iccasionally  chronic  rheumatic  affections 

are  ( xistent.     .\na'mia  is  often  present.     Tarturition  is  intimately 

connected  with  this  cla.ss,  the  deafness  either  apparently  connnencing 
after  labor,  or  being  made  considerably  and  permanently  worse 
thereby. 

Pathology.  This  ajjpears  to  be  an  atrophy  of  the  lining  membrane, 
with  a  marked  tendency  to  the  fixation  of  the  base  of  the  stapes  in 
the  oval  window,  and  .sometimes  im])lication  of  the  internal  ear  in 
the  later  stages.  The  onset  is  so  gradual  that  pathological  investi- 
gation in  the  early  stages  is  wellnigh  an  impossibility:  we  are  only 
familiar  with  the  ultimate  results  produced.  On  removing  the  roof 
of  the  middle  ear  affected  with  the  disease  thr  first  thing  that  strikes 
one  i^  the  wideness,  whiteness,  and  dryness  of  the  whole  cavity,  the 


'  I'ripoee  lings  .it  the  Sixlh  IiiterLintiniml  roiii<ri's>  iif  Otoloxy.  IWW, 

■'  TmiiMi'liotis,  tv'.i  IW,  viil.  i, 

I  MilliKiin.    TninH«riii)ii«i)t(ili)liiKic»l  Suclcly.  IsiKt-lWHi.  vul.  I. 


11!m; 


TUh:  EMi. 


in 


mtaincd  structuiTs  Ix-iiig  fk'arly  dofinod.     Fine  iiifiiibriuiousl'seiita 
irious  parts  can  1)0  scon,  and  arc  a])i)arciitly  tlio  atropliiod  rc'iiiains 


of  the  fol( 


the 


liiiiii<; 


IIICIIll 


iraiie. 


A  \v('ll-iiiark('(l  mcinbranc 


soiiictiiiies  seen  niiiiiiiif;  ii|>  iVoni  tlic  toi.  .im  dl  tlic  tensor  tynipani 
to  the  roof. 

()n  microscopic  cxatniiiatioii  the  layers  arc  atroi)liicd  and  liie 
distinctive  characteristics  cannot  he  made  out.  The  ha.se  of  tiie 
."tapes  is  fixed  to  the  oval  window,  either  h\  calcification  or  o.ssifica- 
tion  of  the  lifiamentous  rinjr,  or  hy  deposit  of  new-formed  osseous 
suhstanc(>  upon  the  inner  surface  of  the  foot-i)late.  and  a  complete 
bony  uni((n  of  the  wall  of  the  oval  window  may  exist  (Politzer). 

The  condition  is  thoujjlit  by  .«ome  to  be  due  to  a  troj)hic  lesion,  as. 
especially  in  the  later  stages,  little  or  no  in.jection  of  the  malleal 
vessels  takes  ])lace  on  eflicient  inflation:  but  tliis  may  be  due  to  the 
fact  that  tli(>  ves,sels  share  in  the  atrophic  i)rocess,  or  are  constricted. 
The  fact  that  ganglion  cells  are  found  in  the  lininji  membrane  sujrf;ests 
that  some  change  in  them  may  possibly  interfer(>  with  nutrition, 
trophic  causes,  however,  will  not  account  for  liony  ankylosis  of  the 
base  of  the  stapes,  a  condition  which  jxiints  to  some  irrit.ativc  peri- 
osteal cause,  perhaps  irritation  due  to  some  chemical  causi-.  Tlioina, 
in  his  work  on  ])atholo)xy,  describes  an  atrophic  catarrh  in  which  the 
mucous  membrane  becomes  thinniT  luid  atrophied,  and  it  nnist  be 
allowed  that  ~uch  a  process  will  most  readily  account  for  the  condi- 
tion found. 

With  rcftard  to  the  secondary  afTection  of  the  labyrintii,  impair- 
ment of  fmiction  may  result  simply  from  di.sea.se:  but  in  some  ca.ses. 
at  all  events,  further  chanjres  nnist  exist.  It  may  be  that  the  atrophic 
process  is  continued  to  the  cavity  of  the  labyrinth,  with  resultinfr 
decrease  of  secretion  of  the  intraJabyrintliine  fluids,  the  i)erilymph 
in  |)articul;ir. 

Some  cases  with  symptoms  chh-^i'ly  resemblitifi  tho.se  seen  in  this 
proup  have  been  found  by  Toynbee,  Politz<'r,  Bezold,  and  others  to 
be  due  to  .i  priin;iry  affection  of  the  labyrinthine  bony  capsule,  pro- 
ducinj;  ankylosis  of  the  ba.se  of  the  st.-ipes,  without  any  patholoiticai 
lesion  of  the  lininj;  membrane. 

Symptoms  and  Signs.  The  onset  of  the  symptoms  is  so  insidious 
that,  as  a  rule,  the  jiatient  does  not  come  for  treatment  until  the 
disea.se  is  well  advanced.  In  some  a  slijjht  hissiufr  *imiitus  was  present 
for  some  time  iiefon-  the  deafness  was  noticed,  a  frradual  decrease 
of  hearing  in  one  ear,  usually  the  left,  being  unnoticed  or  disregarded 
until  the  other  ear  becomes  seriously  affected:  both  ears  then  grad- 
ually becoming  worse.  In  other  ca.ses  tlie  patient's  friends  are  the 
first  to  notice  the  diminution  in  function.  The  tinnitus  is  often  not 
distressing,  the  patient  getting  absolutely  u.sed  to  it:  in  others  it  is 
one  of  the  n,  ist  jiromlnent  features.  When  the  disease  has  aihanced 
eoiisideral)ly  'n  !)otli  e;irs  paracusis  is  a  marked  .symjitom.  Tin- 
he.'iring  is  usu.ally  worse  during  a  cold.  Occasionally  the  disease 
a|)pears  to  sto|)  short,  or  to  |)rogress  \         slowly,  when  the  later 


riii:o.\ir  .vo.v-.sr/'/TAM 77r/-;  middlk-km;  disease.    \\\q 


1^3 


stfific-  lire  rcaclioil,  and  coinplolo  stone  deafness  is  never  ohserved. 
On  intlation  n  very  slifjlit  iniprovemenl  in  iiearinj;  is  jjrodueed,  Imt 
soon  disappears,  and.  as  before  nie"tione<l,  little  or  no  resulting  injec- 
tion of  tlie  nialleal  vessels  can  1m>  seen.  In  some  the  inflation  may 
not  he  felt  in  the  car,  although  the  diagnostic  tiihe  clearly  indicates 
that  it  has  heen  successful,  .\ttacks  of  true  auditory  vertigo  arc 
not  experienced.  The  JMistachian  ttibe  siiows  no  signs  of  oi).struction, 
hut.  on  the  contrary,  seems  unusually  patent,  the  air  entering  very 
clearly  and  dryly.  On  examination  the  inea+us  is  usuallj'  clear  of 
ceruin<'n;  in  fact,  patients  sometimes  complain  that  their  ears  seem 
dry.  On  looking  at  the  memhrane  the  al).sence  of  gro.ss  changes  is 
very  marked:  it  often  looks  unusually  hright.  clear,  and  thin,  with 
little  or  .10  signs  of  dej)ression.  The  memhrane  and  malleus  move 
freely  with  Siegle's  speculum.  The  nose  and  naso])harynx  in  the 
ma.jority  of  cases  a])])ear  perfectly  normal:  sometimes  the  nose  may 
ajipear  dry,  the  patient  stating  that  a  handkerchief  is  not  often  neces- 
sary, and  the  lining  memhrane  of  the  nasopharynx  may  ajjpear  thin, 
the  lij)s  of  the  lOustachian  tuhe  standing  out  boldly:  hut  it  is  never 
dry  and  glazed.  There  apix'ars  to  he  no  connection,  as  one  would 
exjx'ct,  between  so-called  atrophic  rhinitis  and  this  disease.  Paleness 
of  the  .<oft  ])alate  with  a  blush  on  each  side  is  usually  present  (Urban 
I'ritchard). 

Prognosis.  This  is  always  extremeh'  bad:  no  treatment  has  any 
power,  apparently,  to  check  its  progress:  the  deafness. goes  from  had 
to  worse,  hut  may  stop  short  at  .some  j)  «int,  absolute  d -afness  never 
resulting,  the  patient  being  always  ■  '   <■  to  hear  something. 

Diagnosis.  The  age  and  sex  of  the  patient,  the  insidious  onset,  the 
apjK'arance  of  the  membnme.  the  absence  of  I'aistachian  obstruction, 
freedom  .'Uid  dryness  of  air-entry  on  inflation,  the  slight  improvement 
produced  thereby,  and  absence  of  any  cause  in  the  nose  or  na.so- 
})harynx  separate  this  from  other  middle-ear  diseases.  The  tuning- 
fork,  etc.,  will  distinguish  it  from  internal,  and  in  those  cases  in  which 
internal-ear  results  are  produced  by  tlie  tuning-fork  the  presence  of 
paracusis  will  give  the  clue.  In  cases  of  primary  disease  of  the  laby- 
rinthine caj)sule  the  ])ink  lining  membrane  can  he  .seen  through  the 
membra na  tympani. 

Treatment.  .\s  before  stated,  we  have  as  yet  no  treatment  which 
has  any  jjower  to  check  the  disease  when  once  it  has  .started;  it 
remains  to  he  seen  whether  operations  on  the  labyrintiiine  bony  cap- 
sule are  of  real  and  permanent  value. 

The  general  liealth  of  the  patient  nmst  he  put  in  the  best  possible 
condition.  The  local  treatment  is  merely  jjalliative,  and  even  this 
must  be  usefl  with  extreme  caution,  or  the  patient  will  be  made  dis- 
tinctly worse.  Occasional  catheterization,  with  injection  of  paroleine 
or  inflation  with  the  hag.  especially  if  a  few  drops  of  chloroform  be  pre- 
viously introduced,  produces  a  slight  amount  of  imi>rovement,  and  is 
a  comfort  to  the  patient.  The  chloride  of  ammonium  inhaler  produces 
little  or  no  benefit,  except  thit  a  tendency  to  colds  is  held  in  check. 


ll!tH 


////•;  i:.iu. 


Miiss;i<;('  witli  Sicfilc's  spcciiluiii  in  tlic  (inliiiaiy  way  must  lir  \it\ 
cautiously  and  j;i'ntly  applied,  as  in  the  great  majority  of  eases  it  is 
distinctly  detrimental.  Too  prolonged  application  of  inflation  or 
massage  will  produce  luiilue  Haccidity  of  the  inemimine,  and  so  add 
to  the  trouble. 

At  the  Sixth  International  Congress  of  Otology,  in  1n!»!».  .Mink 
stated  that  he  had  produced  good  etTects  hy  using  Siegle's  speculum 
in  a  modified  w:. /.  The  memhrane  and  malleus  arc  first  compressed 
hy  air.  stoi)ping  short  ot  ,,ain.  hefore  massage  is  ajyplied:  this  method, 
whidi  aims  at  moving  tin;  l)ase  of  the  stajies,  has  not  received  a  fair 
trial. 

With  regard  to  operative  intratympanic  measures  the  general 
experience  is  that  they  are  contradictecl:  hut  perhaps  it  is  only  fair 
to  .say  that  tliose  on  tiie  stajjes  and  inner  niiddl(>-ear  wall  are  still 
on  their  trial.  With  regard  to  artificial  aids  in  the  extreme  stage, 
lip-reading  le.s.sons  are  of  great  value,  and  may  entirely  alter  the 
patient's  outlook  on  life.  Mechanical  aids  are  mainly  useful  (dt  indi- 
vidual conversation;  when  ohtaining  one.  all  va  '  'ties  should  he  tried; 
as  a  rule,  die  ordinary  speaking-tuhe  will  he  of  the  greatest  service*. 

( '.  Changes  Produced  by  Variations  in  Pressure.  Negative  Press- 
ure in  the  Tympanum,  ("oncerning  this  little  is  known;  hut  the  adop- 
tion of  a  separate  class  for  it  is  warranted  by  the  deafni'ss  which 
occurs  in  those  who  work  under  increased  atmosj)heric  pressure,  such 
as  deep-sea  divers,  and  in  those  cases  in  which  deafness  resuii.'  as  a 
result  of  chronic  mechanical  oh.struction  of  the  tuhe,  such  as  cica- 
tricial contraction,  pressure  of  tumors,  etc. 

It  may  he  stated,  however,  that  it  is  difficult  to  exclude  the  previous 
forms  of  dise.'i.se  in  these  cases;  hut.  on  th'*  f)ther  hand,  some  of  the 
changes  described  as  having  resulted  from  a  chronic  catarrh  in;iy  he 
due  to  a  long-continued  negative  ])re.ssure. 

Causation.     These  are  of  two  varieties; 

(I.  Long-contimied  or  often-repeated  increa.se  of  ;itmosiihi'ric  press- 
ure on  the  memhrane. 

/(.  Non-aeration  of  the  mi<ldle  ear,  owing  to; 

1.  Mechanical  occlusion  of  the  tuhe  by  cicati'icial  contraction, 
pressure  of  tumors,  etc. 

2.  Xasal  obstruction  due  to  any  cau.se,  especially  wIh'u  atifecting 
the  inferior  meatus,  as  this  place  is  practically  a  contimiation  of  the 
mouth  of  the  lOustachian  tuhe. 

;{.  Paresis  of  the  Eustachian  muscles,  as  occurs  sometimes  after 
diphtheria,  preventing,  by  their  in.-iction.  i)roper  aeration. 

Pathology.  Of  this  we  have  nothing  hut  conjecture  to  go  upon: 
but  it  can  readily  l)e  conceived  that  if  air  is  j)revented  fn.m  entering 
the  middle  ear  hy  the  atmospheric  |)re.ssure  from  without,  or  hy 
obstniction  fmni  within,  a  long  cnntinued  i>r  i>ften  repeated  Tiogati\e 
pressure  in  the  tym])amim  will  produce  a  chronic  dil.atation  of  the 
vessels  of  the  lining  membrane,  with  resulting  hyf)ertrophy  of  the 
tissues  and  fixation  of  the  ossicular  chain. 


ciiiioMc  Mi.\  srirrnATiyH  mii>ih.i:-i:m;  ihskasi:    ]|<)(^ 


i 


Symptoms  and  Signs.  Tliosi'  of  tlic  liyiM-rtnipliic  class,  plus  the 
obvious  cause  wliich  exists  apart  from  catarrliai  conditions. 

Prognosis.  Tiiis  will  (lo[K'n(l,  tiistly,  wliftlicr  tlio  cause  can  (>(■  re- 
move.!; and,  secondly,  if  removal  is  po.ssible,  on  the  results  obtained 
by  subsequent  aeration  of  the  tyinpanuin. 

Diagnosis.  As  far  as  can  be  judged  at  present  this  dt  pends  on 
tiiiddle-ear  .synipt(jins  and  sipis  combined  with  an  obvious  cause  of 
non-aeration  apart  from  catarrh. 

Treatment.  In  those  working  under  increased  pressure  care  must 
be  taken  that  there  is  no  hindranc*'  to  the  entry  of  air  thmuKli  the 
tube.  In  those  cases  in  which  non-aeration  is  (lue  to  obstruction  in 
the  nose  or  nasopharynx,  removal  of  the  cause,  if  f)ossible,  is  indicated, 
witii  subsequent  aeration  of  the  tympanum.  With  regard  to  the 
removal  of  septal  spurs  or  hypertrophied  turbinals,  a  good  rule  to 
observe  is  dia  they  should  not  be  interfered  witli  unless  marked 
blocking  of  the  inferior  meatus  is  present,  or  if  the  passage  of  the 
Kustachian  catheter  is  ijiterfered  with.  When  once  the  ol)struction 
is  reniove<l  and  subs((|uent  aeration  fails  to  produce  improvement, 
the  question  of  intratympanic  operations  directed  to  n moving  the 
rigid  ossicular  chain  may  1k'  considered. 

I).  Changes  Produced  by  Deficient  Blood  Supply,  of  this 
form  little  definite  is  known,  but  cases  are  met  with  in  the  later 
Ijeriods  of  life  when  the  clinical  features — local  and  general — suggest 
that  the  impairment  of  hearing  may  Ik'  primarily  depenclent  on  inter- 
ference with  the  sound-conducting  aj)paratus  due  to  defective  !iutri- 
tion  of  "he  soft  structures  of  the  middle  ear.  The  subjective  symp- 
toms are  a  gradual  deterioration  of  hearing  power  without  timiitus, 
one  ear  lieing  usually  more  affected  than  the  other,  and  varying 
with  the  general  health  and  condition  of  the  patient.  On  objective 
examination  the  membrane  may  be  normal,  but  sometimes  looks 
thinner  anil  clearer  than  usual.  On  inflation  the  Eustachian  \\iho 
is  patent,  but  very  slight  if  any  improvement  results,  the  injection 
of  the  malleal  vessels  after  inflation  iKMiig  also  slight.  \\'itii  the 
Siegle  sj)eculum  the  membrane  and  malleus  often  move  well,  but  as 
a  nile  with  no  good  effect.  When  tested  with  the  tuning-fork  it  will 
be  found  that  the  internal  ear  is  also  impaired;  in  some  the  internal- 
ear  impairment  seems  to  predominate.  Paracusis  and  true  auditory 
vertigo  do  not  occur,  fin  some  cast>s  (iardiner  Brown's  test  gives 
a  normal  result,  owing  t(>  the  equal  impairment  of  both  middle  and 
internal  ears;  this  sign,  first  pointed  out  by  T'rban  Pritchard,  is  of 
gn-at  value.)  With  regard  to  the  diagnosis  of  this  condition  it  must 
t)e  admitted  that  it  is  usually  difficult,  even  in  the  presence  of  marked 
evidence  of  general  arterial  disea.se,  to  clearly  separate  these  cases 
from  those  of  senile  nerve  deafness.  Tlie  treatment  in  tliese  cases 
is  general  \  no  local  trentrnertt  is  of  any  service. 


INDEX. 


Alxliiction.  niirinal.(li'i:ii'''iil.  I'>1 


t  1(1)1  (KNS  pan  >!•<.  17(1 
i\ 

tosliiin  pnwiT  lit'.  ItH) 
Abi'rratidii,  clirumalic.  •>."• 

incrcnsc  of.  willi  incn'a"!'  oi   -ir.r  nl' 

iihjpct.  fi.'i 
splicrii'al.  (i."> 
Absct'ssof  brain,  ill  iiiastiiiililis,  1121 

rrlaliiiii   i>\.   (i>  (iiscnscs  of    tlic 
i-Yf.lVM 
rcri'bollar.  in  iiiiclillc  oar,  1121 
otic,  117:i 

iliauiin-iis  of,  (lifTiTcntial, 

1171 
svinptoiii-(ir,  1 17H 
lii'aliiicnt  (if,  1 171 
ccri'bral,  in  niic|illi--car  di^iasr,  1120 
ot  ic,  1 1 1,1,1 

(liagniisi-iof,  1171 
cliiilocv  c.t',  11(1!» 
■^yinploiiis  111',  1 100 
Ircalnirnt  nf,  1171 
of  lonjiincliva,  2S(i 
of  corni'.i,  .'tO.'i 
of  eyelid,  210 

of  middle  ear,  extradural,  1110 
peritonsillar,  00:{ 
pharynpeal.  007 
retropha'-yiiseal,  1017 
subdural,  1101 

symptoms  of,  1  lOI 
treatment  of, operative,  1102 
tonsillar,  liOll,  Ot):{ 
Aceessory  sinuses,  diseases  of,  022 
Accommodation,  Ii7,  77 
amplituileof.OO 
in  astifiinatism,  103 
in  liy|K'ropia,  Oil 
measurement  of,  tiO 
mcehanism  of,  07 

Helmholtz's  theory,  t)7 
Tselieriiiii(!'stlieory,O.S 
spa,sniof,.Sl.  ls;{ 
variation  of,  with  age,  00 
Aceommoilat  ion-eon  vergenee,  1,52 
Aceoiiimodative  asthenopia,  109 

effort  ."IS  a  factor  in  the  causation  of 

glaucoma,  "iH 
myopia,. SI 

power,  estimation  of,  bv  means  of 
te.st-letters,  7:{ 
.\cid  caustics,  7.")0 
Acne  of  the  conjunctiva,  202 


Acne  rosacea,   nlalioiiof,    !<■  diseases  of 

theeye.fuiO 
Acromegalv,  relation  of,  to  diseases  of  the 

eye,  0^0  ■ 
Adams'  o|i<'iatioii  for  ectropion,  2.V1 
Addison's  disease,  relation  of,  to  diseases 

of  the  eye,  ."iN.'i 
.Vdduction,  normal,  degree  of.  1,")4 

testing  power  of,  l.'iO 
Adeiiocarcinom!!  of  nos<',   p.'itliolog\    of, 
71S 
of  throat,  pathology  of,  71s 
.Adenoid  tuberculosis,  701 
vegetations,  102.'^ 

iliagnosis  of,  1020 
etiology  c.f,  102:5 
prognosis  of,  1027 
svmptoms  of,  102.'i 
treatment  of,  102S 

operation  in,  10'20 
tecliiii()ue  of  operation  in, 
1020 
Adenoma  of  caruncle,  203 
of  conjunctiva,  291 
intrana.sjd,  !S9t) 
of  larynx,  7'20 
of  nose,  pathology  of,  720 
papillare,  S,S.S 

diagnosis  of.  8S.S 
prognosis  of,  888 
symptoms  of ,  88S 
treatment  of,  888 
of  soft  palate.  980 
of  thro.at,  palhologvof,  720 
After-cataract,  tS,-i,  497,  .V21 
.\lbinisni,  371 

treatment  of,  371 
Albino,    ophlhalmoscopie   representation 

of  an  eye-ground  of  an,  52 
.Mbinotic  fundus,  340 
.\lbuminuria,  relation  of,  to  di.^eascs  of 

the  eye,  ,598 
.Xlbuminuric  retinitis,  423  425 
.\leoholism,  i-elation  of,  to  diseases  of  the 

eye,  ()0t> 
.Mderton's  pus  basin,  1136 
.Mlport's  ear  forceps  1143 
.\loi>ecia  of  the  evebrows  and  evelashes, 

031 
.Mteniating  convergent  strabismus.  174 
.Vmaunisis.  infant ilc,  440 

uru'inic,  424 
-Amblyopia  ex  anopsia,  172,  .573 
ti  '  (  1201 ) 


I  •_'()•_' 


iM>h;\ 


\lnl'l\ii|>iii. 


.Ill.lH't 


llUi-trl. 


\||. 


rU„U 


II  ,   ("i^ 


v> 


.1.  I(>.i>> 


1 1' 


■:i 


iri\  ( (i-t:rir.   ."t77 

Imiii  lnriHtr-fliMi;!',  .*>7^ 

li\-lrri,-.-il,.'i71 

HcMii  lij;iiliiii'«  llii-li,  .■>7S 

iii;il;iil.'il.  .">77 

<|iiiriirii',    llil 

i.ll.A,  ,-,7!i 

■.iiiiiil:ilr.l.."i71 

iiiit-riiii',  ."(77 
\rMilni|ii:i,  I'lirri'i'tliiiiiir.Sd 

•  litVii^Miri  iinap'-'  in.  77  7^ 

\  i~i(in  in.  77 
ViiMii'^i.'i,  \  i-.ii:il.  171 

Vinyl  ;il('i>lii>l  .'i>  .'i  i':m<r  nt  lllilllhll'^.'^,  liori 
\nnloiil  (liM-.M-i-  111'  llii'  iiiiijuncliv.'i,  'J.SI 
\njini:i  nl  miM-.  lis'.i 

ri'l.'iliim   III.    Ill   ili-i'ii<i'-  111'   ilir  CM', 

\n:t'-llu'>i;i  111    iiiini':l.    'I'J'J 
111  l:ir\n\.  KUti 

III  11 I(l|(l 

lit  |ili:ii\n\,  10i:{ 

■  liiiluu'viif,  lOlii 
-vin|iliiin-iiif.  KMH 
iir;ilinrnt  nl,  l(»i:f 

ATiii>;nii-i;iki'-  ;inil    Hiil/'<  ii|irrMi inn   I'lir 

iriilii.-i-i~,  2'>'J 
\n:i|iliiiri;i,  17li 
\n.ilrii|ii.i,  17r> 
Aiii'l'-  lai'i yinal  M  I'iiitfi'.  22(1 
Ani'MriMn  li>  an.'i.-tninnsis,  orliilal,  201 

ri'l.'ili r.  til  ili*i':i-i>*  111'  till'  I'M',  t'lUCi 

\ni:iii.-ii|iii:liiitii|r,i.si:i 
l.niiwi).''.-.  l(il:i 

inrnilinniiiu-   i  nmi-iliplii  ln-riii!  i,    !!!)."> 
i|i,'it;nii-i»  III,  'Mt't 

ilitTiTi'tiliiil.  liOli 

■  ■liiiliiiiv  111,  !!!•.'". 

^\  rniitiiin"  uI',  W.'t 
tri';itnii  nt  of,  !t!lli 
Ajjirii'iiia  III  run  juni'tix  ;i,  2.*i!* 

.iliyi'liiN.211 

intranasal,  sxs.      i  ,n'.  .  Iiil  raMa>,il  Aii- 
i;iiini;i,  i 

111  Ian  ii\.  IHI2 

111'  iHi-i',  |iatlLii|iii;\  111',  721 

111' iirliil,  2(11 

111'  >iill  iialati-,  !IVI 

111  Iliriiat,  pallmliiLM  m'.  721 

111  nMila.HSH 
An({ioiirMrii>i>,  (ilM) 
\ni.'li:il|ilia.  \r,:i 

K.inirna,  1."i:< 

inilrr.  1.V2 

\i--ii,il,  71 
\niii(li,i,:tlS 

iniici-nital,  ulai'i'iiina  InllnninL'.  ■"i">2 
\nis()iori;i,  Ml 
Xnisiiini'lriipia,  Kts 

pn  -riiliinj;  ;;ia»i>  I'lir,  \.i2 
\nk>  liiiiii|iii,M-iin,  2.'i."i 
Xiniiilai'  piisiiaiiir  ^vtuTliia'.  :{,')() 
\nii-.inia,   MKiS 


>vtnptiiin»iir,  KCC.I 
l( 


prii;;iiii«i.  nl,  l(IH!l 
iri-alinrnl  nl,  llCt't 
\nn.plni-ia,  I(i:is 

Itinliim  nl,  l(i:tS 
priimin-i-nl,  l(i;t!i 
>\  inplnnisnl,  l():t!i 
lrr,iliMiail  111,  l(i:VI 
.VnliiiiiMJiainlii'f,  H.'tfi 

I'li.anilr-  ill  till  .  HI  priniai\  irlaii- 

inin,a,  .">:t(l 
I'Mlilatiiin  iiiln.  :tl!t,  :(,M 
1,'i.iilriiina    InllnwinK   <'pith<'littl 

l\  its  in  llir,  .'l.'!! 

Iirninrrliaur  illln.  .'<li2 
Alitliiav  111  (liiiyvliil,  21(1 
\n(ilii\n.   ilani;!'!''-   nl,    in    (rratinrnt    nf 

iliplillirii.i,.V{.'> 
.Xntriiin    i\>l«  nl,  <>7'.>.     [Sn    .Miicncclc.) 
<lriip«v  nl,  !t7!».     i.s'fc  Miiidcolr  \ 
111  iiii:liniiiri',  <*2:< 

llrM'Inpnii-nl  111,  It2(i 

Aphakia,  177,  ,V2:i 
Apliakir  lyr,  .V.) 
A()ili'nns  Iniinnr,  :(l,'i 

i-liaiici-i  in  ilii-,  in  piiin:ii\   ulau- 
I'liiiia,  XVA 
.\riii>  M'liiii-  rnrni\r,  :tl7 
ViUxll-IIiilirftoiii  (ipir.atinn  mr  rrlropinii 
2.-1 1 

pupil.  .!2 
-Vryyvia  rnnjiinit  i\  :r,  jss 
Arcymsis,  2ss 
Vrlt's  iiii'lliiiil  111  l.li'pli,ai-iifila>(y.  21,"),  21('i 

n|ii|-.al  inn  Inn  ((rnpinii,  2.VJ.  2.")."> 
\rli'i-,a  iinlialis  let  ilia, ,!:{:{ 
.".rtciii-.  ,1-iiniliiii:  pliarynci-al,  1(K).S 

annnialirsiii  ilis(rilmli(iii  of, 
KMIS 
Artifiii,ij  iyi>,  IKi 
.\>ili  npi'iaiiiin.  I't'J 
\-nill-,  -ii|i'ln-('ii|WMil',    l()."i 
.\-lrniiil  livalili~.  li.s.l 
.X^lliriiiipia.  Kin 

ai'cnini:iii(latiM'.   KMI 

ri'plialalci.i.  l(l!l 

ilnlcns,  KHI 

irrilans.  I(in 

niiisi'iilai',  1(111 

paiiiiniMia,   1(M( 

iTliniii.  KMI 

simpli'x,  l()(t 

tarsal.  Id!) 
Astliina,  SdS 

i-linliifty  nl,  ,Sds 

palllnlnux  111,  ,SdS 

tn'atini'iil  m,  S(hi 
\sliKinatii'    clnik-l'ari-,  vise   nf.    in  ilctif- 

niiiiiiif;  rrfraci  inn.  125 
.Vsticni.'ilisin.  7t) 

alwiliiti'  icfrarliM'  -lato  in, !»!),  10(1 

arroiniiioilalinn  in    10:t 

rninpniiiid  liypi-inpir,   KKl 

<i)rri'rtioii  of,   lo:!,   107 

ilt'dTiiiinatinn  nf,  (ly  skia.Tnp\ ,   122 


iM>h:.\ 


IJO;! 


E 


X-ni^iii;)!  i-iii.    <lt-mrii)iiali<»ii    o]    I  nrrii-al     Vihlitor 
c'iii'\.'iliitr  III,  li\  kc'iMliiiiiilr  V     I  I  I 
ilrMlii|i|iiiM;   111.  lis 
ilillii-iiiM  iniMi:r-(iii,  ItHl.  Kil 
.liriil.  !t7 
fliiil.iUy  III,  lis 
liliii|uilillr.  Its 

illKli;r<  III  :i  Hill'  t'ol'lliril  ill,  lllj 
illMTsr,  !t7 
irrr(jiil;ir.  !I7 

ilrtiTlnillMlion  III'.   Ii\    -ki;l-ni|i\, 

I  L>:t 

iiii'i'iill,'in,'il  ,'il'i  rnitiiiii  in,  !)7 
iililiiHic,  H7 
|i:illiiilii)!l<':il,  US.  m 
|ili\>iiiliit;i<':il.   lis 

liiiscrilmiKKliO"''^  lin'.  l-il 
|iiiin:iiv.  (IS 
ii'Kiiltir,  !t7 
.'iK''ii>i>l  till'  nilo,  '.(7 
with  the  lull'.  !»7 
M'l'miil.iry.  lis.  !i!i 
^-iiiiiili'  li\  |ii'i'ii|iii'.    KKI 

luyii|>lr.    1(11 
>\  luptiillis  III  l'l'll;liliv 


llli;llll'>.     ilifl.'iMllll.'llliill    III,    ilil- 
lllv.    IIKNI 

i'iioliii:\  I.I.  Iiumi 

-Mii|il -111.  KKKI 

iii'.iiiiii'iii  III.  \m\ 

mrM'.  ilisi'a-K'-  III.  I  Kt."! 
ii'iiriiM'-..  1 102 
\llrlrlr,  liti»l-l.ili'  111.   Ins.". 

-v|illililir,llVi  rlliill-..|.   IIISJ 
«iiiiiii|i  iiiiil  iiijiini'-  III.  KIM 
i|i'M'rl|iliiMi  III,  IIISI 
lii'iitiiHiil  1. 1,   lost.  MIS,-, 
\\l:il  liy|H'i'ii|iiii.  !!.■> 
iiivopin,  HI,  S."i 


1).\('<  >N'S  iiipiiiiiu-Kln--.  HHHI 
)     I'lii-  Nvriiitif,    ll)HS 
Hurti'riii.  siiiliiiim  inr,  ill  x<'<'tiuiii  uf  lUi' 

cvi'luill.  fi-SO 
Kiimliili'l  krralitis,  MU 
l<iisi'ilii\v'>  ili-i'a.s'     2()S 

I'l'll"  inn  .il,  liiili-.r,'l-.i'-iil  tliri'M', 
.VS;i 
MiiiiiiraM'  li'iiM's,  III 
no    Hii'iinvi'X  li'M«'>,  111 


vHUiii  III.  III! 
Atnipliic  ratarrli  nl  iiiiiiilli'  car.  1  l!l,-i 
laiisiliiiii  III,  I  lll.'i 
iliauniisi-'  nl,  1  Mt7 
|iath(ili)ny  III.  1  l!t,-> 
|ir<imiii>i?*  Ill,  1 11*7 
syiiiplDliis  111,  \\'.H> 
IrcaliiH'iit   ol.    1 1".t7 

na'^opliiiiyiisiiis.  1022 

pliarynirilis.  1012 

*\lMpl(llMS  111'.    10i2 

lii-aliiiriil  1)1.  1012 
iliiiiilis,  71ti.  7.S!» 

ijiairnii^i-'  "I,  7'.t.'i 
I'lioliiCy  of.  7!M) 
prii^iiii^is  III'.  7if."'> 
s\  inptiiin-i  III.  702 
Irraliiiriit   111.   7!'.''i 
Ali'iipliy.  ('Iiriiiiii'  iiifl.'iiiiMialiiui  willi  In 
ili'iii'y  (II,  7l(i 
III  i'<injuii('ti\a.  2S."» 
111'  I'.vi'liall,  :i7!l 
laiii'ial.  Ill  lyiiipli  I  is. in-.  72ii 

pallidldcy  III.  72ti 
111  iMMpliiiiil  tis>iii'.  72.-) 
nf  Illisi'.  7lli 

foiiii'^  111'.  7111 
111  rt'tiiia.   122 
iif  tlinial,  7lli 

liiriii'^  111',  7lli 
Alropinr,  iist'iif.  a>a  ryi'lnpli'^ii'.  1 12 
\tnipiMr-piiisiiiiiiiir,   n'latinn   nl.   in 

I'asi's  III  till'  rxi'.  2H,5.  007 
Aiulilniv    iiii'aliis.   I'Mi'i-ii.'il.   ilisi'.'ix's   111' 
lOSli 
iiiilaiiiiii.'ilinii    nl.    lirciiin- 
sirilii'il.    10S<» 
lii.'l^llnsis  111',    lll.sii 


Hiiiiiciiiar  field  nl  lixaiimi.  liiiiiti  nl',  Lili 

visinii,  71 
■  lila.k  I'y.',"  2.->li 
Mlaki''s  iniddli'-i'tir  syrinmi',  11:111 

P  liypiis  siiarr,  1  l.'l.-> 
Mlriiiinrrliii','1,  anil  ',  nl   iniijiinil  i\  a,  27(1 
Uliphaiilis.  241 

jx'ilii'iiliisa,    212 
li|ipli;iriipla.-.tv,   21 1 

.Vrll's  iiii'tlind.  21.').  24li 
l)irtTi'iili.'U'ir>   iiii'llinil.   2ll> 
Krirkc's  iMi'tlinil.  21.-) 
Kliapp'"  nirtlind.  21,-).  217 
'iVollf's  iiictliiiil,  2111 
Uli'pliaiiisp.i-tn,    2:11 

Ili'alMirlil  nl.  2:)1 
HliniliH'ss,  ciilnr.  .'it'iS 
ila\.   .■iSO 
iiililil.  '"iSO 
'^nnw.    ,*>SI 
•  MliiikiiiK.'  2.1-1 

lllnnili^ilpply  In  iiiiildir rar.  ilcrK'iciit.l  IIM* 
rliaiiKi's   pmdiu'i'il 

liy,    ■<'<)'.> 
diagiinsi.s  (if.  1 1'.tlt 
svinptDins         and 

■  siKIlSllf,   11<»<) 
liralnii'iit  of,  11!M» 
HiKWiutli''*  nasal  .siw.  7'u 
siiari',  7(>1 
s|)t'i'iilnni.   7:11 
Kinirliiriin's  s]H'riiliiiii.  llt7S 
Ilnwniairs  int'iiilirani',  2it.*i 

npi'ralinn  nl  slitling  ll"'  I'analinilii^. 

221 
prnlii-.  2l!»,  221 

iin'llinil  111'  iiisiTliiiii.  222 
ill  posilinii    22:1 
I'tiiilony  (if,  lOHit      Uraiii.  alisccs.s  ol,  in  niastoidilis,  1121 
syniplmns  of,10S!)  ii'lalinii    of,   lo  dis<'as»'s   nf   ilir 

Iri'.-ilninil  nf.  lOSll  cvr.  (i:i4 


dis 


1-Jllt 


iMii:\ 


lll.lin.  (Ji'M':i»i-'<  111,  fllrrl  it|.  upon  t  It'    r\r, 
Ihil.Thtl 
ilijllll>-   111.    itTi  1  I    111      U|iiiM    III-    i\r, 
1 1.".!  I 
r.niNilrnii'^  turn  iw,  lo:i(l 
llniini'-ni.   rrl.'iliiiTi  iil.   In  ili-i  :i.i  .,  hi   i  In 

IV1-,  {Ant 
Hriiiicliuil  (ulii'»,    ril.iiiiiii  ill  ilw.i-i^  m. 

to  ili-i  .i-iH  111  lliiTM  .  :,'.>:, 
IliiiHu'i     \|iin:iii'   l:ii\  iiv'' ill   »\  miii;i-,  !tl;i 
liiirk'H  liliiiil   (•iiri-ilf.    IIITM 

)jl.i»s  pi|M  iti\  I  l:;!i 

Hiilli.'ir  p.'ii.'ily-i-.  iil.'itiiiH  111.  til  ili-i;i>i'» 

111    till-  i\r.  lil.'i 

liiiiiniis  kiiviiiii-.  .nil 

HiiplillialiiiiK.  ;i.'l 
piiiti.in  ,    "i.Vf 
Hull-'  Imi-ilhir  li;i  tiii.-l:it.  IIMIJ 

/'.\N  \I,.    hv:.li.iil.    .{|l.     •.I.-. 
\       Ml   I'liii.   17ii 

-rliliiiMir-.  :!•_•"..  :(:i'i,  :ill.  ;il.'i 
i.'iii.'ilinili.  Jl  I 

-tiMlli-U  111'.  'Jilt 

<  .■iii.-ilinilii-  kiiiH'.  U    '     ■  -,  '.'•-•.• 
t.'umlii.|il:iM>.  S.is 
('•■Jilt  I        iiiiv.  i'ts 
<':i|'    !i  ir  i'ill:ir;ii  I.  |s."> 
iipacilii-^.  I'.IT.  .'Vlii 
Cup-iiU'  liinip-.  ."ills 

rilmll'-i.    1  I'l 
I'nrimn  -iupxiilr  pni-niiiTii:.  n  latjnii  iif.  in 

ilisi'.'iM-  111'  Ihi-  i\i'.  Kill.  IKIii 
('.•ulillliilr  ill'  r\i-liil.  21" 
I 'arriiinfna.  inlr;uia-al,  N!I2 
ili.'illii'i-ii  111.  VI.'S 
'miM^  111.   S!K1 
p.itliiiliiirv  oi.  .s!t:t 

-\  lllplnlns   111.    SWt 

of  i:irvii\.  '.Mil 

iliamiiivi-  III,  'Ml.'i 

illlii-ITljIial.  (HI.-) 
ili.iln!.'y  III'.  !HI| 
pallioliiuy  III,  (HM 
pmiriiii^is  111.  !KMi 
'yiiiptiiiii^  ot'.  '.Ml.'i 
irr.-iliiii'iil  111.  '.Mlli 
ol   iiaMipliaryiiN.   Ili:i."i 
nl  nci-n',  pal  liolous  i.l.  71s 
01'  Mill   palati-.  !tMI 

-yiiipliiin-  III.  !is'i 
III'  tlirnnt.  patliiiliiL'v  ol.  7ls 
iit'lim-il,  IINK 

ili.-iiiiiiiNis  111.    KKT. 
Iialliiiloirv  111,  l(H)4 
in  .•itini'iit  111'.  HHI.'i 
111' iiMila,  (ISII 

-\  inplnin-  111 .  !tsi» 
CaniTiilr.  aili'iiiiMia  ol.  2ii:i 
ihalk\  i|i-pii-ils  ill.  -J'Xi 
ryslir  I'Tilalirrinrlll  nl',  'Mi 
piipilliiiiia  of,  '2U2 
ra.=^r!hrrrv^  '.uyiit.  .li  i!iii,,iii,   •,ini 

tni>ili(iiil  Alli-ii  -naiv,  '.US 
''ntaplmna.   17li 
( '.■ii.ir.'H  1 ,  ai'iiT-,   IS.",    I'.i7 


t  alaiai  I.  In  uniiiiiiL'.    Is7 
i.'ip-iilar.    IVi 

iiiliiiiir.    Is.'i 
pii-iiriiii.   Is,",.  |i|7 
•  linrolilal.  .Vr.' 
riilliphi.'lli'il      .MM) 

Iri'alnii-iil  nl'.  ."ilHi 
ninicriiilai.  i'iiiilii|;\  ui.  .'iiNi 
iiiiiii-.il.    I'M 
ilmliiLM    III,   "iim 
r\lraitiiiii  111.  ."idtl 

ai-rii!rlil-   illinm:   lln'   iipitalinn, 

.Mi( 

liltrr-llvalMirnl  nl.  ."ils 
alliilli.'llir-  111  lll'.'lillll!,  ."lis 

illiiii I   iipiTatinll,  ."llli 

I  liiirniilal  lii'iniirrliaiii'  I'lillnwine, 

.".17 
uilli  IihIi  iimin  ,  .")10 
«  iiliniil   iriili'iliiniv,  ,"i1  I 
Ili.lMhrr     nl     .'IppKlliL'     i'ir-<.«iiitrs 

allir.    .•.!:( 

tllni|i|ir.llinM-    111     till'    npiTatillll, 
."ll.-l 

-iiii    'i.  Inn  .ir    ."ilitt 
fiilliiHiii,         IoimIiIii,   I!MI 
fri'ipiii  ula-,-lilinMr-.    |S7 

ill  !  1  r.-iiT,   ts7 

In  pi'iiii.iliiii  H 

l.'iiiii'll.ir,    I'.Hi 
Irnliiiilar,    isii 

liriiiin-rrilii'il  -talimi.in-    Irrat- 

IMI'llt   111.   "ilM 

rliiiir:il  -tairi's  of,  li\  piTiii.'iMire, 

i!i;» 

imipii'iil.  ■\'X\ 
intiiniivsivnt,   19:', 
iiialun',   W.{ 
swiijli-ii.    »!•;{ 
..iui-i.iil'.  I!tl> 
il.a>;iiii>i>  nf,  ,l!i:i 
iliiilnity  nf.    ISti 
patholo(ty   of,  4S7 
pmciinsis  of,  4iH) 
i-\  niploiiis  nf,    1111 
lri.;itini'Mt   ol,   ."ifM 

priiL'rr«>ivi.,  ."lOI 
UM'  nf  Miyilrialirs  in,  ."iO."i 
111  iiiyiitic-  in.  "lO.") 
-Miiri;:ii;nian,    l!M 
iiiiilrav.    I!i:{ 
polar.    IS,") 

anti'riiii.    IS,"i,    |!)7 
|if)sli'rior.  )s.-,,  |s(i    1(17 
"ripi',"   l.'vi 
scrondarv,    I!l7.   ."i2l 
'Oin'lo,   ISS,   IS't,    KMI,   MM 
ti-aiiinalii-,    isl 

I'tiiilojix   III.  4S2 
trralini'iil  of,  4s,i 
trralinrnl   of.  ."id:! 
zonular,    l!l(» 

I  rral  inrnl   nf,  ,~id  i 
Catararla  ai-iTrla,  H.')! 
rntarrli.-il  iliplitlicria.  ti!t7 
'piirlniiitis.  si:; 


iM>i:.\ 


I2<W> 


C'liliilrnpia.    i;ii 
Caiintii'.  iiihl.  7.Vt 
Cav"'riiiini:i  nl'  riiujiiiuliv.i.  J.VI 
C":i\'TiHni*  ^iiiti**,  llirinrtliiwis  oi ,  '20\ 

.■iiuiuitv  ui,  -jcn 

iriK  rll\r.    I  lliH 

l-lil.lHdV    111,     1   lllS 

|ti'<iiriii>>is  Ml".  1  Hi^ 
-vinploiii"  111.  lliiS 
^s  iit|iiiiMi-t  III.  2t)2 

iM'UlllM'lll    III.  'JII'J 
('.■ll-i,  itllM.l.l.lllI,  <CS 

■•iiiuliiiiiv  111.  'f2S 

ilr\i'lii|Mni'iil  III.  ilJH 
OIluliliiMl  (liiM.rliil.  I'.l.'i 
CcrrliiH.ii    ali-i'i-i-i  ill  Miidillr-i-iir  ili-M.':!.*'. 

ii'.M.  il-.':> 
mil-.   Il7:t 

ili:iHMii-i-     ill.     ililTiiriili:il. 

1171 
^\  in|itiiin*  111 .  I  I'-i 
liciitiiunt  III.  1171 
CiTi'lir.i!    .ili^n-^    III    iiiiilillr-c:ir   ilisi-ii<c, 
11  JO 
iitir.  Uli'.l 

ilianiiii^i-'  111.   Il"l 
fliiiliiay  111,  I  Hi!' 
syiii|ii(iiii<  111,  I  Hill 
trfllllllrllt  of.  1 171 
nii;riiii  1.    ril:ilHiii   iif,    tii   ilis<'as<'S  of 

llii'iM'.  t,:il 
lii'iiinrrliHU'  ,  rcliiliiiii  nl,  m  iII^k'Sisi-^ 

iif  tin-  I'vr.  filU 
llV|Hnriliiil,    irhiliiill    nl.    In    ili-|.;iM..- 
'  ,if  till' eye,  li:il 


I  I l|ii|ll:l,  li;l«,ll.    '■''>■! 

I  if  in  1^1',  [Hit  111  ill 'i;\  111 ,  7JI 
Iif  iirliil, '.'01 

iif  ihriial,  |iilliiiliitf\  nl.  TJI 
(■llnliliti-  Ilnilii.il,  S'Si 

llilltflln-ii  of,  'iJS 
fliiil(it{\  111.  ^J'' 
■•ymiiti.iir.  nl,  ^J*< 
Irrlllllirlll  iif.  VJ7 
ClinriM  nl  l:irMi\,  lOl'l 

(,'liiiniinlilllti«    ililTll«.-i    >\iiliilit;i:i,    :ilia«- 
lillc    iiiiil    rilaliM-   r\n)l  >rnlniiiiit;i 
in,  :i7l 
pijjiiii'iila,  iniii  niiliiiM  nl  \  iniial  liclil 
ill,  ;{7.'i 

>\  pllililii'.   irlllril  :lli-nlllli-   llll'l   rilii- 
livr  <|.nliifii:l  ill.  )i7  I 

('liiiriiiil.  iiiiatniiiv  111.  :II0 

atrnpliy  nf,  m  ijlaiirniiia.  .V!H 
I'liaiiiti'^  ill,  HI  iiiyii|iia,  .'i7l> 

ill  |iriiiiiiry  Klaiirniii;r,  .VW 
rnlniinnia  nf.  H7I 
ilrlai'liliii'iit  nl,  il"*! 
liyiM-ra'Miia  n|.  :t7-' 
iiijiirit'-  nf.  :(.s:t 

iitTvi'^t  (if,  :ti  I 

i)|>!itlialiiiii«iii|iir  :ip|iiaranii'  nf  the, 

nxsifiralinli  i.f.  :(,S() 

|H'ni-t  rating  \miuih1-  nl,  IIMI 
piiiiiiriit  -liniiia.  I  I'll-  nl,  ml 
nipliirr  nf.  ;>.M 

Irratiiinit  nf,  :isl 
-.'innina  nf.  .{Vl 

srcliiral  1  .iiii  rail  inn  in,  37.J 
tli'.KTriilar  i|ipii>il-  in.  i(7li 


plnsis  1,S2 

,i.|rni«i».  ililTii-i'.  iilalinii  nf,  (n  di^-  (  hnroidal  <alarai't ,  .Ml'.' 
i-a-i-  nf  the  rye.  I'll'.'  riiiK.    1>» 

Ori-lirn->pinal   nii-niiiniti.-,  ri'lalioii      I.  In  pi)!iiiriil,  fnnilinii  nl,  lit 


lisi'asrsnl  till-  I'Vi',  li:i'.t 
liiinnri'liu'a,  Idli 

>lianiiii>i>  nf.  1012 
itinl.itfy  nf,  1012 
<ylllptnlll-  nf,  1012 
rrraiiiiiit  1 4,  10i:i 
Ctniiiirii,  inipacli'il,  lOMi 

(li.'is:nn-.i^  nf.  10.S7 
ilinliit;\  nf.  lO.SIi 
priiKiin^is  nf.  10S7 
-viiiptnms  nf,  I0.S7 
trfalMiriil  nf.  ItLSS 
Clialazinii,  212.  2l;t 

forci'p'^.  Iti'sinani  -    '-'IS 
trcatnii'iit  nf.  2lli 
ChaiiiiliT  ailjn-Ial.li-  -f.it  :iiiil  ili'>k.  1  11 
Chapiii'^  liiiij:i|i'  (lrpri>»~nr.  7ii."i 
Clii-i'k  lisaiurM.  i\!.-rnal.  l.'iO 
iiilri'ii.-il.  l.'iO 
lilj.'iiuciils.  aclinn  nf.   | .">0.   !.")1 
(Jhcmii.sis  nf  riiiijiinilna,  2*<t 


"t'lioroiilai  ili-tiirliaiH'i'."   I>>7 
(linroidili-c  .'intiTinr.  ,'i7'i 
arr<ilari<.  :i7.'i 
cintrali.-i.  'A~'> 
.liffii-a,  :i7li 
ilis.scniin.-iia,  :i7ti 

olirniiica,  p.iiaii-nlral  and  |)f'ri- 
icnti'al  M'olninata  in,  374 
i\iidali\>',  aciilc,  372 

rnlll-M'  nl.  372 
ftinln>;y  nf.  37:< 
syinptnn.-  nf,  372 
tri'attni'ni  nl,  373 
varirtie.s  of.  37."i 
>iippili'aliva,  377 
rniir^f  III.  377 
I'liolniiy  of,  37.*^ 
pi'ii^nnvis  of.  37*N 
syinplnms  of,  377 
tri.'itinrnt  nf,  37"* 
( 'liinnialic  alicrr.'ilinii,  11.' 


Clilnral-poisiininy.   ai'iitc.    n'lalioti   nf.    to  Chrysarnliiii,  im  jiinctivilis  duP  In,  2Sl) 

di.^i':iii"iiif  till- i-vr,  CilMi  Cicatricial  cctropidii,  233 

Clinlcra.  rclatinn  nf.  In  ,|i„-aicvnl  llui-vc,  cut  rnpuiii,  240 

1120  I'ilia,  231 

Chnlotcrin  cryslali- ill  till- \iiii'nM-,  3s7  Cili.ary  hody,  clianitc-^  in  tin',  in  primary 

Chondroma  of  larynx.  'Mr'  slaiicoina.  .")32 


V2m 


IShEX. 


(ill: 


lii.dy.  Ii\  jirnniiia  ol.  M'.t 


>pi 


:lll;lt()liiv  <il'.   :{;{s 


iijiini-li\M.  I>I(mmI  Mipplv 


hull 


ipir  ;iii;iliiiMy  iil,  XiS 


i'pilli('ll< 


cfHiKt'sI  ion.  21 
niTvis,  :{»:( 
Cilici-rciiii.-il  :iiliT\ .  .'il 
Circiiliiliipri,  ili>niiliaiiccsiir.  in  rrlatidii  to 

cliM-a-csol  tlii'iiosranilllircial,{>.S!» 
Ciniilatiiiy  >y<trni,  i-lTcct-  nl    i|iva-i-s  cf, 

lipiili  the  ryi-,  .V.t.'i 
C'iniilii-*  ariiTiosiis  iridic  uiajiir-.  :il2 

niiiidi-.    :i\-2 
f'irnjinciiriH'al  loiicr^tinii.  21 
C'irfiiMilrntal  -pai'c   I7(i 
C'Irl't  ivilatc.  !IMi,  llMi."> 

.•tidliicy  111'.  l(Mir> 
iipi'ialidii  ilrscrilii'd.    l(Mi!l 
syiiiptoins  111.  lOliti 

trriil nt  dl'.  10()(i 

Oicaiiii'-poisiiiiinj:.  ri'lalion  oi,  to  ili.-ca-o 
of  lliiTvc.  2S(i.  liOT 
iiM'of,    ill  i|israsi-<   ol    llir    riosi'  ami 
tliniai,  71.'> 
(-'olirii's  larviiiri'MJ  coitoTi-lioldiiii:  lorci-p., 
Jf.l2 

jPillold  drdcMiMalion.  T2."i 
pallKilogy  ol,  72."> 
rrailioii  lo  ~iaiii>.  72."> 
O'lolioina.  clioniidal.  :i71 

srcloral  I'oiili'aclioM  diii'  lo,  :{7I 
ol'iv.'lids,  2H.S 
iiidis,   HIS 
ol'  iris.  i-oMj;i'niial,  His 

Klaiiroiiia  liilhnviiiir.  .V)2 
l<'Mlls,    177 

ol  -lif.alli  ol  ilii'  upiic  iicrvi'.    l.VI 
Color  liliniliios.  .Vis 

I'lioloyy  ol.  .")71 
inriM<  ol.  .'■)70 
li'-l-  ior.  .")71 
\i.--ioll.    ^'olllll;-H^lTIlllol^/    ihrcrv   ol'. 

■i7() 
VoiiM(i-Hi'lnili.ili/  iliiorv   ol   prodiii'- 
lion  oi.  .")( 
Coinpoiiiid  li\  |«'ropii' ii-lii;iniiti-m.  l(l(( 

opiic.il  <y<ti'iii,~.  liH 
(onc.-ivf  i\lindir.   Idl 

mirror,  u-r  oi.  in  ~kia-copy.   12(1 
<  'onca\i>-ron\i'\  Iimi-i'-.  Iil 
CoMHrslion.  ini\i>d  ioriii<  oi.  21 
Conii'.il  ■■■.riic-,(.  Hl!(.  H20 
I'onJMualr  iocal  ili^iancc-.  .■>7 
ioi-i.  ."i7 

l.-m  oi.  IKi 

ri'l.'ilJM'  po-iiioii-  of.  .■)7  ', 

|'aral\-i-.   Isl 

prou'no~iv  ,,i.   is| 
tri'alinini  oi.   I>2 
roliJMIlrti\.'|.  2.">S 
.il.^cc—  ol.   2Sli 

ain ,  2'.I2 

adi'iioni.i  oi.  2!ll 

am\!oid  di-:ca--.-  o!     2s  I 

aiialorny  of.  2.VS 

.■inirioiiia  oi.  2.Vt  ! 

.-itropliv    of.  2s."i 


catarrh  of,  dry,  2.Vt 

caMTiionia  oi.  2.")!l 

I'liaiifT"'  in.  in  priinarv  glaucoma,  .V2S 

clirniosi"  oi,  2S(i 

'ondi'tiilal  alinornialilics  of,  2.V.> 

lysl-  of.  2ill 

di'rniiiid  iiinior*  of,  2.">!l 

drvclopiniMI  oi.  ;{;ili 

I'lrlivino-iis  of.  2.S(i 

rinpliysrin.'i  of,  2s(i 

t'rcalnicnl  of.  2S7 
I'pillii'lionia  of,  2V2 
tiliroina  of.  2.".!l,  2!M 
Koiit  of,  2li7 

Irratmcnl  of,  2(>7 
granuloma  of.  2!)l 
liy|«Tainia  of.  2,V.) 
injurii's  (o,  2S7 

trcatincnl  of,  2S7 
Icpid.sy  of,  2.sa 
lipoma  of,  2!M 

lii|>ns  crytlii'TnaloMis  of,  292 
lympli.-itii-  M'^srls  of,  2r).S 
nioli's  of.  2.">!t 
myxoma  of,  2!M 
ni'rvr  supply  of.  2.')!( 
ocular.  2.VS 

osseous  growth  of,  2"i!t 
osteoma  of,  2!ll 
p.'ilix'liral,  2.5.S 
papilloma  of,  2!ll 
pitrmontcd  palclics  of,  2.V.I 
.sarcoma  of,  2112 
syphilis  of.  2S;{ 
lars.d,  2.VS 

tcL-iniricctatic  crowths  of,  2.")!t 
lulicrciilosis  of.  2S2 

pri.nary,  2S2 

secondary.  2S.'{ 
timiors  of.  I)c!iifrn.  2!tl 

inaliKii.'int.  2tl2 

simple  cystic.  2!>l 
Conjnnclival  loiiticstion.  T.i 

sacs.  2.W 
•  'onjiiiiciiv  itis.  2."i!t 

aciite  contagious,  2'iS 

coinplii'alions  of.  2li!l 
cont:i)rioii-'  i|U,'ilitii's  of,  2*)'.' 
diaunosis  of.  2tiit 
prognosis  of,  2l>'.* 
prophylaxis  of,  2ti!t 
symptoms  of.  2tls 
trealnii'iit  of.  2(i'.l 
catarrhal.  2lUI 
I'.'il.'inlialis  astiv  ;i.  2lil 
chronic.  2M 

ti-eatieenl  of.  2s."i 
classi(ic;iiion  of.  2.'>(l 
diplitlH'rilic.  27") 

c:ms4'  of,  27') 

'■"iTipiirai itniv  of.  277 

diatnosi"  of.  27li 

ji.itliolocy  of.  27ti 

|*^ciidorrictnln-;mous.  27ti 


i.M  ;:x. 


1207 


I'oiijunctiviti^.  (liplitlii'iiiic.  tifaliiiciii  m, 
277 
f  rzciimtoNi,  27'.t 
folli<'ular.  2ri2 

causi'  (if.  2ii2 

syni|)t(iiM~  III',  2(i2 

tnalmciit  iif.  2ti2 
gonorrhd'al.  27(1 

iicutr  slanr.  270 

cailsr  111.  27(1 

rlilll|iliralli>li<  of,  271 

(liaciiiisU  of,  271 

pallKilii^y  of,  27."> 

propliylaxis  of,  271 

Iri'.'itirii'iii  of,  272 
granular,  2(i2 

call*'  i>f,  2til 

iliaKiiosi-^  of,  2(>.'> 

patholoKy  of,  2(j.i 

prognosis  of,  2ti.") 

Iri'alMU'iil  of,  2('m 
lacrynial,  2(i(l 

iliagnosis  of,  2(>() 

trcatinrni   of,  2('i<» 
lithiasis.  201 

Ircatnii'nt  of.  2i>l 
nic  inliranc.iis,  277 

<au.-«'  of.  277 

cliagnosis  of,  27^< 


In'atiiirnt  of,  2li() 

.snhacntr,  27(1 

iMiis.'  of.  27(1 
ctintagiousncNS  of, 
trcatniriil  of,  27(1 

to\i<',  2.S.-1 


27(1 


lo  atnipiiii',  2.H"> 

to  hill's  of   insiM'l<, 

to  rhr\saroliin.  2St> 
III  corailic.   2S(i 
to  I'srrlhi*.  2S(i 
2S(i 


lIlH 
llllr 

ihii 

illH 

ijni 

tn'.atnn'nl 
vi  rn.il,  2til 

caiisi's  of,  2(il 
iiatliolocy  111,  2li2 
prognosis  of,  2(12 
syinplonis  of,  2(il 
Irratnii'MI  of.  2tl2 


2S(i 


i; 


trrattnrnt  of 

27,S 

iion-spi'citir  lorins  of.  2li(l 

I'arinainl's,  2117 

faust'  of,  2(17 

tri'altnrnt  ol 

2(17 

phlyflcnular,  2711 

oaiisf  of,  27! 

(liaKiiosis  of. 

2S1 

patliolouy  of 

2SI 

tn'.'itinrnt  oi 

2S1 

pnt'lltliororcic,   2(' 

>t 

ciiiitairioiis  qiialitii's  of,  2ti!t 

(jiagnosis  of. 

27(1 

prognosis  of. 

27(1 

pTirnli'iit,  27(1 

simple.  2(1(1 

causes  of,  2(1(1 

progiiovis  .i| . 

2(1(1 

syinptoin*  o! 

,  2(1(1 

('onus,  annular,  s7 

eongenital,   ^7 

terraced,  S7 
( 'onvergcnce.  152 

acconuiiodatioii-,  152 

insulticieney  of,  15H 

negative,  152,  15s 

paralysis  of,  IS\ 

pinu'tuiii  proxiniuin, 
reniotinn,  157 

wi'akncss  of,  1.5H 
Coiivergeni   sipiint,  172 

straliisnius,  172 
Converging  meniscus,  (11 
(,'onve.\  spherieal  test,  ItKl 
Cords,  vocal,  |Kilyps  of,  714 
Cored opia.  Ills 
Corel vsis,  ,{7(1 
Corne.i.  2<i:{ 

alisccss  of,  ,  05 

ana-sthesia  of,  52!l 

ai'lloniy  of.  2!1H 

anterioi-  epitlielial  layer  of,  205 

lilood-staining  of.  .'{22 
treatineit  of,  .i2'.i 

liurns  of.  :r2:< 

changes  in  tlie,  in  priiiiarv  Elauooma, 
52!l 

conical.  ;<HI,  :{'2(l 

deiKisits  upon  posterior  sinface  of,  in 
cyclitis,  H51 

development  of.  :W.5 

ectasia  of,  ;U7 

fistula  of,  ;{(I5 

treatment  of,  MH't 

foreign  iHidies  in,  :121 

treatment  of,  :{22 

inliltralion  of  tin',  originating  from 
the  p<isterior  siuface,  :Uli 

injuries  of,  .'521 

manner  of  testing  sensiii\enessof,  27 

nerves  of,  2!Mi 

oblique  section  of,  2!Mi 

sc'tioual  view  of,  2D1 

'■  s.M-p.Mit  iilciT"of,  :t(Ki,  :<(it 
smallne-s  of,  as  a  factor  in  tin'  caiisa- 

lioii  of  glaucoma,  .511 
striated  opacities  of.  'M.'t 

treatment  of.  :!l(i 
ttunors  of.  :(21 

ulcer  of.  acute  sloughing.  Htll 
infected.  ,■«)() 

eiiural,  :i(12 
serpent.  HtKl.  ;<(M 
-iinple.  :iiKl 
variolous,  M)'t 
Corneal    curvatun*.    applicalion    of    I'la- 
ciilo's  disk  ill  (lelermiiiiiig.   Ill 
epithelium,    iiiiule  of  ilcmoiistratiug 

loss  of.  27 
loiip,  25 

rellex,  e\amin;itiiiii  of  the,  21 
t'ssne,  regeneration  of.  2'M'> 
Coriiii  hmnaniim  of  evteriiMl  car.  Kixii 
Corlic.il  calar.ict.   Kit 
Cough.  rcHc\  nasal.  I(l»:{ 


1 
I 


ll'OS 


im)j:.\ 


"On'ck  ilutri 
Crow 


H 


i|),  ili|ilitliiritic.  s:t2.     (Si:e  l.aryiiKeul 
IHplitlicTia.) 

iliacmisis  of, 815 
■  liology  ot,  SU 
|>.itlu>l());y  of,  Sl,"> 
pruRiiosis  1)1,  SIO 
•ymptuins  of,  .Sl."i 
Iriatiui'iit  111,  Sltj 
Crusta  lactca,  2;i!( 
Cryptorilillialinos,  2;<!S 
Crystalline  lens.  t>3 

anatDniy  of,  47  J 

clianjji-s  ill  the,  in  primary  glau- 
coma, a.i'A 
Kiloboma  of,  177 
lOMjrcnital  abscnri'  of,  177 

anomalies  of,  177 
lortcx,  471 
ili'formity  of,  in  a  cataract  from 

chronic  glaucoma,  50.'{ 
ilcvclopmciit  of,  ;{:j2 
ilislncation  of,  47'J 

glaucoma  liue  to,  549,  550 
into  the  anti'rior  chamber, 

480 
into  the  capsule  of   Tenon, 

4S0 
into  the  vitreous  cliamber, 
181 
''iuliryoIog\-  of,  47t) 
e(|uivalenl    rcfr.-irtive   inilex  of, 

lossa  j>ati'll:;ris,   17t> 
liyaloiil  f(wsa,  47<i 
Icni-ocylic  infiltration  of,  :>22 
IMldcM*  of.    174 
upai  itiesof.  4S5 
|)oles  of,  I7t> 
|irismatic  fibres  of,  475 
wounds  of,  17H 

glauciiniaibie  to,  54H 
Cm-ctlcmeiit  of  laiynx,  !M<1 
"urvature  hy|x>ropia.  (t5 
myopia,  pcrniainnt,  85 

lrai]~icMl.  xt 
•o's  laryngeal  foreep>,  !ll<i 
.clitis,  couise  of,  :i."i,'{ 
etiology  of,  :{51 
prim,-iry.  .'!55 
se(]uehe  of.  :!.">:( 

Ireatmeiit  of.  a:,s 
-erou<.  glaui-oma  following,  ."ill 
Minploms  of,  :!52 
treatineiii  of.  :(.'i(l 
Cyclophona.   15S 

detection    of,    l.v    .\la.l.lo\    (h.ulile 

prism.  171 
ii'eatrncnl  of.  171 
Cycloplegie,  rjielhoil  of  instilling  a,  112 
f'yclopleL'ii-;.  necessity  I'or  using,  ll:i 

't^''     "' .    Hi    defeitnniihg     ri'fr.n-tivc 
errors,   112 
in  ^kiax'opv,  121 
(Miri.l.-r,  e,,nve\,  I(i:{ 


(Jvliiidi'!,  determination  of 

i:is 


t  lie  axis  of  a, 


distortion  produceil  by  a,  138 
t'ylinilers,  tipplnation  of,  in  corn'ction  of 
astigm.atisiii,   107 

bisyinmetrical  method  of  indicating 
tim  .axes  of,  105 

crossed,    lo,s 

p.irallcl    method    of    iiKlicating    the 
axes  of.   105 

symmetrical    method    of    indicating 
the  axes  of.   105 
CyliiKlrical  lenses,  <>() 
IVsticorcus  cellulos;c  in  the   vitreous,  388 

of  retina,   13S 
Cystoid  cicatrix   lollowing  extraction  of 

cat.'iract,   .521 
Cysts  of  .-iMl rum,  !I7!».     {Sre  Mi celp.) 

of   conjunctiva,   2!tl 

of  eveli.ls,  21 1 

of  ii-is,  35!l 

of  lacrvinal  gland.  217 

of  l.irynx,  722,  iXIl 

nasopharyngeal,  722 

of  nose,  palhologv  of,  722 

of  orbit,  20S 

polypoid.  SNO.    (Sie  I'olypoid  Cysts.) 

of  throat,  pathology  of.  722 

of  tonsils,  pathology  of,  722 

hACin'itADKNiriS,  acute.  21li 
treatment  of.  2l(i 
chronic,  21(i 

tre  tmi'nt  of.  210 
li.icryocystitis,  227 
.symptoms  of,  227 
treatment  of,  22s 
l>acr\ops.   217 
Dalrymple's  sign  in  eM,phtlialmic  goitre, 

209 
l)aturine-|)<ii<oning,   relation   of,   to   dis- 

ea.si .,  of  till'  eye.  1107 
Daviel's  lens  scoop.  511 
l>ay  blindness.  .5S0 
Deaf  nnaism,  1 105 

etiology  of,   1105 

svmptoms  and   di.agnosis  of, 

1100 
treattnent    and    prognosis  of. 
1107 
1  >elstaiiclie's  in.alliu- e\tr.Mior.  ll!tl 

m.c^enr,    lis] 
Dench's  ear  punch.  1 1  1 1 
Dendritic  keratiti.-.  :(07 
Di'orsumvergenee,   1.52 
Di'pression.    o|><Tation    of.    in    lieatmi'iit 

of  cataract,  ."lOil 
Deriniiid  lutiiois  of  conjum-i  i\a.  2.59 

of  iris.  :i5!l 
Dcsi'emet's  ne'mbr.Mni',  295 
Desiccation   ker.-itili-.  :i07 
Desmarn''s  chala/ion  fi.reeps,  21:1 
lid  retractor.  22 
secondfiry  knife,  51 1 
De  Wecker's  iridotomv  sei-^ors.  :((i5 
iris  .scissors.   51 1 


iM>i:x. 


1"J(>!» 


Diabotes   iii-iipi(lu<,   iclatidii   of,    to  ilis- 
fascs  of  t  he  cvi'.  .">S<) 
mt'llitus,  relation  of,  to  diseases  of 
the  eye.  oSti 
Diabetic  atiiblyopia,  4,>S 

n'tinitis,    42(> 
DietTeiibaeb's  metliod  of  blepliaroplastv, 

2UJ 
Diffusiori  eircles.  7i> 

iinaties  ill  ametropia,  77,  7H 
in  astiniuatisin,  100,  Ktl 
Digestive  system,  effeets  of  diseases  of, 

upon  tli<^  eye,  oitl 
Dioptre,  definition  of,  ti2 
Diplitheria.  intubation  in,  837 

after-treatment  o''.   8J,'? 
instnimeiils  for,  .S3S 
nieehaiiiriil  treatment  in,  8117 
cii«Tation  of,  teehni(iue  of,  839 
when  to  operate,  844 

to  remove  tube,  84,1 
lar\MKeal,    832 

(hagnosis  of,  H:^',^ 
|)atholo)»y  of,  832 
s<'(]uehe  of,  8.'t4 
symptoms  of.  S33 
treatment  of,  834 

dangers    of    antitoxin    in, 
83.". 
iia>al.  S20 

definition  of,  82!t 
chaKno>i>  of,  830 

differential,  830 
etiology  of,  829 
pathoK'.gy  of,  830 
-^vtnptoms  of.  830 
treatment  of.  831 
of  pharynx,  831 

diagnosis  of.  S32 

(litVerenlial.  833 
pathology  of,  831 
treatment  of,  834 
relation  of.   to  diseases  of  the  eye, 

(ill 
varieties  of,  ti97 
Diphtheritic  ronjimetivitis.  27.") 

croup.     (.S'((  Laryngeal  Diphtheria.) 
DiplacMsis  cif  inttrnal  ear,  1 104 
Diplobacillus    of     Morax -Axenfeld.    ile- 
scription  and  pathological  significance 
in  diseases  of  the  eye,  (183 
Diplooocpus   of   acite   folli(ular   latarrh 
(  psi'uilogonocoi'cus ).    <lescrlption 
.and    p.'ithological    signilicance    in 
diseases  of  the  eyi-,  (i81 
laneeolatiis(pnemnocoeciis)of  Iraen- 
ki'1-Wciilwlbaum,  description  and 
patlioliigical  significance  iiidiseasi's 
of  I  he  eve,  ('.83 
Diplopia,  monocular,  103 
Diri'ct  asligmiitism,  97 

illumin.j'.tion.  determination  of  refrae- 

tion  l.y,   117,  118 
i>phth;dinoM'opic  examination,  40 
Disk,  optic,    18 
Distichi,i>is,  218 


Divergence,  l.")2 

fusion  near  |H)iiit,  l."i2 
Divergent  squint.  17") 

strabismus,  17.") 
Diverging  meniscus,  til 
Dropsy  of  antrum.  979.    (Sir  Mucocele.) 
Dry  catarrh  of  the  conjunctiva,  259 
Duboisine-poisoning,  relation  of,  to  dis- 

ea.ses  of  the  eye,  1107 
Duphiy's  nasal  speculum,  731 
Dynamic  strabismus,  1,")8 
Dysphagia,  hysterical,  104(1 

^j'AR,  examination  of,  107.") 
J  instruments  used  in.  1077 

technique  of,  1079 
external,  cormi  humanum  of,  1083 
dis(>as<'s  of,  1080 

malignant.  1083 
eczema  of,  1080 

diagnosi-  of,  1081 
etiology  of,  1080 
symi)toms  of,  1080 
treatment  of,  1081 
foreign  bodies  in,  1092 

diagnosis  of,  1092 
prognosis  of,  109.3 
symptoms  of,  1092 
treatment  of,  1093 
herpes  zoster  of,  10.82 
lupus  of,  1082 
tumors  of,  benign,  1083 
internal,  anatomy  of,  1097 
diplaeusis  of,  1104 
di.seases  of,  1099 
functional  paraly.sis  of,  1104 
hy(K'ra\st  hesia  of,  1103 
paracusis  of,  1104 
phy  iolog)   of,  1097 
suppurative  processes  in,  1101 
tumors  of,  1104 
middle,  ab.seess  in,  cerebellar,  1121 
cerebnd,  1120 
extradural,  1119 
anatomy  of,  1108 
atrophic  catarrh  of,  119,5 

causation  of,  119.") 
di.'ignosis  of.  1197 
pathology  of,  in.i 
prognosis  of,  I  lit7 
.symptoms  of,  1196 
treatment  of,  1 197 
cereljeljar  abscess  in,  112.") 

pathologx  of,  '.  12,") 
changes   produced    in,   by  defi- 
cient blood  supply,  1199 
chronic     non-suppurntivj     dis- 
e.as«'s  of,  1 1 76 
classification   of, 
1182 
vasctilar  engorgement,  with 
evi!:!alion,  llSfi 
ili.agnosis  of,  1188 
etiology  of,  1186. 
(.rognosia  of,  11,87 
symptoms  of,  1187 


1-21(1 


iM>t:x. 


Kar,    iiiiililli'.  (ic'licii'iii    IiIimmI 
ll!t(t 


iipply  to.    LIcpliaiil' 


l>ls  ilMhlllll.  11 
•a«'^  1)1  till'  v\i\  iVM) 


'l.'iti 


.1'.  1.1  (lii 


iaM>;r>   priHliici'il     Klliptiral  lenses,  tlO 
liv,  ll'.t'.t  


iliaKiiiisis  <>r,   I  I'M) 
svinptiiMis     ami 
siyiis  ol,  ll!(!l 
Irealmeiit  ol',  ll<.li> 
■  •i»easeiii'.iioii-siippMralive,cica- 
trieial   stage  of, 
IHH) 
iliaitiiii-is  1)1',  I  I'.M 
propiosis  ul.  1  l!ll 
symptiiiiisiir,  ll!H) 
treat iiieiil  ol,  !l!ll 
iiiMTative,  im2 
stages  ol   proliferation  and 
eoiitraetioii     in, 
11S.S 
prognosis  ol,  US!) 
svinptoinsof,  USII 
treat inent  ol,  ll.sy 
lyiieral  inleetioii  in,  112") 
livpirlrophie   eat.'irrli    of,    I1S2. 
llSti 
canses  of.   1  I.S2 
pathology  of,  11S2 
stages   atiil    svniptonis 
of,   list) 
iiife(li\('  Ihroniliosis  in  sigmoid 

sinus,  1122 
iridainm.ation  of,  piinili'iit.  IIOH 
etiology  of,   1110 
pathology  of,   nil 
prognosis  of.  1 112 
svinptoms  of,  1111 
inflation  of.   I  lT!t 
leptoMieniiigilis.   anile,   in.  1111* 
paeliynieningitis  in.   111!) 
sinus  phleliilis  in.   I  121 
Iiil>eieiil;ir  disease  in.   1 121 
rtlatioM  of  diseases  of.  to  diseases  of 
the  eve.  ,-><».-) 
KctasiM',  >elenil,  ;12S 
Kctopia  lent  is,    t7s 

piipilhe.  :US 
Ketropion.  2.") I 

eieatrieiid.  2:V.i.  2.")1 
organie.  2') I 
spasMiodie,  2i")l 
Ke/eiri.a  of  iMernal  ear.   lllSIt 
di.'ignosi,  ,,|,   Ki.M 
eliiilog\   of.   IIISK 
~>rnptiiins  of.   KISII 
tre.'itnienl   of.   KIM 
of  eyiliil>.  2:{'.l 

rel.-liion  of.  to  disease- ol   the  eye,  (i2!» 
Kivein.-itoiis  keratitis,  2!ir 
Kgyplian  opiilli.alniia.  2112.  2V) 
Kleeirie    liiilli    with    nlleetiir    lor    i.s,.    Ill 

operations  on  the  eve.  iiii:i 
K|ei.tif.|y-i-.    Tr,2.   !»!''' 
'ippliiatioii  (It,  7.")2 
niel.'illic.   7."):f 

.■111  ion  .-ind  ii»e  of,  7.');i 
u~e  and  iiiiiiialion-  m,  7")2 


Kmliolisni  of  central  jirleiv  of  retina.  1;12 


if    ei'i-ebral 


els.    rel.-ltiol 


I      ol.      to 


disi'a.ses  of  the  eye.  Ii;{:{ 
Lininelropi.-i.  delinition  of,  l>4 
Kinmetropie  e\ .      7") 
Kinotiolis,  depre^-iiig.  a-   a   faetor  in  the 

eaiisation  of  glaiieoina,  oU 
Kinphyseina  of  eonjiinetivii.  2S») 
Kinpveina  of  aeeessorv   lavitie-  of  nose. 
!»,S2 
signs  of.  !t.S2 
ill  any  aeees-ory  e:i\  ily,  1t;i7 

syinptoins  eoinrnon  to,  !i:{7 
of  anterior  ethmoid  ei'lls.  <M,s 
diagnosis  of,  (Mi'.t 
freqneiiev  of,  itlis 
prognosis  of,  !(72 
symptoins  of,  (Ml!) 
tre.ttment   of,   !t7lt 
of  antrilin  of  Higliniore,  (112 
diagiiiiMs  of.  !t4K 
symptoms  of,  '(12 

exploralorv     piini  lure. 

'J4.> 
iiis[M'('tion.  '.)12 
tK>stiire  te-t.  ".Ml 
test    of    traiisillumina' 
tioii,  <t41 
treatmetit,  !t|S 

eanine  fos«a  operation, 

after-tre.-tlnii'iit  of, 

<);">.■) 
Ieellllii|lle    of,    !t,")l 
indie.atiiiiis  for.  !t.")li 
through    .dveolar    sm- 

laee.  ilUt 
lliroiigli  l.ic-ia!  ^iirlaee, 

m'.t 

through  na>al  suiiaee. 

!)tS 

•  liriinuli  iiaiiir.il  orilire. 

ills 

eonipliratioiis  of,  inlraeiaiiial.  din 

prognosis  ol.  im 

treatnieiii  of.  "(11 

e\ideiiee  presumpil\i'  of.  li:17 

eiiimier.ation  of  |Hiiiils.  11:17. 
ICIS 
gellir.ii    alVeelions, 

'll(t 

reinot'  ^\  miitoins. 

!».l!t 
svmptoins      in 
ni'ighlioring  re- 
gions. It:i7 
pngiiosis  of.  nil 
treatment  of.  lUI 
Kiicrjiiiaiociii'  of  orhit.  2t')ii 
Knelioriilroin.-i  of  orliil.  2111 
Knophthalmos,  I<)1 
Knosto.sis.  n.'isal.  Sill 
l'".nto/o;i   ill  \  it  reiiiis,  ;iss 


1 

i.\i>i:x.                                      1211 

Kiilropioii.  ciiiilriciiil,  Jlil 

Kutautlms,  2112 

-^PMsiimhUc,  2I!> 

iiialiKiia.  21(:< 

Kniii'liatidi].  (i|H'r:iiii>ii  nl.   112 

Kii..,.i<liiaii  catarrh,  iliroiiii-,   llsl 

ilaiij!^  i>  ,unl  ;iil\;iiil,it;r< 

of.  411 

iliatfiiosis  of.  1  IS") 

Kpiciiiitlms.  2.'iK 

proKtiosis  iif,  ll,s,-> 

svmptoiiis     ami     si^ns     of. 

Epiplioni,  21,H 

1IS4 

I'lidldKy  (il,  21N 

trratmrui  of.  Ils.'i 

licaliMciit  111.  221 

catliiliT.  1  ISd 

Kpi.scliTilis,  lintiiiidiis,  :t2.") 

Kvcrbiisch's  o|H'nitioii    for  iiirrritioii  ot 

v»n^-  (il.  :t2."i 

ptosis,  2:t."> 

Iri-aiiiiciii  III.  :{2"> 

Kvisfcratioii,  oprratiou  of,  410 

IHTsislflH.  ;<2.') 

dancers  ami  ailv,-intaKis  of,  414 

cause  <i|,  H2l> 

K.xciitfratiiin,  ii|«ratiiin  of,   lit) 

pnipiosis  of,  ;{2li 

dantriTs  ami  ail\aiitapfs  of,  414 

Iiratinriii  ol.  .T2ti 

of  orliit,  2(17 

Kpisi;i\is.  7is 

Kxophoria,  S4,  l.iS 

clicddjjy  ()t\  7  (s 

(lotcrniination   of,  hv   parallax    lest, 

trcatiiicnt  i>l,  7t!l 

Hi;} 

I'-pitlu'lioma  «>('  i-<iiijiiiuii\a.  2')S. 

2!  12 

i'tiolo)ty  of.   Hit 

Ill  c'Mrriial  rav,  l().s:{ 

Maililox's  roil-lisl  lor,  lli2 

III  iKisc.  patliiilii^ry  ul,  71S 

symptoms  of,  l(i,") 

ol  tliioal,  patliolotfy  ol.  7IS 

treatment  of,  lii,"> 

Kpillii'liimi.  iiliiitiiin  tiiiiiiir.-*  ul. 

722 

Kxophthulmir  Koitn^,  2(1S,  .5.S1I 

KrKol-poisiiiiiiit;.   rrlalioii   nl'.  In  i 

lisi-asfs 

Kxophtlialnios,   I'M 

ol'  the  cyr.  11(17 

intennitlent,  2(14 

Kry>i|H'las  III  ryrliiU.  2H!» 

piilsatinu,  lit!' 

rrlatioll  ol".  to  disi-.'iso  ol'  llir  i 

yr.till 

etiolojjy  of,  2(1() 

Krythciiia  liiilliMiiu.  i>!M 

proifiiosis  of,  2(K» 

niiiltiloriiii'.   relation   of.  m   i 

isi-asi's 

symptoms  of,  llMl 

of  till'  eye,  (iliO 

treatment  of,  2(M1 

Krytliriiphla'iiii',    elTiTN    of.  upoi 

rolor 

Exostosis,  ivorv,  of  frontal  sinns,  2(12 

\isioM.  .'tM) 

na-ai.  Sill" 

Krytlitop.sia.  .Vsl 

Exotropia,  l.iS,  17.") 

Est'rinc-poi.ioiiiti^r.  irlatiou  of,  in  . 

israsrs 

External   anilitor'     meatus,    disi  ases   of, 

of  tlio  lyr.  2sti.  (MI7 

KISli 

Ksophoria.   l.iS 

elieek  lipanient,  l,"i(l 

Maililov's  iiiil-ioi  1,11.  102 

ear,  iliseasi's  of,    lOSd 

syiiiploius  of.   1(17 

ophthalmoplegia,  istl 

ircatiMi'iit  of.   Iti7 

E.xudation     into     anieiior     clhimlier     in 

Ksoiropia.  172 

ryilitis,  :!,"il 

KthiMoiil    ri-lU.  aiiti'rior   >iippiii:ilioii    in. 

in  iritis,  M'.> 

!M.7 

into    posterior    eh;tiuliei*    in    ('X'clitis, 

il"si-,|.  illiS 

;<.")2 

iliattnosis  o 

.  'M\S 

ill  iritis,  liVI 

I'tiolojsy  of 

tIDM 

into  stroma  of  the  iris.  3411 

•symptoms 

if.  litis 

into  vitreous  in  evelilis.  H.'yJ 

Irratmrtit 

if.  litis 

E.ve,  the  aphakie,  oil 

n\n-n.   lati'iit    or 

maiii- 

hloodvessels  of,  ,'{41,  .U2 

Irsi,  (Ills 

ett'eits     of     eonstitutional     ilisea^es 

symploiMs 

if.  lltill 

iilMiii.  ."),s:{ 

tn'aimi'nt 

if,  117(1 

of  diseases  of  the  liraiii,  ti;il 

);tliiiiiiiil..l  ,■,!!,>.  !I2S 

of  i-iriiilalor\   traet   *)l*"> 

anatomy  of,  !t2s 

of  dijrestive  system,  5111 

siiMls.  alTri'tioMs  of.  irralnii'iil 

of,  2i:{ 

of  nerves,  (),il 

rrl.HtioM    of   ilisr;|si-s    <i|. 

o   (lis- 

of  iispiratory  trail,  .")03 

1-a-i'S  ol    llir  ryr.  .'")(l| 

of  sexual  organs,  (iOl 

Iri'atmi'iit  of  atlfciion^  o 

.  2i:i 

of  skin,  ()2!1 

sinusitis.  (I(>7 

of  spinal  eord,  04,"> 

siippuratioti.  !I72 

of  urinary  organs,  ."ills 

ilianiiosis  of.  i(72 

of  iiifeetions  diseases  upon,  liOS 

inatiiu'nt  of.  072 

of    injuries    lo    ihe    lirain    and 

iuilii-ations  for.  !»72 

»pin,al  eord  iiiHin,  ti,ill 
of  poivius  ii|Min,  litll 

Ktlimoiilitis.  7(),H 

liistolojjy  of,  70N 

of  liiiphoneiiroses  upon,  (ilH 

Willi  ii;isal  polvpus.  s,s|.  SS2 

eiiiliryojogy  of.  :t:(l 

1212 


I.SOhX 


•.  <'iiil)rvniil('  lildiiilM'-MK  111',  :(;{;{ 

c'iniiirtriipic.  7."i 
I'Xainin.'itloii  ui.   I<l 

aiitrrinr  t-li.-inituT,  27 

li<'li;ivio|-  III  (lie  pupil  III  (|i>i';l!it', 

M 
III Ivi-i>rls  of   the   ixliiior  of 

tlic>.  J-i 
liliarv    or    cirriiiiuiirni'al    lOii- 

^I'stitm,  21 
coMJiiiiiliva  anil  il~  ciil-ili'-sacs, 

22 
(■<mJMiicti\al  I'oiigi'stioii,  23 
roiiiia.  21 
toriu'al  reflex.  2! 
tlireet  iMS[HH'tioii  of  the  eve  anil 

its  appeiiila^es,  21 
liy  ilireit   iiis|Hilion,  2t> 
liv  iliicii   iiietlio<l,  4ti 
fainil>   anil  (MTsonal  history,  20 
treiieral  eoiisiilemtions,  19 
physieal  condition,  l!t 
inilireei  nietliod,  45 
iris,  27 

laervinal  apparatus,  22 
I  ills,'  22 

niixeil  loriiis  of  congestion,  21 
normal  eyegrouinl,   17 
ocular  history,  21 
ophthalniosiopic     e\ainin:'tion, 


Ks'liils.  aliseess  of,  21(1 

atiatoniy  of,  2.'<l 

anKioiiiata  of,  21 1 

anthrax  pustule  of.  211) 

carlmncle  of,  2lli 

eiilohonia  of,  2H.S 

eon^fenit.'il  anomalies  of,  23S 
trealnient  of,  2:VS 

cysts  of.  241 

(li'Velopiiient  of,  '.VM'i 

eczema  of,  2:i!( 

einphysi'ina  of,  2.>(i 

ervsi|M'las  of,  2:i!l 

furuncle  of,  21(1 

liiM[>es  /osier  of.  2:t!l 

injuries  of,  2.")(> 

maliiriiani  (jrowths  of,  214 

icilema  of.  210 

n'lative  positions  and  sizes  of,  232 

syphilis  of,  241 

tumors  of,  244 

ulcers  ot,  240 

variolous  eruption  iifion,  240 
Kyes,  artilicial,  4!li 

I.,V\('1.\L  hemiatrophy,  proffrcssivo,  rela- 
tion of.  to  diseases  of  the  eye,  (mO 
iiiTM'.   relation   of   paialysis  of   the 
ocular   lir.anch   of.    to  diseases   of 
the  eye,  (i.">2 
I'actilioiis  myopia.  S4 


rliit    and    the    position   of   the    lacultative  hy|K'ropiu,  !Mi 


Tar  point   in  hy|)eropia.  UO 
in  myopia,  HO 

direct  determination  of.  124 
Farlow's  opi'ration  for  forward  prolonga- 
tion of  septum,  7t>2 
punch  forceps,  O'.ts 
larsitthtedness,  7li 
Fa.scicular  keratitis,  2!tS 
I'avus,  relation  of,  to  disiases  iil  the  i-ye, 

030 
I'iliia^  arcuata-,   20.-> 
normal  adult,  cardinal  noints  of,  til    I  iliioansioma  of  nose,  pathnlocy  of.  722 
ciir\alures  of,  (iM  of  throat,  palholoiry  of.  722 

indices  of,  1)3  I'iliroina  of  conjuiietiv.a.  201 


evel.all.  :!2 

pupil.  20 

tension.  3I> 

1\-  inuismitted  li>;ht,  40 
foreimi    liodies   in,    inunafiement   of, 

401.  4(i:< 
ireniTal  development  of,  331 
liori/ontal  section  oi.  in  orliit,  MS 
liype|opi<',  7ii 

lymph  p;i~sap's  of.  311    31.') 
myopic,  7ti.  Ml 


iMitntion  of.  3t.~) 
the  reduced.  01 

the  selieni.'Hie,    113 

shade.  (i.'>!i 
s|)cculuni.  .")0t> 

teehniijUe  of  pathological   and  liac- 
teriiiloirical  examinations  of.  litio 
Eyehiill,  .aliophy  of.  370 

eenlic  111  rotaiion  of.  14."i 
iiisirumem  lor  measurinc,  titi7 
mm  ions  of,  i  1.') 

deraii>;eininls  of,   14."i 
penelraliiij;    woutiiI      of    the,  1  reat- 

ment  of,  .[OS 
|K)sition  of  lest,  1  17 
pr-jKiiali-.i:  "!'.  Int    pallloiu;;:r:;i   and 

haclerioloyieal  examination,  titi" 
primary  position  of,  1  l.'i 
Eyeh.dls.  .associated  nioM'iiients,   152 
i^\*e-i;rinind,  icinial.    17 


of  external  ear.  10S3 
inininasal.  SS5 
of  l;iiyii\,   001 
of  nasopliarvnx.   1032 
d'anniisis  of.  1033 
histoloitic.d  pathology  of,  10.32 
pro>;ni>~is  of.  1033 
-ymptoms  of.  1033 
trcatmeiil  of,    1033 

cold  wile    sii.iic    ill.  1031 
ek'etrolv:-is  in.    1034 
evulsion  of.    1035 
external  o|Kralioii  for.  1035 
Halvanociutery   in,  1034 
of  no-e,  patholo^v  of,  720 
|-a(n!lare,-  SS7 

of  throat,  pathology  of,  720 
I'ii'ld  of  fixalion.   151 

liinocular.  limits  o(,  l.")(j 
monoculai,  151 


/.v/>/;.v. 


121  a 


I  ii'Irl  oi'    fJNaliiiii,   iiiiiiiiM'iiliir,   limits  nl', 
151) 
mriisiirciiit'iil  of.  Iiy  im'':iiis 
(it  the  |M'riiii('lrr,  l.Vi 
FilaiiifiiliMis  krralitis,  UtMi 
Filaria  sniieninis  liotiiiiiis  in  tlic  vitrrmis, 

3H« 
Fissure,  orliilal.  iiilfridr,   1!I2 
su|X'ri(ir.    l'J2 
l)alp<'l)nil,    l!ta 
Fistula  of  oiiriifa,  iiO'. 

of  lacrvinal  jrliuiil.  L'17 
lacniiialis,  22S 
Fixation  fornps.  'rOCt 

foiiit,  nK'thixl  of  ili'ti'iiMiniiisx,  12 
interval,  'M> 
Foci,  ronjupato,  57 

rolati\c  po-iitions  of,  57 
Focu-.  real,  57 
priiuipal,  57 
virtual,  .57 
Follicular  conjuixtivitis,  202 
Forcipn  bodies  in  aiccssory  >iiiusrs,  Osl 
in  external  car,  l()il2 
in  nose,  S7I 

rcninval  of,  75(1 
in  plmrvn\,  lOKi 

symptoms  of,  lOlti 
t'realllieiit   of,    lOlll 
removal  of,  (M5 
in  throat,  N71 
in  tonsils,  HNKt 
Fornix  conjunct ivic,  2.5H 
Forstcr's  ])lioloinetcr,  .'{5 
Fossa  patellaris   of   the  crvst.iUinc  lens, 

47t) 
Fox's  fixation  forceps,  412 
FVacturc  of  nose,  10,5() 

Iri'atiucnt  of,   10,")('> 
Friinkel's  nasiil  s|)Oculuin,  ~IU 
Frcnular  keratitis,  2il,S 
Frpuiienthal's  electric  \ilinitor,   7,">5 
Fricke's  nietljoil  of  blepliaroplasty,  215 
Frog,  entire  embryo  of  a,  Xi\ 
Frontal  sinus,  ",)2() 

chronic  mucocele  of,  210 
development  of,  !»27 
ivory  exostosis  of,  202 
opciatioii  on,  (Mil 

exploration    of   frontonasal 

duct,  'M» 
progress  of,  !Mj,5 
Kuhnt's  operation,  Utitl 
sinuses,   relation   of  diseases   of,    to 

liiseases  of  the  eye,  ,")94 
suppuration,  i)72 

di.'iRnosis  of,  072 
treatment  of.  !t72 

indications   for,   !)72 
Frost-bile  of  auricle,  10S5 
Fulniinating  glaucoma,  .512 
I'vindus  refjev.  42 

variations  in  color  of,  37 \ 
Fungus-poisonini;,  relation  of,  to  di9ea.se.s 

of  the    v,  ('07 
Fir       '•  keratitis,  :^(I7 


I  Obi 


,  geiienil, 
.5>M) 


relation 


Furuncle  of  eyelid,  210 

relation  of,  to  iliseases  of  i  he  eye,  tiSO 
Fusion  near  point  in  divcigrnce,  li52 

/lAI/KtN  whi.stle,  1177 

'1     (Janglion  cells  of  the  rciina,  mellioU 

of  staining,  ti7s 
(iangrenous  pharyngitis 
<!auss,  formula  of,  tU 
(ieronloxon,   ;{17 
(ilanders,  7(Mi 
(jhinduK'ir  enlargement, 

of,  to  dist>ases  of  I  hi'  e\( 
(Hands,  Meibomian,  2,'{2 

ocular,  development  of,  ,33ti 
of    Zeiss,    2:{l  . 

(ilassblowers,  fre(|ueiicy  of  cataract  in. 487 
Glasses,  adjustment  of,  l:i(i 
allaly^^is  of,  13H 
difliciilties  encountered   in    wearing, 

1,'il 
rules  for  the  prescription  of.  131 
Ulaucom.'i,  ,'ibsolute.  ophthalmoscopic ap- 
[learance  of  the  optic  disk  in, 
.537 
.s<>ction  of  the  optic  n.  rve  head 
in.  .537 
a'^iile.   clinical  application   of  treat- 
ment  in,   .5().5 
congestive,    ,542 
age  as  a  factor  in  causal  ion  of,  ,540 
changes  in  the  conjunctiva  in,  528 
chronic  deformity  of  lens  in  a  cata- 
ract from,  .503 
non-congeslive,  51 1 
congenital,    ,5,53 
cupping  of  the  optic  disk  as  a  result 

of  glaucoma,  .53s 
following  extraction 
fulminating.  ,542 
hereditv  as  a  factor  in  causation  of, 

510  " 
loss  of  sleep  as  a   factor  in  lau.sation 

of,  541 
primary,    changes    in    the    antcric" 
chamber  in.  .5.40 
in  the  aqueous  humor,  .533 
in  the  choroid,  ,532 
in  th<'  ciliary  body,  ."i,32 
in  the  cornea,  .520 
in  the   crystalline  lens,  ,533 
in  the  ir> ",  .531 
in  the  optic  nerve.  .537 
in  the  retina.  .533 
in  the  sclerotic.  .528 
in  the  vit:.>ous  humor,  ,533 
clinical  ty])e.s  of,  .542 
diagnosis  of,  ,545 
predisposing   conditions 
acc<immodalivi 

,541 
ace.  540 

constitutional  condi- 
tions,  .541 
depressing  emotions, 
.541 


of  cal.aract,  521 


540 
effort. 


1-214 


IM'KX. 


Ill 


mnnnia.  pr'in.ii  \  ,    [MtM!i>|M)^iiiir 


iiiiili-     ll:i\   li 


Ml.  ili:nriMi>i- 


snl 


I'llol 


Iniilioii.  .") 


II 


lipty 


Ih 


•.10 


liM'.'il  iiijiirii'^,  .">ll 
I(is>*  (iT  xli'i'p.  r»4l 

u|M'niliiill    1111   lilir    ivr, 


i>l,  7!t.s 
liriitfiiiisj^^  111,  SOI 

^MMptciIlls    1,1,    HINl 

lic:iliii«Mi(   (if.  ,S()L> 
lliaiiii);.  siilijiciivi'  ■.(■M>;iliiiii>i  iil,   ll(»:t 


•.11 


li-iiiiK  111',   I  ITii 
Hilniliciltz*  thnirv 
amiiiiiiKMlatiiin,  i 


111  llii 


II-  iiiri-hanisni  iit 


■.1(1 


Ml 


llirnilii|li.t,    .•)S(I 


»iii:illiii~'    111    (Diiiia.        lliiiiialKipir  iiii|iillaiv  iiiaitiiiM  •<i(tii,  :U 


•>11 

llM'    111     Mi\l 


Iriar 


trratiiiriil  iil.  .•.."ili 


Hiiiiiaiii.|.sia.    Icrt-Milcil,     Mi' 
.11     lli'iiiil'iirial    liy|)iilrii|.li\ ,  ri'lalii.li    iil',    to 


111,  .■. 


10 


-<iiiinlai\ .  varii  Iil" 
»iliiplr\,    riiiKTliliir    riiiil r.irt inn    i.l 
tirlds  i.r  \  isiiiii  in.  ">;|." 


Hi 


ili.s  .'IM'S  111  ihr  cvi'.  (m(I 


•.:«'. 


(;ii 


■^Illl.llUtl',    ."> 


axin'.-i  nas.al  "^imm-uIiiiii.  7 
i:ts,  IH'.t 


<  iliiiina  (.1  ri'ti 
(ilvco-iirir   am 


illMip 


(Jiiitri'.  I Ai.plillialinic.  2(l>».  .'.S'.t 
I'liiiliidv  111.  2(l.s 
>yiiiptonis  111',  'J(KS 
liralini'iil    nl.  20!» 

(iiiiiiii'iiiriis    ( N'cisst'i),    (U'Mcriplii 


Hi 

H 


iKirrliaKi'.  aiiililyi.pia  Innii,  'uS 

iiitii  llir  anirriiii'  ih;uiil)<'r,  'Mi'2 

111'  DOM',   fi'NI 

Iriiin  pliarxiix.   1(11.". 

Ill'  throat.  (HHl 

into  ll 
iiiorrha^rir 


hi-  \  itf K,  :ws 


itiiiitis.  427,  42H,  42'.) 


i'r|M's  ronjuiictivH',  2t>l 
ii.iiia'.   .'{lO 

tri'atiiiriit   ol',  :{ll) 
pliaryiiKis.  (.ill 


(..'itliolo^iral    si^iiilii-ai 
111  tlw  ryr,  (i.S:{ 
iiottslcin's  (iiri'ttr.   I(»:»0 


tier     111     lllsejl.'*4's 


Mlltt 
till 


iiriN,  ri'latioii  nl',   to  iliscascs  of 
.  (Kill 


(i 


iilil' 


pns 


liatti 


l.-.'.l 


zoster  ol  I'xttTiiiil  oar,   1(W2 

of  IIOS)',   lli:<toll.KV  of,  (.00 


•  Joiit  of  conjiinrtiva.  21.7 
liiant'i  Bii.irilril  foicips.  tllCi 
(iraniilar  conjiinrtiviti'*.  2li2 


oi.litlialiiio 


2.l!t 


rrlation    of.    to   ilisca-srs   of   thi- 


I'Vi'.  i>:H) 


pliary licit i>.   i 


I'tioli 


'K.v 


■liroiiir,    10111 
111.   1(11(1 


Hrtrrorliro 


of  throat.  Iiistiili.)jy  of,  lilKI 


:i4(i 


(iianiiloii 
(iravi" 


iiploins  of,  1011 
t'ri'atiiiciil  of.    101 1 


(lisras 
I'lat 


111  riiiijiii,rli\a. 


20S 


iflatioii   iif.    Ii 


ili 


thi' 


I  liiiiiili 


."..Mt 


ii'i'i'ii'-^  (.1,1  oiH'iatiiiii  fur  rir.atiii'ial  en-    Hrtrrntropia.    172 
ti'opion.  'i.'.l  '    ■ 

In'iii'^  piiwili  r  hliiwiT.  012 
Inilirr's  sp^ 


Hi'toroplioria.  LIS 

ili'tiTiiiiiiation  of.  l»\-  coiivfx  sphcr- 
ical  test.  Itti" 
iiy  par.alhix  ti'st.  HU 
iiiiac  iiiiiM'iiii'iil  in,  llll 
nil  (.'las<  trs!  in.  KiO 
spasnioilir.  ISl 
yiiiptoins  of.    Kil 


MTcisi'  of  thr  \vi;ik  I'VI'  in,  1!M( 


nil 


107 


ilsi*  of  till'  strri'i 


I'll 


riiiiii;'>  niiiilitii'il   lint/ 


•lltlirr   iipil'.- 


linn  fill*  cnrrrrlion  iif  ptn^i-i.  2;l."l 
( Irunwaliri  Innip..  (•.".:{ 


H 


A.\]i'."i  niaiinil.   Id.". 


Hrnrtrlniip  ariiliiial  li'ich,  ',iM.  ;i.")7 

Hippiis,  ;io 

HirMhliirK'i  pnpiUomrli'r.  20 

sii|i'roscii[M'.    It.;: 
Hnin's  ili'Kini'ralion  nf  inula.  721 
lii>tiil<nry  of.  72.") 


II      n-Hi'N.  M 

Hnlninren's    «nnl-te«t     for    (letectinii    nf 

H;iniatnnia  nf  il\  ilia.  OSS 

rnlnr  lilinilne.ss,    •>71 

Ha'tnoiiliilia  nl  now.  palholotrv  nf,  (iOO 

Hnmatropine-pnisiininc,    relation    nf,    in 

rrlation  of.  Imlisi'ascsof  tlic  I'yi',  .".S.". 

iliseases  nf  the  eye.  (>07 

of  ttirnal.  pallinliiKy  nf,  (i<KI 

use  of.  as  a  nivilriatie.  1 12 

Ha.ji'k'-'    hook     !nr    npinini;    -pliinoiil.-il 

Hniileolmii.  212 

-inii<.  077 

Mlltehillson  teeth,  itllt    .'11  1 

H.'irlinaiiii'- lar  Iniirps.  ll:i.">,  1112 

H\';iliin'   ileceneration.    72.". 

n.'i^al  ^iHTiiIuni.   7^11 

pathology  of,  72.". 

iniijiiur  fiinrp>.  1 1.".2 

leaelinn  tn  stains.  72.". 

'Harvi'stfi-'  keratitis. "  :{01 

H\,ilitis.   .'IS.") 

H.-fiii-r's  valve   2 111 

asten.iij,  ;is."i 

Hayes'  knife  i ille.  .-,0(i 

piinetala.  ;JS.". 

May  lever.  70S 

suppurati\a.  :iSt'. 

ilelinilinll    nl,    70S 

treatnieiit  of.  :iKti 

iM)h:x. 


121; 


Hv«liiiil  .iiiiT^.   |i<T»i«tfiit,  .'{X'. 
•■aiiiii.  :tu.  ;{»■> 

li'«Mi  (il  crvstalliiir  liii>,  I7(i 
nirinl.niin-  ..I  \  ilinnis,  (tluiicomit  fol- 
l'i«]Mit  .iiilirior  syncchiir  of,  ■>48 
Hyiiroi(|i|i,iln,,  ri'lation  of,  ii>i  i^-iist's  of 

the  lyi',  lit  1 
llyilriipliilialijiri-.    :r.>I 
Hy<lroj)s  iiiitri.   !t7!l.      tS,r   Miuocrle.) 

iiiniiiiiiiititiiriii-,    tl7'.) 
Mydri.rrhii'.i,  nii^.il.  KMl 

pniitniisi*  iif,  10-12 
-viiiptDiiiM  i)f,   |(»42 
irtiiliiMiil  .II.  I(M2 
Hyiisry,(liiiii.-|K)isiillili>r,     irliiljoii     111,     III 

ilisi'iiw-.  of  tlir  CM',  l'A)7 
HyjMTiiiniii.   tisit  ' 
Hyponrstliisiii  „(  iiit(innl  lar,   1102 
of  liirynx.    KMti 

Iri'atiiiriil   ii| 
of  iiiiM',    1040 
III  pliarynx.  I04:i 
iliitKiiosis  III. 
itii>lii(ty  of 

MlliplOlll'i  of 

tri'jilmi'iit  of 
Hy|icrr>opliori:i.  1.>S 
HypiTfxoplioriii,   I. is 
FlyiMTkiiH'sis,  Lis 


.\linlili.\'~    1111I-I1-.1 


IO)ii 


1044 
104;{ 
1(H4 
1041 


ll\|HTplioria.   ii)jlil. 
lor,  102 
Hyniploiiis  of,  l(i!» 
K'xts  for,  170 
tri'atiiii'rit  of,  170 
llyiMTfropia,   I7() 

HyjxTtropliir  latarrh  of  iiiiiMlr  rar,  1182 
ciiiisaliim  of,  11S2 
rhroiiic.    ll,S(i 

cioHtrii'inI  or  p<»i- 
latarrlial 
HtHge,   11  (HI 
<lia){no«is    of. 

1191 
proKnoHi.s    of, 

1191 
Kvniptoni.*  of, 
'  1190 

trealmont  of, 
1191 
ilajti' 


Hyprrmi'tnipia 

lorri'itioii  of.  Iiv  a  coiivi'x  Irns,  4:< 
Hy|K  lopia.  7ti.  !H) 

ahsojuti'.   '.Hi 

ardiniiiHMlaliiiM  in,  'Xi 

amount  of.  9li 

axial,  9.i 

I'orrcii ion  of,  91 

i-oiirsr  of  fiiiiTKi'iit  ravs  in,  !K» 

riirvaliirr,  O.i 

t'XiiTiial  r\  iilrnrrs  of,  97 

fariiltativr.  90 

far  point  in,  !M» 

inili'X,  9.i 

lati'iil,    94 

iiianilr<t.  94 

hi'ar  piiini  in,  93 

priMiiliinR  glasws  fur,  l:<2 

rrlativi'.  !Mi 

>yiniitoiM»iif  n'fracliM'  .rrors  in,  110 

lolal.  !M 

\arii'tit's  of.  9.") 

\  isioii  in.  90 
Hyprriipir  rvr.  70 
HypiTo.-^inia,  10;W 

prosnosis  of.  lo;ls 

-yiiiploins  of.  I0;{,s 

In'atini-nt  of.  IO;{.S 
Hypinisplirisia.   lO.'iS 

pioifniisis  of.  10:{,S 

^VHiplunisof.  io;w 

Irratintiil  of.  llKis 
flypiTplioria.  lis 

•  ti-l*  luiinai  inn 

lo:{ 

imairr  iiioMiiii'iit  in.  100 

Irfl.  .Maililox's  roil-iist  for,  102 


parallax   irsl. 


of  fiiKorjfe- 
int'iit  of  vt'»- 
sols        with 
exudation, 
11S6 
(liagnoNia    of, 

ll.SX 
prognosis    of, 

1187 
tri'atincnt  of, 
118S 
stages    of    prolif- 
fration    anil 
rontraction, 
1188 
prognosis    of, 

1189 
svniptoius  of, 

1189 
tri'atnii'iit   ol 
1190 
palliologv  of.   11N2 
.subgloftii-  iiiflanunation,  71."i 
HyiHTtropliy  of  pharviigeal  tonsil.  1022 
of  tonsils,  !)9ti 

etiology  of,  IKMi 
symptoms  of,  990 
trivitmont  of,  997 
local,  997 
olMTalivi',  9!«) 

aftcr-ln'atmi'nt    of, 

1002 
rolil  wire  .snare  in,  1001 
eleetric   »iR'  siian'  in, 

1001 
emicleatioii  in,   100:{ 
guillotine  in.  999 
of  \entrieular  region.  7l;{ 
Hyph.Tniia,  XV).  ,{02 
Hypoesoplioria,  l.iS 

image  movement  in,   100 
Hypoexoplioria,    1.">S 

linage  movement  in.   loti 
Hypokinesis,  10.V2 
Hy(H)phoria,  l.">N 
HyiMipynn.  297 


I2i)> 


i\ith:\ 


Hv|>i>|ivi>ii  krnitiii^'.  'W-i 

HysttTiii.  rxlrrmr  ciiiiniiliii-  coiitriiriioii 

in,  .'>7."> 
Hysli-ririil  .•iinlilvnpin,  ATI 

1t;jirHY<»SIS.  nlalicm   »\.  u<   illsi>u«-. 
Ill    IIk'   I'M'.  tilfO 

IlliiiniiKiiiiiii.  iKc'iil,  2li 

(>lili<|ll>'.  J)i 
llimitr.    ii'liiml.    liiriiliil    |ir"jrcli(iii    .•iiid 

nclitir.iliiPii  111,  till 
liiinK*'^.   tiirtiiMtioii  «>1'.  .">."i 

ililVii~iiiii.  Ill  :iiiirlrii|iia.  7".  "H 

lllllKliUll.     lllalillll     III,     to    (IJM'IISIV    Ol      till' 

c'vc,  <i,{l 
Intlox,  iiiuivali'iil    nlnntiv.-,  iif  crv-tiil- 

liiii'  li'iis,  an 

hyiMTcipia.  '■•.■> 
llivopil.  St.  "*.', 
rclalnr  irirartivc  .Vi 
Inli"<li(>ii>'  (li-.c-ii-..-.  ffii'ctv  111',   M|«iii   111'' 

ryi'.  tHIN 
IliHamiii.iliiiii.  1  liniiiic    nasal,   witli    li'ii- 
ili'iiiy  111  .ilidpliy,  71'i 
cirriiinscrilifil,  nl  ixliTiial  aiiilitory 
iiirafJi.    lOS'J 
iliacmws  nl.   IO.S',» 
,iiul<mv  ..I.   10S!» 
s\  iiipttiiiiMil,  1I>S'.< 
Iriatini'iil  "I,  lOW* 
ilitTiK''.  ill'  r\tiiiial  aiiilitiirv  inralus, 
llltNl 
ilidlosy  (.1.   Kf.Ml 
-vnipiiinisdl,  HKtO 
irr.aliiii'iit  111',  l')*" 
tiyiwrlriipliir  siilijilottic,  7l."i 
ui'  lynipliiiiil  lissiir,  ti!»:i 

line  111  iiiiiTii-iir(!aiiisins,  ti'.l7 
of  inuriiii-i  iiii'iiilininr^.  I'l'.Kt 
(if  nOM'.  tl!MI,  70(i 

rlimnir.  willi  aimpliy,   li'.M) 
with  hyiMTtnipliy,  ti',M) 
infi'i'liuiin,  ti!l2 

rliuloiiy  of,  Ii!t2 
iiruriitic.  O'.MI 
pillllnlilKV  (if.  7;Mi 
iraiiMialic,  ti!l2 

cliiiliiirv  111.  Ii".l2 
vaiiftics  (if',  (iiM) 
parciicliynialdiis,  7(Mi 
pcrirlidiiilrial.  "(Hi 
[M'ridstc.al,  7IMi 
siiliiniii'dils,  ri!t."i 

patlidldcy  (il,  li'.l.'i 
siii>rrli(ial.  7(Mi 
mippiiiiilivr  (if  iniilillo  pnr,  1100 

inl rairanial    /nniplira- 
tidiis  ol     I  IIKI 
Inlliiin/a,  VMi 

(■iinipliraliim-  nf.  ^07 

iliamidsi-.  ililTiTi'i.iial  .if,  .SII7 

•  ■li<ili.ir\   iif.  MMi 

pailiiildiry  df,  ii"s.  li'tii 

priicnd^is  of,  MIT 

nlaliiiii  df.  td  diseases  of  llircyc,  I'll!) 

«yiiipliiiiis  iif,  MMi 


Influcii/.a,  Inalniriil  nl,  S07 
Infrailuction.  iiira!<iiiiiiiriil  of.   I.>1 
Insanitv.  rclaliim   nl.   In  ili-cii'i'-  nf  the 

eyi',  VilO 
Inli'rnal  iiii",  ili^ra^'s  nl.   IIHHI 
InliTslitial  kiralilis,  ;{1 1 
liiKTvaKinal  ^pacc,  'H'l 
liitrncruiiial  coniplinitidii.  nf  inipycina, 

(MO 
Iiitrahiryncial  iiiji'iliiiii-.  Mill 
Intranasal  ailiiidiiia,  H. 

iliat!nd-<is  df,  SIM 
itiiiliiBV  111.  HfKI 
palhiiloKV  (if.  S'.HI 
priitftio'-is  of,  S'll 
syinpldins  of.  S!tl 
trpatincnt  of,  W»l 
adhesions,  7.'>I 

••I  idiocy  of.  7i")l 
syniptonis  of    7.'»l 
tri'atmciit  of,  7.")1 
aneioina,  .S.S.S 
oarcinoina.  S!»2 

(li.iKiiosi.s  of.  X!U 
I'nniis  of.  .s!»:l 
pallidloity  of.  S'M 
synipldiiis  111,  .SilM 
callictcr  syrinK*',  712 
(ibroiiia,  NS,j 

(liagnd-is  of,  .s,H7 
fitioloiiv  of.  S,S."> 
pathology  of.  ss'i 
proiiiidsis  of.  NN7 
syinptiiiiis  df,  SSli 
In'atiiicTit  df,  SS7 
dslcdni.a.  MM 
p.'ipilldiiia.  Ns7 

iliaciidsis  df,  .SSS 
lonns  of,  .S.S7 
prognosis  of,  SHS        ' 
sviiiplonis  of,  SS~ 
Ircatincnt  nf,  .SSS 
polypus.  SSI 
sarcoma.  Sliij 

iliatrnosis  of,  .S!!."! 

clidli-Ky  (if.  S!t.-) 

mil  riisi'dpical     apiwarancc     of, 

S!l."i 
patlidloity  of.  Sill 
pmnndsis  df.  H!l,"i 
s\  MiptdlllS  (if,  .sit.") 
Uratmcnt  of.  S!Mi 
Intra-dPular  tliiiil,  composition  of,  .")2l 

tiiinor.  u'laiicoma  fdllowinu,  .Wl 
Intiib.atiiin  in  (liplitliiria,  s:{7 
Intiimcsccnl  catarac'.  49:i 
lodinp-piisoninir.  nl  ition  of,  to  diseases 

of  tlu^  eye.  tiO.") 
Iridectdiny  :!li."i.  ;i('i7,  liliU 
indicatidiis  fur.  :<li7 
in  treaiiiiciit  of  jilaucoma.  .">.")l> 
Iriilectomydialysis  in  trealnicnl  of  Rlaii- 

idiiia.  odii 
Irideraaiiia.  lUS 

traumatica,  iifil 
Iriilesis,  ;170 


iMii:.\ 


1-217 


Iruloi'lioiiiiilitl^    liilliiniiik'    lAliiii'liiiii    of 

cntHrnil,  .">l!l 
Iriiloivilili-.  iMriiiiiiiri  liillnwiiiK,  4".K) 

lolliiu'iiii:  lAlrartiiiM  iil  ciitiiriii't,  .'>19 
pcrliir.iiirnr  injury,  :!."i2 

m'cdiiiliirv,  U.V» 

sym|)nllirti(:i.  H.'iti 
Iriilodinly^i-,  :tiil.  :<ii<) 
IriilndiiiirslH,  JS 
Iriiloplciriii.  :i:t 

n'flcx,  :{2 

iiiiiliiti'r.'il,  :U 
Iriiliiloiny,  ;{l>'.»,  ;{70 
Iris,  iiimtomy  nf,  Itjti,  :{;t 

Bntcriiir  MiiiMlihi 
liiwinir.  "it" 

Ixmibe,  ;).■>:<,  .jlii 

rliaiiKci  ill  I  111',  ill  priiiiarv  (rhmciiriin, 

.".ai 

c'linitiiiitir  aMViiiiiiftry  of,  27 
c'liliiliiiin,'!  of,  iiiiii:i'iiittil.  'AH 

lllaiiconiM  I'olldwiii);,  5.^i2 
■  ysis  III',  ;i.v.) 

fxiiilaiioii  into  till'  stroma  of,  3-19 
faciiirs  iiitliii'iicinii  color  of,  ;i38 
forci'ps,  ,")0S 
foroJKii  hodiis  in,  :t(ll 
funrtii)ii  of,  ii.'i 
hooks,  :{()» 
liyjx'nrinia  of,  :MS 
inrt.iininatorv  disfasts  of.  34s 
iiiiirrv,itioti  of,  2S 
iiivirsioii  of,  .'it'i2 
liircralions  of.  liiil 
ini'laiioinata  of,  XV.) 
o[)i'ratioii.s  upon,  :i(«;{ 
pt'iietraliiii:  woiincls  of,  .Stil 
piilialcl,  JT 

["ostcriorlaMTsol  the,  of  an alliinotir 
liiiiiiaii  I'yi',  337 

syiic'i'hiii'     of,     following     glau- 
I'oma,  .VHi 
prolap.sc  of,    followini;  oxtradioii   of 

oataract.  :,\'.l.  .520 
soi.o.sors,  412 

tiaiiinalir  cli.iMtfis  in,  3112 
tiiiiiiirs  of,  tHMiign,  339 

trial nirnt  of,  359 

(liinioij.  :i.-)9 

tiialiifn.'inl,  3.'i9 

Mvalniotit  of,  3(iO 
v,iriatioii^  in  mlor  of.  ,'?4r> 
Iritis.  349 

course.  3.53 
iliabrtiia,  3.">."> 

tn'tilMirnl  of.  3.kS 
rtiolc-k'y  of,  354 
^lonorriia'ira,  3.5,'> 

tri'aliui'iit  of.  35S 
iiliopathira.  3.)5 
primary.  3.")5 
ill  liiap.-iiiii  !'i  Vi  r.  it.Vi 
rliciimatira.  3.'>.> 

tri'atuiriit  of.  3.">S 
"iTofiilosa.  3.")5 
sciiiiiilarv    3.")'i 


Iritis,  s)'!  I  III  I. 3.'i3 

tnaliiinit  of. 
syinploiiis  of.  .3.">2 
sypliililii-.  3.-i."i 

trcalnirnt  nf. 
trauiiialir.i,  3."><i 
treatniiiil  of.  3,")t> 
luliirriilosa,  3.">,"i 
in  xariolii,  3.'>.5 


3.">.s 


3.'VN 


lACKSO.N'.s  liiiioi'iilar  iimiitiiififr,  20 
«'     Jacsolir-.VrIt  o|H'ration  in  treatment 

of  triiliia-sis,  249 
J8rvi.s'  nasal  snare,  7tM 
f,  glaiiiipiiia  fol-   Javal    ami    .S'liicitz's  opiitlialmumeter, 
114,  115 

i/Ki{.\rK('r.\si.\,  319 

I\     tn^atiiient  of,  319 
Keratitis  arlmresi-ens,  307' 

lianilolrl,  3lli 

liullous,  31(1 

patlioloKy  of,  31 1 
treatnicnt  of,  311 
lindritir,  3f)7,  li30 

ili'sieration,  307 

syniptonis  of,  30S 
treatment  of,  308 

eozeinalous,  297 

complications  of,  299 
diagnosis  of,  299 
proKiiosi.s  of,  299 
Mvniploms  of,  297 
treatment  of,  299 

fa.soicular,  29H 

filanieiilous,  ,3fH5 
idiopathic,  30t> 
.symptoms  of,  30»i 
traunialii',  3(Hi 
tn-alment  of,  .300 

frenular,  298 

furrow,  307 

harvesters',  ,301 

hypopyon,  303 

marginal,  300 

diagnosis  of.  302 

duration  and  symploin>  of    301 

treatiniiit  of,  302 

mycotic,  307 

neuroparalytic,  308 
treat iiiiiit  of,  309 

oy.ster  shockers',  30O,  304 

parenchymatous,  311 
.symptom.s  of,  313 
treatment  of,  314 

phlyctenular,  297 

punct.ata  su|)ertii'ialis,  310 

ramiformis,  tJ30 

rililion.  310 

sclerosing,  314 

symptoms  of,  315 
(lealliient   iii,  315 

scrofulous,  297 

.suppurative  forms  of,  297 

trophic.  310 

vascular,  deep.  310 


12   »                                                     'Wm 

V 

Kfl   itL'             ;i^i  ul;tl       !i  •   ■',  f;tUt»             -irtt 

.i;.  .1  |i.ir:il\ 'i»,  .-liiiliii;v        .   Ill 

-      1..    r.     ,.f.  ;ni. 

1.  .  iirii-iil.  iu.'.;i 

'..     ...         .1.  :iii, 

lli-'l'ii.r.-il  iiii.hii'l.        H!.-|;i 

KiTiii.'         ,:;•■•       :  .           '.117 

vciiirii-i.-,  jinil,i|i«   iif         ; 

Ki'r:ii.      iiii».  :tr 

1.  .ryniritii,  ni.si.-.  Mo 

ll       'ilicTOis  III. 

111  <  ii  MIhkmI,  s|  I 

s\      M|tlt.|ll4    *>t.          _ 

•li;l(riliii.|i  of,  HI 

ll..;iHr.>lll    .i!         .ill 

liiiloitv  I'l  ">i ; 

Ki-1.|1..L-I..l  11..  :cM 

illiiil..i;s   .  ■    ^l."i 

l"llu.i.ii.  :tLM 

i..({iiii.i«  ..i ,  s|(i 

uil-.|.     .  .121 

III). 1. nil-    ..!      .S|."| 

Kt'rrili 1.1,  M<^ 

tilmi-iii          ■'111 

KirilniiM       ;((.( 

'-'(,  ,-,y\  111    >l(i 

i        '  .1.    I T 1     ,(♦  tt.i  ii,            I   M      ttnt-  il 

':ifltOll|x    ..1,    N|   i 

.1 1  111  Hit     ■     t.'iintTi             li\  ,      M 

■  lIHtlt    I.f,    H|l. 

K        riluHnilW          '." 

"12.  HI.H 

K-  :  lliisin.    ■           ..UlUX                     ! 

luiiilini.s  III,    H2I 

KWi-    '     '!|lllll      :               iciUu- 

'   '  1-1    In  iiiTirniili       712 

M-f                         ;MllHii*ii:h         «iirrTih 

.    ,H2:i 

ill  •]'                         tir  r\  f.  *>■ 

i-lii.li.i.".  I.f,  S21 

Kllll(l|i            |ii turn  |.       JIMi 

■<yiii|.'    Mi«  111,  .S2I 

till  :l,<i.|  11            lili/irnpl 

In-'         111  i>f.  H24 

u|H'rriiiii:           r,  *^**2 

-Siitrv           712    .HIH 

Kiiigh''-        111-        -  ihaiK"  uir- ' 

.,g\,            s22 

inoi 

ill,                ..f.  S2;l 

fc    u-ll   '                                  •..      <;                 i"li      t 

.11.             ■    S22 

'111                                     !.  ;ilH                       )  .es 

liM.-,:                v2:< 

-Mil)       ,1-  III,  V22 

(            .  ■.ir«  ■                             IV                     20.' 

trcaii      III  111.  S2U 

|i:ii  lioli.i;i.     I  i-liiiii^i"-  ill,  7 

1             :\\\                                               .'•MUV     of. 
1.          .•!! 

|ii.iiriiii-i-  .  1,  .S21 

-\  lll|ili.ti,-   ..f,   -Sl't 

.III.       -J 

trrjitiri'  t  1   ..1 ,  H2I 

■  -Ullg  p.      ■!, 

liii-iiiorrli.-mi.  ,1,  sl:{ 

e):«u      2U 

|>lltliiili.i;\    of,  M,i 

1  ■.!■.  .'17 

.yii-i.i.iiii-  iif,  S|:i 

tl-.i...Mti,,ll     .                     N 

In-     Mil-Ill  iif,  ,sltl 

\tir|i:.ii..'  •           1 

liv[.iiirlin,ii-:i,  x|:{ 

iiil.'i  III 

.  lii.liiuy  111,  SI  1 

:-,|>.                                                            7 

|i,-illiiiii...'\    .if,  M  1 

-ll|.|                                       nil               1      of, 

-MII|.tllIM-    III,    SI  l-|i. 

Jl- 

In  .itiiiiiii  ..1.  .s|i- 

lllMli 

mill  !i.'i-i.|)li,-ir\  ii;;ili-     7|ii 

...       Jl.'. 

P:i('I-m|i-i  1111,-1.  S2.'> 

.-.Mill                                 -'.ii 

i|i.-ti:ini-.is  of.  s2ti 

},ll                     Kltl-lii    1  1-            '1 

.  lil.l.lL'.\    of,   sj,-, 

Mo|..->     .         («tl 

|.i.i(riiosi-  III ,  s27 

ni]. f,  <K»I 

-yiiililoins  111'.  S2.'i 

-.•:il|||.-  .       .1.  Wi 

Ins'iliiH'iil  of.  K*27 

iiBH-       .iliii...;.  'ZVJ 

rli.  iiiii.'itii-.  S12 

t-         Ml  111  (if,  X'lA 

rliol.iO    of,    SIJ 

ik.   ..       I'        riin-r       .-111.1    iii.-iis    Ijiiok. 

r,.ili.in-  ol.  M2 

>i 

11    :  iiiii'iil   of.   Slti 

-....■ll.'i.                 .          1 

sii'i.-i  .-iiiilii.  SI2 

.    illiir 

(|i'M'i-i['i ion  of,  S12 

\ . 

in'niiii.-iii  1.1,  .Mil 

i..iiiii*.!i  '                             ii;iiti-iinficr,   l.'i7 

I.Jii-yiiiiiis.-ojM',  liiiw  to  1I-1-,  7;i7 

'  irMii;.,il  ,;                       n;{.> 

iii.-llio.|-i  of  illiiiHinaii.if.',  7:)^ 

■  ll,-.                 >.:i:i 

I,.-ir\-iipts(-iin\ ,  7.111 

|..-.il,.i..j:.    .1.  ,s:i2 

iii>Iniiii(-iii..  .-Hill  mi-ll,  I.I-,  7  '... 

■^.-t)l|i-l;i-  iif,  s;l  1 

i.-iryii\.  a(lcii..iiia  of.  '.Mi;i 

--. i!ijti;':i:-  -if.  ■-:;>; 

an:r-41-.r -;,;  of,   iirir. 

trc!it!ii.-nl  i.f.  s:u 

ansioi.  -1  of.  !t(l2 

ilaiiiri'i-^  fif  Miiiii..\iii    s;l."> 

i-ari  ii!    ;pKi  of.  'MM 

Ii.-ii;lK-ii.    Ill.'i2 

.l.aiiiio.-ii-  .1,  ttO.^i 

liihiii-i-iil  .-lii.lii.t.ir    10,-,:! 

.lilTi-i-.-rilial    'Ml.-. 

/.\/>/-.'.\ 


I  ■_'!!» 


^ir\ii\    larciiiiiiii     nl ,  I'l  ml- -j\   nl,  '."'I 


|W 


iIm.I.. 


.1.   '.Mil 


|iniuii(i-i-  ..I.  !HHi 

^  V  tti|il<'!tii  ttl ,  *HI't 

In'OliiH-ril      I.  mHi 
t  )i»*ri(lr<'tttH  of,   '«-J 

itl.lKIM'"i'<  III.   Kfi 

rtititoirv    III.  !«VJ 

■^\  n.;iliiiii-    ■■     'HI. 

'naMiii'iji  'Hi; 

ilMiriui.l,  mill 
mn/ltcmi'iil  m  1'' 
fVi-H  III.  TJJ.  '« 
illirnijl.'i  111,  'Hll 
frticliiri-  ol,  'Cli 
liv)xr;rsllir^i.i  ■    ,  liili. 

iM'filmi-iii      '     liit'i 
iiijii,!'-^   "I,   '.M'l 
hpiiliiii  of,  -MU 
lupus  i)f,  SiWi 

||iaKf.">i»  111,  Hl(7 

path<.lii!;v  I.I.  Ktiti 

>i>U.|lt(lllc-  'if.   HiMi 

I n-iu nil-Ill   111.  '^'i' 
tiuAi-nia  .if.  '-"il 
iii'iipl.tmii-       ,  V.17 

■  liiitfn    MMif,  .si«( 

-itliTiiilial.  >*'•'< 

'■I    il  .ixy  of.  .S<»S 
lildliillll.  IMH 

p;illl..|otf\    of.  .S!I.S 

oroiinosi.'*  of.  IKK) 

Mnptuni-  I'     iHSK) 
rratinini    .u.  !I0(( 
liiiiralcia  HII7 

h*'iiro?ii>  ■        .illli 

iiioi  1017 

papilliiiii       I.  -Vl" 
panrstlw -i;i  ol.  1(U7 
pftr.i'.vii-     i.Sfc  I.MiMiKiai  l'aral)>i>. 

HC.2.> 
rplatum  m  li.si'aii-  ol.  to  ili^i'ases  of 

Ihr  I'M-,  .V,l.') 
^itri'OMKt  III ,  *M)S 

iliacnii-i''  "f.  '•<«• 

I  tiiiloiiv  of.  im^ 

IMiliolonv    'if.    '«WI 

-iti-s  of.  IMIS 

>VI!ipt01ll^    ol.    ^KHt 

rii'atiiii'iii   III.  'Hli.t 
-pri*iii  lit.  in  MiliilN.  M)M» 

di.'imio-i-  of.  MM'.' 
.•l;iiliin\   of.    Hint 

>x  lliptollls  of.    Kll'.l 

Iri'atmi'iit  01.    Kll'.l 

U.    I'llilillKKIil       1017 

(li:iiriio«i,  of,   KM.s 
el  ..liiL'V  of.   HUT 
--\  iiii'tiiiH-  "!.   1017 
rn':iliiii'iil    III.    101s 

pluiiiatiin  ,    111  111 
,strnii-i;  nf   Hti7 

i-tiolocy  of.  HiiT 

pal Ii'iliijiy  of.  ,Mi7 
-ivinploms  of.  SIVS 
Iii'.'itiiiiul   of.   'Mi> 


l.iiryii\.  ^1  pini  -  ol.   nI^ 

>*i'riilnl;irv  .    SIS 

illai!!ii'-is  of.   sis 
pallii  iii){y  111,   sl». 

-MUpli.lll^    of.    SIS 

Inaliiiiiiit   III.  ISliS 
ti'rliar\ .  H.">1 

|>!llllo|.i«V    of,    S.'ll 

ln:i'iiiint   o|.  s,"il 
lliyroiit  tiiiiior  of.  !Mi;( 
traiiiiiati>iii  ol ,  !ll!» 

ll-i-alllHllI     nf.    'HO 

apparatii-    'or.   '110 
loial,  <)I0 

Hlij-ilii'^ia,  i||  1 
inrilii'iiial.  IIIO 
mi'thoiN  of.  (Ill) 
in'liiili/,i  1-  anil  aliiiiil/irK,  'III 
»urgir:il,  'iMO 

IIII<llKHii4.    'M  ( 
tuiilTCUloHis  of.    701.   S.M 

rliiiiral  iip|K;iraiiir  of.  70'J 
iliairmi.i^is  of.  S.Vi 
patliiiloKV  of,  TOli.  S.Vt 
pio^jnii^i-  of.  sni 
>>lllplo|ii~  ol.   S."it 

.ippraranii's,  XH't 

i'\pi  rlnr.aliiin  anil  sorrotion 
s.-,l 
trialnii'Ml  ol,  s.")!» 

can'rry,  siH 

iiili.'il.'ir\'imi'al    injri  iiiin.i. 

Sim 

ilinili:ilii.N.    sill 
lor.ll,   Mill 

-iiliMiii(oii<  injcc'tioii^.  HliU 
Ir.'icliriiiiiriiy.    sill 
tumors  111.  s'.i7 

VlTtlKO  of,    IO.")I 

(•lioliii.'v  of.   lITil 
priiyno^i'*  111 .   lll.">2 

i\lliptii|H-   111,     lll."i.' 

Ircatiiu'iil  111,  10.'i2 
Wound.'*  of,  !I20 
!.,<'  Coiitr'i  >r!ii'iiir  tor  ili'ti'cl ion  of  color 

liliniliii'.^>.  r>7l 
I.cail-piiisoiiiiii;.   I'liniiiir.   nlaiion   of.    t  > 

ilisiiasi's  of  thi'  I'M-,    IMI.  IKI.'i 
I.i'ii-   rapsuli  .   L'laiic<)tii;i   folloiving  .'inte- 
rior ^viii'cliiai  of.  .Vis 
(li'vrlopinrnt  of.  XV2 
lihrcs,  priniitivc,  '.i'.V2 
fi.i-al  li'iic'li  of  a.  (12 
n  'rai-tioii.  lill 

rardinal  points  in.  Ii2 
I.i'!:"s.  i-l:i.^.>ificatiiin  ol .  lin 
!fiiiT;ttiiin  I 'I.  li- 
I7'^ 


ll'L'O 


i.\i>i:.\ 


l.iprosy  111  iliioai,  S(i7 

liailiiiliiiry  ol".   704 
Li'pti>iiii'riiMi:itis.     aciiti'.     in     ini<lill<'-i'ai 
iiitlainiMiilioii,  1 1 1!) 
piinilciil,   1  Itl2 

(liairiinsis  ol.    1  !•>:( 

cliiilofiy  (if,   1  Hi2 

In   niasl<>iilili~.    II  111 

)pmcnii>i<  cii,  1  l(>;j 

svnipliitns  ol'.   1 1(12 

iriatincMl    of.    1    'i'' 
s-'i     IS,    Il(i2 

cli.'lKllosis  of.    I  Itii 

syinpt<iiii>  of.   I  lti2 

trcalnniit  of,  1 1(12 
liilHTciilar,  In  inastoldllls.  1121 
I.rptollirix  mycosis.  70."> 

clinical  apprarami'  of,  70.'i 

niorhiil  anatomy  of,  70."> 
Leukaniiii,  rdalloii  of.  to  ilisoascs  of  ilic    Mackcn/lc'>  liull's-cvc  Iimis  ami  nllcctor. 


l.upiis  of  lludal,  (iin);i;osis  ol,  SCiO 

"liolocy  of.  .Stiti 

liislolonical  patholony  of,  702 

syinptoiiis  of,  Hiill 

Irc-ilmciit  of,  .S()7 
Lymph  pa.s.saj;i's  of  eye,  ',U-i.  ',\\'> 

tissue,  atiopliy  of,  72.'> 
LyinplindciioMi.i  of  orbit.  201 
Lymplianiticctasis,  2!H) 
treatment  of,  2!)0 
Lymphanttioin.i  of  orbit,  20-1 
Lympliold  tissue,  intlammation  <if,  ii'Xi 
Lymplioiiia  of  orbit,  2lfl 

1I(('IIV'S     larvniieal     porle     laiistique, 

lU    ini 

M(  Hardy  peiliniter    U  1 
McKay's  ear  forci'ps,  IHl 
.Macewen's  lnirrs,  I !.")() 


eye,  .'iM 
I.i'iikainir  reiinliis.  427 
Levis'  wire  loop,  ")1 1 
Liclien  nilier,  relation  of.  io  dl~e,isr-  of 

the  eye,  Ii:l0 
Lid  retractor.   I  tesm.irns'.  22 
Liebreich  baiidasje.  modllied.  li.'i'.l 
Linameiil,  e\iirnal  cl k,  l,jO 

internal  check.   I  • 
LlKamentimi   |M>ctlnaUi-ii.  XiS,  ;(;{!• 
lyiffht  pencil,  .'il 

ra.\-.  ol 

sen.s*',  maniita'  of  testini;,  .'i.> 

wavis,   ."i;{ 
Lightning;  Hash,  amblyopia  from.  .■>7>* 
Linjniiil   tonsil.    lOO.'i      i.sVc  'roMsil.  Lin- 

Cual."! 
Lipoma  of  conjunctiva,  2!tl 

of  larviiN.  !H)2 

nas.al,'  .S!I2 

patholoi."-  of.   72t) 

of  orbit.  201 

of  throat,  p.iiholojiy  of,  720 
Li^hiasis  conjmictlvilis.   2111 
LonKsluhtediu'ss,   7li 
liOring's  oplithalnioseopi'.  Ml 
Loup,  corneal.  2.") 


11)7: 

cuttini!  forceps,  itl,") 
tonsilloiome,    lOtK) 
^^•^cula,   ,")2 

holes  at  the,  AliS 
Intea,  Cl.") 

symmi'tricil    disease    of,    in    young 
children,    -i;il 
Miularosis,  210 

Maddox  iloubli'  prism,  use  of.  In  detecting 
cvdophorla,  171 
miihiple   rods,  ltd 
roil-test   for  esophoria,   1(12 
('■'    . Aoplioria.   102 
ior  ii\|iei|    lorla,  UI2 
for  orthoplioria.  102 
Malaria,  rehilinn  ol.  todisi'asesof  the  eve. 

017 
Maltirial  amblyopia.  ."i77 
.Mallorv's  methods  for  ^tainiiiK  neuroglia, 

070 
Mnrchl's  method  for  >iaining  sjx'cimcns 

of  the  optic  nerve,  li7S 
Massage,  7."  1 

beiietits  of,  7.V1 
indications  for,  7')1 
inetho<ls  of  application,  7.5.") 


Ludwid's  aiiKina.  lOl.T.     iSee  I'lileitmon-  Mastoid  disinse,   rekition  of  diseases  of 

.ms  I'haryncllls.)  to  ijiscax  »  ol  the  eve,  .")9.") 

Luer'.s  eye  spiculum,   112  |Mrio»iitls,  .icutc,  1110 

Lujius.    ervtheniatn^u-.    oi    eonjunciha.  cansi's  of.    1 1  Iti 


202 

of  eMernal  c.ir.  10N2 
of  larynx.  Stifi 

diaRiiosis  of.  M07 

palholocy  of.  KtiO 

symptoms  of.  .SOO 

treatment   of,   >«17 
of  liosi',  .Mi.") 

diatmo-i-  ol.  SOO 

etiology  of,  SOO 

h|s|ol(ii;ieal   patholoKy  of.    702 

^vinploins  of.  .sot) 

ire.atincnt   ol.   Mi? 
of   pharynx.   .HOO 
ol    throat,   ,Sti.") 


patlmlojiv  of,  1 147 
irealinen't  of.   1147 
Mastoiditis.    1110,    1147 

bruin  ab.se<s.s  in,  1 121 

diainiosis  of,  1 1  IS 

eburnation   in.    Ills 

etioloKv  of.  1 1  Hi.  1147 

pathology  ol,  1 1  Iti 

prognosis  In,  I  l.'iO 

purulent   leptomininpills  m,  1119 

svmptoins  and   pathologv  of,   1116, 
■  1147 

irealinenl   of,    11  IS 
operative,  1140 

.•ifter-trealnieiil,    1 1.",!» 


" ' -"^ 

/v/>/;.v.                                        1221                     1 

Mastdiiliti^.    iiilicri'iil:!!'    |i'|iti>iii('iiiiii:iti-^ 

Molliisciini,  simplex,  211 

in.  1121 

Monovular  diplopia,  lO.'l 

Mathi(>\iV  idiisiUiitimic,  tt'.t'.t 

Hold  of  fi.\ation,  limits  of,  l.'iti 

Mn\itlimT's  silicinc  Inr  ili'liclimi  nl"  llii- 

measurement  of,  by  means 

atlVctcil    imisclr-    ill    nciilnr  paralysis. 

of  the  pi'rimeter,'l.")5 

17S,  17!l 

squint,  172 

Maxillary  sinus,  !lj:i 

MorKatsni,  spheres  of,  tS<i 

rhrniiic  suppuration  ni,  IM'J 

MortjaKniaii  cataract.  l!ll 

suppiirati'Mi.  'MI 

.\Iort<m".s  ophthalmoscope,  HO 

iliatiniisis  (if.  OT'J 

.Molais'  (i|»rali(in  for  correction  of  ptosis,                                i 

trralincnt  <.l,  !»72 

2-M) 

iniliialidiis  Inr,  '.>72 

.Muc<i(rlc.  22:1,  ",»7!» 

M<'aslf,~.  rclatiim  ii<i.  In    iliscasi's    cil'    ihe 

chronic,  210 

(■>'•.  Ill  ;i 

tn'attnen'  ..  ,  21 1 

Mratus.  middlr.  pus  in.  !IS2 

(•ourse  of,  224 

diatnosi-  111.  'J\2 

in  infants,  ■220 

ilitl'civiilial.  !tS2 

tn'atment  of,  2'2(i 

Megulocorma,  :i2l 

patholoRv  of,  OSO 

Mogalopsia,  .'iSl 

sympt<inisof,  224,  070 

Meibomian  ttlamls,  2:t2 

t'realMient  of,  221,  OSO 

Melanomata  of  iris.  .'{.V.i 

Mucosa,  tumors  of.  retention,  722 

Menihrana  pu|)illari<  pir^iMiaus,  31(1 

lym|ihatic,  7"22 

Iri'alMiiiil  of,  .US 

vascular,   7'22 

Ivinpaiii.  wounds  (if.  1()94 

.Mucous  dcKeneration.  p.'itholojty  of,  723 

ctioloo  '•!    l(l!tl 

membranes,  iiiHainmatiou  of,  t)03 

synipli(ni~  cf.  Kf.Mi 

Mules'  o|n!ration  lor  ptosis,  TM 

tri'atnicnt   of.   lO'.Mi 

vitreous  spheres,  410 

Meinliranc.  Howiuan's,  2'.i."> 

introdacer  for,  411 

l)f>ccni*'rs,  21*."> 

Muller's  fluid,  composition  of.  007 

IM'rsistinir  papillary,  lU'i 

nuiscle,  232 

Mpinl)ran<'Us  ronjunitivilis.  277 

Mumps,  relation  of,  to  di-eases  of  the  eve, 

.Meningitis,  ichilion  <•!,  {<•  di-eascs  df  the 

(120 

''VI',    (i;{7 

.Musc;c  volitantes,  1 10 

.Monisms,  convircinc  Td 

Muscle,  advancement  of  a,  ISO,  1S7,  188 

divcrttiiitf,   1)1 

e.xleriial  rectil-,  iilt;iehment  of,   148 

Mereury-|«iisoninc.  acuic.  relation  of,  to 

origin  of,  147 

disca.si'xif  till'  eve.  (j().") 

iiaialy-is  of,  170 
extra-ocular,  insertion  of  the,  149 

Meridiaiial  alx'rralion,  ((7 

Mrtamorpliopsia.  .VSt 

extrinsic,  in  locidization  of  cerebral 

-Metastatic  puruliiit   niininnili-.  relation 

di.-eases.    1S2 

of,  111  diseases  (if  the  eye,  l'i:i',l 

inferior  obli(iue,  or  ,i:u'  of,  14S 

Metlivl  alciiliol,  a-  a  (aiisc  of  lilindnoss, 

paralysis  ol,  ISl 

(KXi 

rectus,  ori)tin  of,  MS 

Metre  an>:le,  l.")2 

paralysis  of,  ISl 

Microphakia,   177 

internal  rectus,  attachment  '>{,  148 

Mirropsia,  ,"i.s| 

origin  of,  1  17 

Mierotoinc,  knife  f(ir.  lUlli 

paralysis  of,  Isl 

inediuin  lalioratiirv.  tiii.") 

ocular,  anatomv  and  phvsiolojiv  of. 

Middle  car.  cat.'urh  ol.  atropine.  1 1'.l.'i 

14.". 

ii\  pcrtidpliic.    nstl 

development  of,  :i:ili 

clironic    i.ascni.ii     cnirorjremenl 

external.    I4."> 

of.  list; 

rectus,  147 

deficient  hlddil  -uppiv  to.   I  l>l!l 

extrinsic,   14.'> 

dise.-ise,  eicalrieial  -lane  of,  11(10 

innervation  of.  145 

proliferation    .ami    eoiitrac- 

inferior  oliliipie.  1  is 

tioii  In,  1  ISs 

rectus,    :  IS 

purulent   itillannnalion  nf.   1I(),S 

insullicii>ney  of.  l.")S 

Migraine,  iiplitlialin<iple>:ii',    ISO 

internal,  1  i.") 

scintillatitn:  se(it(irn:(  in,  .'»70 

rectus,    147 

Militiin.  relation  of,  to  diseases  oi  the  I've. 

intrinsic,    14.) 

IVM) 

nerve  supply  of,  l.")l 

Mind  lilindncss,  171 

operations  on    ■■idvancement  oi 

Mo!.-  (if  coiijnini  ;•.,•!.  2."i!t 

,1  mils,  i.\  l.Sil 
tenolomy,  180 

Mnlluseiiin  contai;io-uni,  211 

relation  of,  tn    diseases    of    the 

para  !y sis  of,  170 

ev.  ,  (>;io 

diagifosis  (if,  177 

I.MH.X. 


Mll^clr.  onilav,    f>:il:i\\  -\ 
ITii 
r<l;itiuii>  III  ill)'  ilouhlf  im- 
:ij:rs  ill.  I7,s 

~\  IllplcMIl-  I.I,    17ii 

■.ii|KTiiir  .ili|ii|iic.  1  IS 
lrilll~.     I  IS 
i.iliilal,  .•illiirliiiM'hl  i.f.   1  Hi 

iiiiilalrnil  |i:iiiil\-i~  cil,  IT'.I 
|in"liiiini:  iMtrnil  i'\iiir~inii~.  ti'>tiii!; 
riiiH-iiiHi^  1.1,   |."i!i 
\iilii:il  .■MMir-ioii-,  i.'-.|iiii;  I'uMi- 
tii.ii-  111,   l,')<l 

I'-fiim    i.:il; 1'    till  ,    ,-il     till'    Mi'lir 

I'liiiil.   I.V.I 
.«ii|)i'riiii-iil)ii.|iir.  i.riiriii  ..i,  I  is 
|i:il;lly.>i^  iil,   ls() 
iri-liis,  iiiiiriii  111.  1  IS 
p;ir:ily-i<  nl.  ISO 
tliyrii-.'ir>IiiMii.|i-i,  |iMr:il\ -i<  il,  Kl.'il 
Mlisciil;ir  .•i>lliiiin|ii,i.  Km 

lll.n.«.  iliL'ciiiT.'ilioii  of,  ill  iniil.i.  7'2\ 
iiiilcil.-inii.,   l.'iS 
.\lii..iriilii>  iili,iri~  llii.|,iiii,  J:iJ 
.Myiii>i^.  Kll,-) 

l'uiip.iili.~,   701 
syiii|iliiiiis  ul'.   |i)l."i 
Iri'iiliiii'iit  111,  10l."i 
.\lyrnlir  kiT,iiiii~.  ;<07 
.Mvilriasis.  |i,ii;il\  li.-.  :{;i 
-paslir.  :fJ 
tr;iri.iii'm,  .'V^ 
Aiyiiri:iIii->,  u>i-  i,     ;i<  a  lacmr  in  tlir  caii- 
s,'liiiii  111'  srl;iii('iiin:i.  .'ill 
U-^i'      '.  ill  li'lllirlli;l|-  r;ilar:li-l,  ."lO.'l 
.Myl's    n,i..,ij  >pi'('iiliiiii.  7UI 
Iriiiar  ami  laiiiil.i.  itlli 
Mvdiiia.  7li 

..■nillllli.M|;lli..li   ill.   Sl.> 

)lllllliii|;ili\i',    SI 
.lAial.  S|,  s,-i 
rliaiiKi--^  ill  ill.'  iliiir..i.|  ill.  :i7ti 

inlllpliralinlli   ill,    Sli 
.■III1II-,    S7 

IiiihIii,^  I'liaiiiri'^,  S7 

M-lirii-rliipriii(liti.i,    pii~tri'iiii',    S7 
iiiiitri'iiiliil.  ss 
lorrrdiiiii  nl'.  S| 
riiiirsi' 111  i.|iii.rir"iil  i;i    ~  in.  SI 
ciirwiliiii'  111',  prriiLiiiini,  s,"> 

!|-aii..iiiil.  SI 
i'\liTii.-il  I'viijiiiri-    .1'.  slI 
lai-lilioii-,    SI 
l.'ir  iMiiiii    ill,  so 

iliriTi  i|.  liTiiiiiiatioii  of,  121 
iin'        s(.  s.-) 
II      1    •■  ...  I    ill,  s-.> 
p   ...r   .       .  SS 

p-.         ,    ..         r  ^rla,.,.-    I,, I,     lai 

pn  of,  s7 

priiiti.    <'\\r,  ss 

si-hiHil.   SS 

>\  iiiptoms  of  rvfrtf! 

\  ision  ill.  S>l 
Myopic  I'M',  7li,  SO 
.Myo«i.i,   paral\  lie.  ;tl.  -i 


f,  .'liolofis  of.     Myosis.  spa~lir,  ;>l,  :{2 

.M.vdtics,  iisi'  of,  ill  li'iiliriil,irraiai;n'l.  ."lO.'i 

ill  Inaliiiciil  of  ulaiiriiiiia.  .")(i:{ 
.My.xuiliiua.   nlalimi    of,   to    ili^'a^-rs    of 

till'  I'yi',  ."iSil 
Myxoma  of  ronjiinitiva,  2!»l 
<if  l:inii\,  !Kll 
of  (iiiiii,  Iil  1 1 
of  tliioal,  p:itlio|..s.'\    of.  7l'(l 

>'.\lll'>,  po>ii-rior.  pl'i.,;i;iiii:  of,  7l',l 
-  I     .\a-.,il  liiiri'«.  7.'." 
ilipl.tlii'iia.  siMI 

.iriiiiitioii  oi,  si,'!l 
.li;ii:iio-.i-:iiHlililT.'n'iitiali|ias- 

iio-i-  of.  s:io 
rtiolon\  of,  .S2',) 
p:illiolo;;y  of,  S:{ll 

~\  iiipioiii^  of,  s:{0 
tri'aliiii'iil  of.  s:t| 

I'lioiiili'oiii.'i,  S!I2 

iloinln'  cup.  7)2 

.'iio.''lo.-.i.<,  .Sill 

i'\iisto,'.ii».  .sm 

liyilriirrliii'.i,  lOll 

pioL'llosis   of,    1012 

~\  iiiploiii<  of.  1012  . 
In'.'iliiii'iil  of.  HU2 
liypi'iliiipliii's,  7li2 

Iii'iitiiictil  of.  7li."> 
iii^illlicii'iicy.  hysterical,    UMI 
lipoiii.-i,  .S02 
oiloiitoiii,-!.  S!I2 
p-ilypi,   7li:! 

trc'itnii'iii  111.  7li.'i 
IMilypiis  with  cthiiioiilitis.  ssl.  ss2 
lii'phiin's.  7.")7 
tiilii'rciilo>i-.  S,')| 

p.'lllloloi:y  of,  ,s.52 
-yiiiptoiM>  of,  S.V2 
Ircaliiiciii  of.  s.VJ 
.\Hsopli;iryiii;i'.il  cvsis,  722 
NiisopharyiiKili^.  acute.  1020 
I'tiiiloL'y  of,  1020 
symptoiii>  of,   1020 
Ucalnii'iil  of.   1020 
atrophic.  1022 
chiimic.  1021 

iliiiKiioviv  of.  1022 
I'tioloKV  of,  il!2l 
syniptoiiis  of,  1021    22 
Iri'iitini'iit  of,   1022 
anil  laiyiiiiiti.-,  710 
Nasopharynx,  .•m.-itonn  oi.  l(Ml,"i 
iliM-a'scN  of,  its.'),  1020 
minor-  of,   10:{2 
lii'iiik'ti,   lo:i2 
lihroinata,  10:{2 
liliii.iiiiicoiis  polypi,    10H."> 
ni.-iliniiaiil,   lo:f.') 
Nc'ir  point   fii-ion,   l.')2 

ill  In  [H'lopia,  !i:i 

lO"  iir    iiMopia,   S2 

\car>iclili'iliics<,  70 
Necrotic  iliphthcria,  ll'.tS 

p.'illioloifv  of.  (iOS 


iM>i:.\. 


I  l-l-.i 


■,\\i\  \< 


niatl  |>:triit'(  iii 


.">(Mi 


stniiitlit   catanirl.  .")()7 

Neoplasms  ul'  larviiN.  X'J7 

.lianMiisi,  ,,|.  S(»<» 


am. 


iiiilial,  S'.C.I 


ili(il(i;;y  111,  S!tS 
path.ili'iiry  II,,  ,S!IN 
priii;nii~is  ul,  !I(K» 
patliiilii'-'\  III.  NUN 
syiiiptiiMi-  ui.  S'Mt 

li-ral nt  ul,  !WIO 

III'  Mosc,  N77 

nialiciiaiil.  Vt2 
NorvP,  luurlli.  parah  ~is  ni.  IM).  IMl 
.sixlli.  paralysis  ,, I,  1711.  is:} 
sup'riiir  larviicial.  jiaralvsis  ol'.  1054 
third,  paralysis  ni,  l\(l.  1S2 
Nerves  ol   llie  ilMiruiil,  :{ti{ 
eiliary,  M'.i 

efl'eet  nt'  ilisi'a^isDi,  upmi  1  lie  eye,  i\'i\ 
Neiiralcia  ol  larynv.  1(117 

tri^eiuinal,  relation  ol.  to  diseases  of 
Iho  eye.  ('i."i2 
N'>j(irulKia.s  (if  im^e.  KlU 
N'pura.stlieiiia,  rever-al  of  lii  Id  in,  .")75 
Neiiii'itdiuv,  iiptieoiiliarv ,  oper.'itioii  of, 
ll:i 
daiiyer-  .iiid  ail\antaf:es  of. 
ll.-i 
Nciirilis,  limit  iple.  rilalioimf,  lo  diseases 
of  the  eye.   ImI 
optie,   l."i(l 

spii"!.iiis.   I.'il 
retrolmlliar,   I.")!! 
Neiiroiilia  of  the  optie  nerve,  iiielhod  of 

.stiiinint.  Ii7'.t 
Neuroparal\  tie  keratitis.  :{0S 
.Veurost's,  aiiditorx,   11(12 
of  larynx.  IIIMi 
motor.  1017 
sensory,   lOlii 
of  nose,   \(i:W 
of  pliarviiv,   lOl^i 
of  thro.'it.    KKtii 
Niehols'  s|Kikeslia\e  knife,  7-'>0 
Ninlit   lilindness,  ,-)S(l 
\od:'.l   point,  .'lO 
Nod'.ile>.  vocal.  7l."i 
liy|M»tlleses.   71.') 
.N'ose,   ader.oeari-iMi)iit;i   of,   p.atholojiv  of, 
7!.S 
adenoma  of,  p.al  liiilo);y  of.  719 
aiiasthesi.-i  of,   1(1)0 
anirioiiia  of.  pathology  of,  721 
applie.'iliiiii-    Ml.  741 

.'itropliN Hi 

-Meed.  7' 

eli.     ,uy    ii,   7|.S 
tn'aliiiini  of,  71'.' 
eareiiiiinia  ol,  pathology  of,  711^ 
ehoiidroiiia  ol .  H!)2 

paihohnjy  of,  721 
evKt-c  ti:',   tiatlioln^jv  of    722 
ilerciriiiities  of    lO.V) 

artihi'ial  siippori    in,   I0t'i2 
appliaiiees  iis<'d.   l(Mi;{ 


le.     deformities    of,     eoiieaM 
1000 
treatment  ol 
diplit'ieri,!  of,  .S2!l 
(li.soa 


i-rtieal, 


1000 


f,  hislolo(rv  of,  (is'.- 


ji.illioloiry  of,  OV 
dl.sliirlnnee-.  of  seeretioii  of     1041 
doiiehi  s  and  sprays  of.  7;iO 
epithelioma  of.  patholotry  ol,  71.*^ 
e\;imiii.alioiis  of,  methods  of,  727 
tiliroaiii^iiiiiia  of,  patlioioity  ol ,  722 
iibroina  of,  patholoey  of,  720 
foreiiin   liodii-   in.   7.'>0.   S7  J 

diai.'iiosi>  of.  7.">0,  S74 
reinii\al  in.  7;-  I.  .S74 
^\  nipt  mils  of.  7.'>0 
treatnienl  of,  7.')0 
fniclllre  of,   Iiecleiled,    UHil 

liialnieiil  of.  1001 

lii'morrha^es  of.  O'.H) 

hyiienesthesia  of.  10  Ml 

svmptoms  of,  10,0 

ireiitnu  lit  of,   Kill 

iiiHamiiialions  of.  (iOO,  70<i 

patholnsy  of,  70(i 
lepros\-  of,  .S07 

p.itholotfy  of.  704 
lipoma  of.  S!)2 

palholoty  of.  720 
lupus  of.  Nti."> 

histoloiiieal  patliiiloty  of.  702 
neop'  isms  nf,  s77 

IiialiKiiaiit.  >>02 
neuralgias  of,  1011 
neuroses  of,   10:fO 
odontoma  of,  S02 
osteoma  of,   sol 

patholotfv   of,  721 
papilloma  of,   hislolouy   of,   71'.i 
para'sthesia  of,   1041 
|M)ly^ius  of.  S77. 
.olnlion  of  diseases  of.  t.>  diseases  of 

the  eye,  MKi 
sjire<iina  of,  patholoiry  ol.  710 
scurvy  of,  tiSH) 
spurs  of,  7.")0 

diagnosis  of,  7.">li 
patholoiiy  of,  7.'i(i 
Ireatiiient  of.  7."iii 
syphilis  of.  Sir, 

patholot;ieal  aiiaiomy  of,  70.S 
.secondary,  S17 
U'rtiarv,  S4!) 
tilberculosi.sof,  patliolo>rv  ;it.  0Utt,700 
tumors  of.  ,S77.  S91 
lieniBll.   710 
malitiiiaiit.  71 S.  S02 
n'tetitioii.  722 
N(ives-(i«iild  apparatus  ^ii  ti.- itiiiei.i   of 

exophori.i.    iti."! 
Nuelpar  cataract.   103 
Niitriti!in,  (iisturliances  m.  7ls,  723 
Nyc'ftiopi:..  ;;S(! 
N'ystagiiii^    I'vS 
aeiiuired.  l^'.i 
coii(feiiii;i!     !ss 


If 

A. 


li'lM 


iM>i:.\. 


t  kCULAl;  l)allott«>mi'nl,   ISl 


(IphllialiiKxIvnaiiiiiiiirti'r,  l."i7 

■oiijmuti\a.  L'.".S  Opiitlialmimialiuia,  a7!> 

iiuijiclcs,  iiisutlicifiicv  ot,  1,'>S  Ophthaliiioiiicln-.    .laval    and    .Scliinlz'a, 

-i(rn»  and  svinptotns  atlcniliiifj  dis-  114.  11.') 

i-a.HCH  III'  ihr  lirain.   111.')  ()phtlialni(iplii;i,i.  ixlrrnal,   IW) 

ti'iiNinii.   nicrrasid.  I'lTrcts  (if,  (in  llie  inlcrnal.  a:t.   Isii 

ritriictiircs    (it     the    cyi'    and  pniErcssix  c,  rclaliim  (il,  to  discas.-:, of 

their  rts|K(iivi' Innclinns,  52S  tlic  eye.  111.' 

luiiinal.     ineclianisin     for     the  total,  Isi) 


niaintenance  of.  524 
Odontoma,  n,i.-«il,  S!t2 
0'lJ«vei',s  iiiliiliation  tnlies,  83.S 
(JOdeiiia,  cardiac.  li!M) 
of  evdids.  211) 
icnal,  (i!K) 
Olfactory  cleft,  pus  in,  !>S2 
di'iKiiosi.s  of,  <».S2 
dilTcn'iilial,  !tS2 
Opacities  m  im-dia,  diacnosis  of,  y,i 


parallactic  displaceiiient  of,  43      Optic  disk.  4.S 


I  IphthalrnoplcjiJc  niiiiraiiie,  Ixd 

()phtlialn'.osco|ie,  :{7 
description  of.  ;i.s 
.stationary.  40 

Ophthalmoscopic  evaniination,    indirect, 
45 

Ophthalmoscopy,  application  of,  to  deter- 
mination of  refr.iclion,   llfi 

Opium-ixiisoninc,    acute,    relation  of,  to 
diseases  df  the  eve,  fitMi 


OperatiiiR-mask    for    practising   on    ani- 
mals' eye>.  (>(i;t 
Operation  of  depression  in  treatment  of 
cataract.  AtMi 
Karlow's.   for   forward    proloiinatioii 

of  .septum,  "•'>2 
the  pin.  7iil 

teclmi(|lie  of,  7I>1 
of  solution  ill  treatment  of  cataract, 
507 
Operation-    on    the  eve,  after-treatment 
of.  (ill  I 
anasthesia  in.  ueneral.  (i5!) 
local.  til'iO 

infiltration,  fiOl 
illumination  of,  (ili.'{ 
position  of  oiicnitor  in,  titi2 

of  patient  in.  (ilil 
preparation  of  dressiiitis  for,  058 
of  instruments.  Ii."i5 
of  patient.  ii.'i:{ 
of  region  of  operation,  1154 
of  ,'*ponges.  *i,"i7 
of   surgeon   and  .a.s.-^istants, 

ti55 
of  sutures  and  ligatures,  ()57 

lii if  pcrformaiic(^  of,  lifvl 

on  tnn-ils,  ii((!l 
Ophthalmia.  25'.» 
catarrhal.  2tiO 
chronic,  2S1 
Kg.vptiaii.  2112.  2s5 
niililarv .  2112 
ucon.itorum,  27:t 
cause  III.  27,'{ 
cjiinplicatioiis  of,  274 
diagnosis  of,  27  1 
iMllmd  of  iiilcclion,  271 
pathology  of,  275 
prophylaxis  of.  271 
iiiidos:i.  2.Mi 
sympathetic,  '.i'.m 
i-!i.-.|.-.gv  of,  ;i<to 
palhologv  of,  ;{!>:{ 
proph\la\is  of,  :i!l4 
-\  uiptonis  of.  .'Jil2 


cupping  of.  as  a  n  suit  of  gluu- 

com.i.   'I'.iS 
opiil  halinoscopic  apjiearance  of, 
in  alisohitc  glaucoma.  537 
foramen,  licj 
ner\e  aiiaiomy,    110 

atrophy   (if.   IliO,  4(12 
changes    in.    in    primary    glau- 
coma. 5.37 
coloboma  of  sheath  of.  450 
eongrnit;il  iM'culiarities  nf.   l.'iO 
developni'iit  of.  331 
fihrts,  opai|ue,  420 
glaucomatous  excavation  of.  539 
head  of,  49 
injuries  to,    105 
nuliations.  441 
section  of,  440 

in  alisohitc  glaucoma.  .537 
sheaths  of,  441 

retained.  420 
tumors  of,  201,  401 
symptoms  of,  201 
treatment  of,  205 
neuriti.s,  450 

spurious.  454 
papilla,  4S 
-stalk,  334 

tra(;ts,  developiri'  lit  of,  334 
vesicle.a,  primary,  470 
Optical  sy,stems,  compound,  03 
Opticociliar\    neiir  rtomv,   operation   of, 
413 
danger-  and  .idvanlagcs  of, 
115 
<  iplic-,  ili-linition  of,  .53 

physiologic'il.  .53 
Ora  serr.it.a,  331 
Orbicularis  muscle,  232 

pupillary  reaction,  35 
Orbit,  analomv  of.   1112 
eelhililis  of,  104 

ctioiogv  of.   itit 
symptoms  of.   104 
treatment  of.  105 
cvi.sceration  of,  207 


i\iii:.\. 


1  -iU ") 


Orbit,  rxfiilinilioti  i>f,  207 

foHMtfn  l.inlii's  ill,  trcutiuoiit  <if,  190 
iiijurii-N  ol.  Irr.'itinciit  nl',  l<)f» 
iiistcitis  of,  l!t.') 

ulitilciisy  III,  195 
syiiiplDins  of,  19(1 
tn'iitmi'iit  of,  197 
I«Tiostitis  of,  19.5 
itioloitv  of.   19,") 
--yrnploms  of,   1911 
Iri'Mlinriil  of,  197 
3;iicorii;i  of.  202,  2(W 
tumors  of,  2112 

t-\|)lonitory    incision    to    detor- 

ininc  naluri'  of,  203 
Kronlrin's  ostcopl.astic  rr'scition 

in  (li.'ijtnosis  of.  204 
>yni|>tonis  of,  202 
Mili<;il  MTtioM  tliioiiKli  the,  149 
Orf)itul  nnisilis,  ati;i(liniiMit  of,  14(i 
tissu.->,  ilcvilopincnt  of,  'SMi 
tinnoi-i.    aiii'Mi'i'-ni    hv    iinastonii>si.'<, 
201 
ancioni;!.  201 
I'lioncli'oina.  20 1 
rysK.  208 
I'nceplialocolo.  20<) 
inilionilmnia,  20} 
lipoma.  20 1 
lynipliailinorna.  201 
l\  Miplianaioma.  204 
lympliom.i.  204 
myxonja.  201 
osteoma.  20.) 
sircoma.  200 

tumor  of  the  optic  none  204 
v.-uicosc  veins.  201 
Oroiiliarynv,  iliscasi's  of.  98.") 

tumors  of.  1017 
Ortlioforni   in   tn'almcnl    of  inlicnMilo-i- 

of  larynx.  S(i(p 
Orthopliori.'i,  l.")S 

•  lotermin.-ilion  of,  livcon\r\  -plicrical 

test.    l().'i 
Mnddox's  roil-tesi    for,   lti2 
Os.seons  growth  of  conjiini'tiva,  2.")9,  291 
Os.siciili<toiri\.    1141 

|if)sI-o|KTalivc  care  of.    1144 
(Ksihcation  of  ilic  clioroid.  3S0 
Osteitis  of  c>rbit.  19.") 
Osteoma  of  nose,  p.'itliolc>t;\   oi     7;il 
intran.isal,  891 
of  orhil.  2tl.") 

treatment   of.   2011 
Otliaiiifitonia,    I  OS.") 
elioloiry   ol.    10s.-, 
symptoms  oi,   Hi8() 
tn-atment  of.  108t> 
Otii'  cen4>ellar  aliscess.  117:) 

difiereiitial      di.'ienosjs      of 

1174 
symptoms  of,   117;i 
iicalnMiil  iii,  1174 
eerc4.ral  alisc'ss.  111)9 

diaRiiosi.s  of,  1171 
eliolo){y  of,   11(19 


(.•tic  ccrobrrtl  absci'ss,  prognosis  of,  1171 
svmploms  of,   11(19 
I'reiitment  of,  1171 
Otitis   medi.i  piinilenla.    (.Sec  Inftairmui- 
tion  of  the  Middit-   Kar, 
Purulent.) 
acuta.  1127 

<liagnosis  of,  1129 
paracentesis  in,  1 131 
prognosis  of,  1129 
symptoms  of,  1127 
treatment  of,  1129 
ilironica,  11.33 

diagnosis  of,  1134 
prognosis  of,  1134 
removal   of   larger  os- 
sicles, operation 
for,  1140 
after-treatment  of, 
1144 
-yinptoms  of,   1133 
treatment  of,  1135 
ttlomycosis,  1091 

fungi  causing,  lOttl 

diagnosis  of,  1(K)1 
treatment  of,  1092 
O.xaluri.a,  relation  of.   to  diseases  of  the 

eye,  (iOl 
"(Jvster  shuckers'  keratitis,"  300,  304 

IJACHYDEHMI.V  of  vocal  co.ds,  713 
I     I'aehynieningilis  externa  with  extra- 
ilural  or  epidural  abscess,  1160 
prognosis  of.  11(11 
symptoms  of,   1 101 
treatment  of,  11(11 
in  middle-<>ar  inflammation,  1119 
relation  of,  to  diseases  of  the  eye,  639 
I'agenstecher's   o|)eralion    lor   correction 

of  ptosis.  23(1 
I'alate,  cleft.  KMio 

etiology  of.  10(1.", 
symptoms  of,  10(1(1 
treatment  of,  KMKl 
o|)oralivc.  10(19 
soft,  989 

adenoma  of,  989 
angioma  of,  989 
benign  growths  of,  989 
carcinoma  of,  989 
malformalioiiK  of,  98.") 

congenital,  985 
inaiignant  growths  of,  989 
papilloma  of,  9,S9 
sarcoma  of,  990 
W'.undsof,  1008 
l'alpi4)ral  lonjunctiva,  25S 

fissure,  193 
Ptiiias'  operatifni  for  correction  of  ptosis, 
23(1 
probe  for  I'xploring  the  frontonasal 
duct.  9(13 
l'ana.s-.-Mielleiio|)iMiilion  for  trichia.sis,  2.'>3 
i'anmis.  309 

cjiriiosus.  309 
cra.s.sus,  30'.» 


\-i2i; 


iMii:.\. 


Ill|nl( 

.  :i(Ht 


*y 


.1.  ;)ii',t 


I'i 


illr:i   ITlillir.  :i:VI,   iU.'i 


l'rll;ij:rM 


r1:il 


loll    111.   Id    (Iw 


ii'iiiii-.  :iiK) 

tirati!ii'il   III.  :tl(l 


VilM' 


iilaris  :«H» 


vyr.   Ii:t 

'iMiipliijrii 


JUS 


Hiiiioniiiia  .'i'-ilirii<i|ii:i,  Kit) 
I'anzcr'i  -iiisMir^.  '.•.").") 
I'apillilis.   »,-)! 
I'apillHMia  111  r.iniiirlr.  '2'.>J 

111  iiii;jiiiiili\a.  '_".•! 

inlranasil.  ss7 

111  larynx.  S!t7 

111    IHiv.    Ilislulncy   111,    7hi 

miiii\ai  lit.  "M't 

uf  thnial.  liisli>loi;y  ul,  71!t 

I.I'  iiMil.-i.  !IMI 
I'ar.Jiiiliiiilal  IriKis,  m 
l'ariirriiti'>i-.iil'  aiili  riiir  rliaiiilirr  In  Ircal- 

lilrlil   III  tilauriiTiia.  lt<V.i 
l'ar.iiii-i>  111  iiiliTiial  i-ar.  1101 
I'araildxiral  |Mipill:.i'v  irarlioii.  35 
I'ara-stlii-ia  nl   lai\  m\.   1017 

111   nii-r.    Mill  ■ 

111  pli.iryn.\.  101  ( 
piiiHii<isi>.  loll 
Miiipliini^  111.    101 1 
rarakihfsii.   Lis 
l'aral!a\  ti-l.   111:! 
I'araly-is  m  al..liiit.iii  nl  innU,  1051 

auitans.  n-latiuti  nl.  to  iliM'ti-i^'.-i  ^il"  the 
I've.  (il2 

liilatrral  ;iililiiiliir.   105:i 

111'  ci'iitral  aluliiftiii^.  1051 

riin.iiis.ili'.    1^1 

n!   i-niniT^i'nri'.    iNl 

III  rvtiTiial  irrlii>.   17'.1 

III'  I'liurlli  iirrvf.  ISO.  ls:i 

tinirtiiinal.  nl  inli-inal  rar    I  101 

111  inlrniir  iililii|nr.  Isl 
rciiii>,  IM 

111"  till'  iiisanr.  rrlatinn  ii!.  'n  ilist'asi's 
111  till'  I'Vi'.  lilO 

ul   inti'inal  rcrtiis,  Isl 

111   li'valm   ,'ihr,   1011 

111    iinilar  iini'^rlr.^.    17li 

1.1  pliai-vnx.  1015 

ri'inrii'nl  l.irviiKi'al.  105:t 

111  .-i\tli  ni'i-vi'.  I7!».   ls:( 

lit'  Tiuirt'riiii'  lar\nj;i'al  ni-r\i*,  1051 
iililii|U<'.  I'SII 
ri'ilii-.  ISO 

til'  tliiril  iiii'M'.  ISO,  1S2 

111  lliyrii-arMi'iiiiiili'i  iiiiiM'li's.  lO.Vl 

iinilalrial  aliiliirtiii'.  105:i 
1.1  mhilal  niiiM-li'^-.   17!t 
I'.'inilytii'  inMlti,'i>i-i.  Xi 

myo.'^i.s,  .'{1.  ;i2 
I'ari'nchyinatiiiis  krr.'iliiU,  :!ll 

infl,'ininiatiiin<.  7IMi 
I'arin.'iinr.s  runjiiiu'lu  iii.-.  2t>7 
I'ariisniia.  KKill 

I'liiiliiirv  111.  lino 

Iri'.'itnii'iit  111.  1040 
Parry's  ili-^i-aw,  20S 
I'ar.s  riliari"  rrtina'.  IWl.  iWS 

niilii'.i  nliriM'.  liiil.  :i:ri 


aii-M'  (>r.  'JliS 
I'laliiiii   III.   Ill 


iM'f<     Ot      till 


tin'   t'j-c, 


7(H) 


ti:{0 
tn'alniriil   nl.  L'OS 
Prriclininlrial  intlaniinalinii'^,  t^ 
I'l'rirlliinillit  is  nl    >i'pluni.  litMi 

li\  |in|ila>tir.  70tl 
I'lrii'lininiila!  spaii'    :UI.  :U5 
I'rrinii-ti'r,    nii'asur"nii'nt     nl     iiiniux'niBr 
lii'lil  111   li\alinn  In   ini'iiiis  of, 
155 
III  M|iiiiil  witli,  17:5 
l'<'rin«ti':il  ii|l|anini.'iliiiii>.  "IKi 
lVrio.ll  it  is,  aciitr  ina-tniil.  1141) 
laiiM's  nl,   mtl 
p;itliiilni;y  nl,  1 1  17 
lii'atinrnt  of.  11  17 
111  orliit.  105 
111'  >iptiini,  700 
IN'ri.Tiipir  lri'.M''i,  01 
IVritonsillar  al>sri"<s,  !)<<;{ 
I'tinlncy  of,  !Ht:{ 
s,\ini>lnius  iif,  WA 
I'rtalincnt  ol,  0!»l 
IVrriuN  .'irtiliiial  rvi'>.  1(7 
I'etit,  ranal  of.   17li 
I'etvnsal  sintl.sc-,  inlii'tivi'  tlironil'osi!*  of, 

1100 
i'liarv  iitii'.'il  alisd's-^.  (i07 
artiTi"'..*,  KHIS 

annnialirs    in    ilistriliution    of, 
KNIS 
tonsil,  1022 
I'liarviiKitis,  arilti',    UHfS 

.linlocy  of,  1»H)S,  KMMI 
plilcKnioiiiiiis,  10l:( 

svniptnnis  of,  1013 
tn'aliiH'iit  of,  1013 
sviiiptonis  of,  l(K)y 
In-alniput  of,  KXK) 
atrophic,  1012 

symptoms  of    1012 
ticatmi'iit  of    1012 
rhronic.  tOlO 

granular.  1010 

I'tioloiiy  of,  1010 
symptoms  of,   1011 
trr.afmrnt  of,  1011 
simpli',  1010 

I'tiulocy  of,  1010 
svmptnms  of,   1010 
tri'.'itmi'iit  of,  1010 
Kanfrrciions,  l()l;j 
granular,   1010 
IMiarvngofcli',   KHIS 

symptoms  nf.  KHts 
I'liaryntiosrnpy,  735 

ti'rliiiiiiiii'  of  rv.'imiti.'ttion  in.  73.% 
riiHiynx.  aiiastlii'sia  of,  1043 
t'liolojty  of,   1043 
synipioms  of.  1043 
tri-atiiii'iit  of.  1013 


IM'UX. 


1 227 


I'liHi'Viix.  I'l  loiiijir  -  Mini  iii.'illi>irii.'iiiuii^     I'llociirpiiK'-iMiiMiiiiiii,'.  ii  l.il  mii  nl'.  I<>  di 
of.  I(HI7  fiis<'~  III  tlif  r\r.  (HIS 

<li|)lilli<Tia  I  ,     ,s:tl 
iliHjrnii^i^  III.  s:;2 

(lilTiTcnii.'il,  s:t:{ 
|i,-illiiiliit;y  III,  M{l 
tlc.itnirilt    111.    Mil 


liiM-Mst'.-,  1)1'.  iims 

riiii'iui'  limlii'^  in.   Kllti 

^\iii|ili.iii-  111.  lOHi 
lli'MIMli'llt   Ml'.    IDHi 

li>'!iiiiri'li;ik;r  Iniin.  !lll.*i 

li'Tpis  1)1.  km;! 

-viii|)t(iiii«  111.  ioi;{ 

IllMlllll'lll    111.    idl  1 

li\  |Hr:i>lliisia  nl.   lon 
(li:ii;iiiisi-i  III.   Kill 
(Miiiludv  I.I.   Kli:( 
<yiii|ili)iii^  ill,    K»l  I 
tri'iitiiii'iil  111.  MII 
lupus  dl',  M^i 

M  iiipliiin.-.  Ill,  "■•ill 
iii,'ilfiiriii:itiiins  nl.  KHIT 
imitiir  .li>(Mili:iiiii'~  nl.    Kll.'i 
MiMiiiisi-s  ill.  Kli:t 
I  •ira'.Klhrsia  nl,  1(114 
pronniisi>i  nl.  Kll  I 
syiiiplii|ii-<  111 .  Kill 
paraly>ls  <il,   K)l"i 
para.sitic  disi-isi-  nl.   Kll  I 
nivcn^i-;.   Kll."» 
thVusli,   Kll  I 
n-latinli  n('  (li.s4Misr?i  nl",  in  ilisrast'.s  (*!" 

the  lyi-,  .">!):{ 
»|iasin  nf,  KM.") 
stoIKi.si.s  nl,   KKIS 
t<'rti;iiy  .syphilis  nl .  S,")!! 

iliauiin-i-     4,  S.')<l 

(lilT.      iilial,  .S.".(l 
palllnlni;.    111'.  s.'>0 
sviiiplnins  nl,  S.-iO 
trr.Mlmriit  nl,  .H,">(l 

lllhl'l-rulnsl-    nl',  .S,'>2 

<iiaUMnsis  nl",  S"j2 

(liliVrciitial.  S.Vi 
patholngy  (if,  S.VJ 
pmillinsis  nl,  Hi)2 
syinptnins  nf,  ,S,")2 
wiiunds  nl,  KHIS 
I'liillips'  plinliiplinii',  7;{(l 
Phli'gmniiniis  pliaryiijjilis,  anili',  KM  i 
syiiiptiiiMs  nl,  |in:< 
tiTatiiiriil  III,  10l:{ 
Plilydena  pallida,  2t)l 
Phlyctenular  cniijiuu-tiv  iiis,  27!* 

"  keratitis,  2'.t7 
Phosplmturia.  n'lalinn  m.  i 
the  eve,  tiOl 


I'in  n|H'i'alinii,  7(il 
I'iiiKueiula,  2S.S 
I'iiik-iVf,  2(iS 
I'lacidn's  <lisk,  2r) 

appliratinii  nf,    in    drti  riiiiiuii)! 
cnriif.d  (urvature,   1  H 
I'laiie     iiiirrnr,     ux'     nf,     in     -kiascnpv, 

121 
I'laiin-rniii'.'iM'  liiisi-,  (il 

-riiiiMA  liii>i'~,  I'll 
I'lexu.s  annularis,  2!Mi 
I'liia  seniilunaris,  -'.'iS 
riu'Uinninicie  innjum  I  i\  itis.  2(i(l 
I'neiininni.i.  relalinii  •!{.  In  diseases  nf  the 

eye,  .'>'.).', 
I'nlliiiriii,  :{IS 
Polilzer's  liajr.  llSd 
s|HMiiluiii.   Kl77 
Pnlypi  nf  iniijuiiiti\a.  2'.II 
eysis  in,  722 

filirnniiienus.  nf  nasnpliarvnx,  IdH.') 
I'lilypnid  i-ysts,  SMI 

syliiptnliis  nf,  SSd 
treatment  nf,  SSI 
Polyps  111  inrds.  7H 
Polypus.  Iileediiij.'.  of  septum,  88H 
intranasal.  .SSI 
iia.s;il.  with  sinusitis,  S.S2 
iliai:iiiisis  of,  SS.'{ 
prnjinnsis  nf,  S,s:l 
tre.'itinent    nf,    ,SS| 
nl   nnsr  (ledematnus),  S77 
elinliiKy  nf,  S77,  S,S(I 
luiernseopie  ap|)earanee  nf,  880 
pathnlojry  of,   S77 
retronasal,  SSI 

palholn^v  and   ilinieal   liislolnnv  of, 
714 
Poiiierov  head-liand  and  minor,  729 
'•  Pop-eye,"  ,S!» 
Pori'iieephalus,  relation  of,  to  disiases  of 

the  eye.  (145 
Posterinr  ehamlier.  340 

e\u<latioii      into,     in      cvelitis, 
:{.-.2 
in  iritis,  :j,-,(| 
.syiieehia',  .'{."lO 
Postnasal  grnwlhs,   102:t 

iliatrnosis  nf,   1027 
etinlngy  nf,    l(l2:t 
proKnnsis  nf,   |(|2S 
.symptoms  of,   1023 
(iratmenl  of,  102,H 
PruK'.s  asiiKinalie  letters,  12."i 
iseases  ,,\     i'li'.sbyopia,  (ill 

"  Pressiin'  points,"  231 


Plio.sphorus-pnisnninn.  lelal ion  nf.  In  dis-  Prince's  a<h ancenieiit   fnneps,  IS" 

ea.ses  nl  the  eye.  tHI.".  Principal  focus,  .17 
Phthiriasis  eilioruiii.  212  point.  .5!) 

fpl.'itinii  1.:.  ■••  di-f:i-<-snf  the  i-.r,  ti;-;o  Pri.'^ni.    lictcniiiiiat i.Ul    OI     tliC     ,ixi.s   of 
Phthi.sis  liiilbi,  3.54,  37<»  1 10 

essential.  37'.»  ilisplaceiiienl   produced  liv.  140 

Pigment,  ihornid.d,  fiinctinn  nf,  til)  Prisms,  aclinn  nf.  upon    retinal    im.i({e.s 
retina!,  fuiiclion  nf.  (Hi  l.",:i 


1  'i'iM 


l\ll^:.\. 


IVi-irn- ill  tri'atriiciii  Hi   iliMi-tfiiit  ^^tr!lllis-    riini.li'iit  iilitis   m.'ili.i.  ilirniiip,   riiiioval 


mil-',  IT.") 
of  i's<i|>liiThi.   ItiS 
of  c'Miplmria.  il>."> 
(if  liy|"'r|>lii)ri:i.  170 
Prismatir  (ihirs  oi'  irv<t:tlliiir  lens.   17.) 
Psou(loKlioiii:i  (if  the  vilri'oiH.  :{S7 
P8oriii.Mis.  n'l.ilioii  iif.  to  (li<i";i->i's  of  lln' 

eyp,  t't'M 
Pt<-"rvniiiiii.  L'SS 

iliaHiiosis  of.  '.N!t 
n'ciirrrni'i's  of.  2!K) 
liratini'iil  of,  2S!I 
Ptoni:iini'-|M(isoniiii;.   ri'latioii  of,  to   ilis- 

eiis<s  of  till-  t'vi',  IKIS 
Ptosis,  ISO,  2:u 
acquired,  J:{."> 
ailiposa,  2:{,"> 
aloiiiia.  'J:t."> 
rorebral,  1S2 
paralytic,  2H."i 
tli'atincMl  of.  2;{,') 

WoltT'-i  o|«'r;ilioii,  i'M 
unilateral,   is2 
I'linita  lacryiiLilia,  21  I 
atresia  of,  21!l 
Puncliim  |)roxiiiiuiii  of  converKenee,  1,)7 

remoliini  of  coMvcrteiice,  l.")7 
Pupil,  accoiniiiodalioii  .iiid  i-oiiver);enre 
reflex  of,  M 
.VrKvll-liolieitsMii,  ;!2 
associatcil  iiaction  of.  :{1 
cerehral  cortev  rellc\  of,  :i  1 
color  of.  2'.l 

iiiiisi'iisiiO  refli'x  of,  ,'{0 
direct  liu';i  ntli'x  of,  :{() 
exclusion  of,  :{.V) 
indirect,  n^flcx  of,  ;{0 
occliisiiin  of,  H."i0 

follnviiiv'  i\irai'tioii  of  cataraet, 
.■i.'t 
n|>iTations  lor  ciilari;einent  of,  3t)5 

for  ocelus'on  of,  ;!(l>t 
sli.iiie  of.  '.Jit 
variat'iMis  in  si/e  of.  2!l 
Pupils,  separation  oi,  iroin  each  other,  20 
Pupillary  im  inhr.itie    oersistins;,  XVi,  346 
n-aetl'  M,  oilii(  iil.ir.  :i,') 
pnaiioxical.  :!."> 
Purpur.v,    rtlalioii  of.  to  .lisi'ases  of   the 

eye.  'mI 
Pniiileir.   I' ptoinei,!n;rilis.  lli)2 
^!  rifio-i,  ,>i.   lltiii 
cliojosry  of.   11112 
proL'icisis     and     treatment     of, 

lli;:{ 
symptoms  of,   1 1(12 
otitis  media,  acute,  1127 

diasjno^is  of,  U2!l 
paracentesis  in,  11:51 
piiiixnosis  of,  112(1 
->.  iiijitoin:-  of.   U27 
treatment  of.  112!) 
1  hronie,  1 13:! 

fliajriiosis  of,  1131 
[iroiriiosis  of,  ll:!l— !."> 


of     large     osui- 
cles,     oix'ratioii 
for,    lilt) 
after-lreatinciil 
of,  II 1^ 

-viiiptoinH  of,  ii:t:{ 

Ireatmi'iit   of,   11  :(.'>- Hi 
l'u~tulc.  malignant,  relation  of,  lodisi'ii>«'s 

of  the  eye.  till 
I'ya'inia,   relation   of,  to  diw.ase.s  of   the 

eve,  (ill 
Pya'mic  retinitis,   130 


<l 


riSlNK  aniMv.ipia,    Uil 


K .VCK.MO.sk  staphvloina,  317 
Kadial  fihres  of"  Muller,  334 
Ue.il  foeih    ,"i7 
Ued  liliiidness,  ,'(70 

glass  test  ill  lieterophoria,   I'M) 
Hed-Kreen  hlindness,  ."i70 
lietli'x  anililyopia,  .'>7',l 

eonsi'iisuai,  of  pupil,  30 

corneal,  ex,'iiiiination  of  the.  24 

direct   liilht,  (vf  pupil,  :tO 

fuiiiius.  12 

Haali's.  :U 

indirect,  of  pupil,  Mt. 

iridoplegia.  ,32 

unilateral,  32 
nf   pupil,   ai'eomiiiod:ilioii   and   con- 

vergeiici-,  31 
streak,  .50 
lief ract  inn,  ,')fi 

absolule,  ill  aslifiinatism,  UK) 
I'ardiiial  points,  ,")'.l 
collective,  ,Vs 

formation  of  iinaces  liy,  ,'i!> 
at  curved  surfaces,  .Mi 
di.speisive.  '>S 

deterniiii.it ion  of,  application  of  oph- 
thalmoscopy to,  1 II) 
conditions  i^overning,   110 
hy  direct   illumination,  117 
liy  the  direct   method,   UH 
liy  the  indirect  methoil,  117 
errors  of,  as  a  factor  in  the  causation 

of  glaui'onia,  ,')40 
Rcneral  rules  for  examining,  with  the 

triiil  ease,  12t) 
lens.  oO 

oardinjil  points  in.  f>2 
Nulljecti\e  tests  lor.   124 

astigniatii-  clock-face,  12,") 
direct  delcrmination  of  the 
far  pomi  in  invopia,  124 
tesi-<ards.  12l> 
trial  casi',  12l) 
Refract i\ I-   condition,  estimation   of,  hy 
riicans  of  test-icittT.-;.  7:i 
errors,    liygienie   treatment    of,    141 
(.liiective  tests  for.  111 
subjective  tests  l"or,   1 1 1 
symptom  ■  of,   IDS 


/\/»/..v. 


I T2U 


Itilrmlivi'  iiri)i>.  Miiiplnnis  of,  in  :i^ii«- 
iiiiiii!<iii,    IK) 
in   liv|»'r<i|>iii.    Ill) 
ill   iiiMipia,    l()l) 
u*'  <>l  cvcloplt'isics  in   (IcIiTiiiin- 
iiiK,  il2 
imlox.  ri'liitivr,  .j(i 
Hi'jfrrssivc  (lisliirlmni-cH  of  niitiitii)ii.  723 
Keik's  foriniilin  sicrilizor,  ti.')7 
RelapxiiiK  lr\pr,  nlatiiin  of,  to  iliwaws 

of  the  oyi',  (il7 
Uespiratorv  trncl,  cITicIn  of  disiiisc*  of, 

upon  the  vyr,  VXi 
Kpiiiih.  nniitoiiiv  of,  117 
atrophy  of,'  422,  l.<:l 
rhnnKCM  in  llir,  in  iiriinaiv  Kliiucoiiia, 

coiiKcnituI  piKnirnlat.'oii  of,  i:W 
cysticorciis  of,  i'.iX 
dftiicliiiicnt  of,  l:i."> 

Klaiiroiiia  followini;.  .'>.51 
devclopiiiriif  of,  ;{;«.  3;u 
(list  rihiit  ion  of  vi'-si>l.s  of,  .'lO 
eflffot  of  liglit  upon,  JX? 
pmbolisiii  of  ii'Mlial  artrrv  of.  431 
Klioma  oi,  43.S.  »;!!) 
rirxaeonal  picmi'iil  cells  of,  341 
injuripn  of,  43X 
sclicini'  of  stiiKliirc  of,  41^ 
tliromliosi.s  of  iintnil  artery  of,  433 
Retinal  asthenopia,  1(H) 

image,  mental  projection  niul  rectifi- 
cation of,  (Ml 
pigment.  Iiiiiclion  of  the,  00 
veins,  glaucoma  following  fhroinbo- 
sis  of,  ."),"i2 
Retinitis,  allmmiiiiiiic,  123,  425 
ciniiiata.  431 
degenerative,    424 
dialietic,     '20 
hemorrhagii .  427.  42S,  429 
inflaniinatory,  421 
leukii'inic.   427 
pigmentosji.  434 
proliferans,  430 
pva'inie,    1,30 
striata,  4.30 
svphilitic,  121 
thromhotic,  427,  I2S,  429 
Iletrohnlbar  neuritis,  4.50 
Retrona-sal  polyims,  SS4 
Retropharyngeal  ahscess,  1017 
iliagiiosis  of,  lOlS 
etiology  of,   1017 
svmptoms  of,  lOlS 
(«>«••■     it  of,  lOlS 
Rhachitir  te       ,  313 
Rhachitis,  n'lalion  of,  to  diseases  of  the 

eye,  r,H5 
Rheiimalie  laryngitis.  S12 
etiology  of,  S12 
s\mptoni.5  of,  St2-St0 
treatment  of,  816-SlS 
Rheumatism,   relation  of,  to  disease^  of 

eye,  012 
Rhinitis,  acute.   70S 


Rhiiiiti.>,  acute,  diagnosis  of,  771 
etiology  of,  70H 
prognosis  of.  771 
syinptoiiis  of.  770 
tn'atment  of.  771 
alrophie.  710,  7S!) 
diagnosis  of,  79.'i 
etiology  of,  7!K) 
prognosis  of,  79."i 
>ymptoms  of.  792 
ihronic,  774 

di.ignosis  of,  7S2 
etiology  of,  77."i 
prognosis  of,  7H2 
sjnipfoms  of,  777 
treatmi'Iit  of.  7S2 
dry  anterior,  7IH 
filiriiious.  7H0 

diagnosis  of,  7H.S 
etiology  of,  7S7 
prognosis  of.  7H.S 
s'  inptonis  of.  7SH 
trealmeni   of.   7HH 
hyiMTtiophic,   774 
diagnosis  of.  7S2 
etiology  of,  77.") 
prognosis  of,  7H2 
symptoms  of,  777 
trcatnient  of,  7S2 
sicca  anterior,  71>< 
simple  and  chronie,  774 
diagnosis  of,  782 
etiology  of,  77."i 
prognosis  of.  7s2 
symploms  of.  777 
treatment  ol',  782 
vasomotor.    091 

pathology  of,  091 
Rhinoliths.   K7.") 

diagnosis  of.  H75 
pathology  of.  S7."i 
symptoms  of.  87.") 
treatment  of.  87.") 
Rhinorrhoa,  SOI 

rerebro-spinal,    1042 
diagnosis  of.  1042 
etiology  of.   1042 
symptoms  of.   KM2 
treatment  of.  nil,  1043 
diagnosis  ot.  80") 

differential,  .SO.") 
etiology  of.  ,S04 
prognosis  of.  80,5 
symptoms  of.  80,5 
treatment  of,  800 
Rhinoscleroma,  70.5 

histology  of,  70.5 
Rhinoscopy,  anterior.  727 
attitudes  in.  730 
instruments  used  in.  731 
reflectors  for.  728.  729 
source  ol  light  in,  727 
technique  in.  "32,  733 
r)osterior.  733 

examination  in.  733 
^quisites  for.  733 


i-.';;n 


/../'/•■.v 


Wiclni'-    npii  iiiiiii     i.ir    ci'tro,!!..!!.    ■.'.Vi, 

.'.V. 
Hini.',  ilii.n.i.iil.   IS 

-ili-nil     IN 

111   Wnl.l.  w  1,   llKi.-. 
linn;"'  *•>»'  iii;t-k.  ti'ts 
•  l!i|ii    '  r:il;ir:iii.   IVI 
l{ii|r\  'i  riil.irv  |iii-iM,  llil 
l{ii|inirr  111  rlmniiil.  H>«J 

^AN  li 'MN  I't'l'-'lMN"  i.   ri'latiiiii    ot, 
i'     III  ili>iaM'~  III  till'  ryr,  (K)" 
StCl.iii'    riHiMi^iin's  lurri'ps.  !•7^ 
SiijiiiH'  li.i-.ll  -nail',  Till 
Surriniiii  <>i  rliiiinlil.  :(>•<• 

III  riinjiini'livM.  Jll'J 

III  ■•xtirii.il  lar.  KKi 

iiilraiia>al,  Vi:» 

iliamiii>i>  111.  "»!•-■> 
i'liiiliii;v  III.  sot 


-.li'tal  iTl,i-i-.  iM'.itliiilil  I.I,  :tJs 

nni:.   IS 
,-iliTiii-,  Mr, 
ili-.|i,  :i2i. 
MTiihiliiii".  -i-' 
SiliTii-i'lioriiiililK  |iii-iiiiiii.  s7 
Si  liiii-kir.itii-iiilii.    :iJ7 
s\'ni|iliitiii  111.  -127 
Iri'atini'iit  ul.  Si' 
^ilirii>i>.  ililTii.-J'  riTilir.il,  rrlatinii  ul.  In 
ili-.i-;t>iH  III  llif  rvi'.  (ii:; 
iliTwiiiiiiatiil.  nlatiiiii  nl.  to  ili.sfa.si- 

lll   tl vr.  ti»J 

.Sill. rill  ir.  rliaiik'i-  i"  tl"'.  m  primary  (tUtl- 

coiiia.  vVJ'S 
.SiliTiitiiiiiv.    iiiitrriiir.    ill    Irialmrnt    of 
ulaiii'iiiiia.   ."it'll 
jMistiTiiir.  ill  Ural  Mil  lit  111  ulaui'oiiiu, 

■■'•'-' 
Srii|Milaiiiiiii',  iiM'  of.  as  a  iiivilriatio,  112 


mirii.siiipii-  appiar.iiii-r  m.  s'.l.l     Sfii|Milaiiiiiii'-piii-iiiiiii»t.  ri'latloiiuf,  to  ilii»- 


p.llllnlilliy  111.  S!ll 
priiuiiiisi-  111,  yt.'i 

-yiMplnlll-   111.    S!t."i 

trralini'tit  ul.  .H!ir. 
fii  larvnx.  IHls 

iliaminsis  iii,  '.HKI 
i-tiulucx    111.  !KIS 
palliiiliitfv  ul.  IMMI 
sili-s  111.  !H(S 
syinpliims  ul'.  '.Ml*.! 
tii'almriil  111'.  '.'Oil 
111  iia-iipliai\  hX.   I():>."i 
ol  tuisi'.  palliiilni!     111.   .  I'' 
of  orl'it.  2112.  211..  'JIMi 
tifaiiiii'iit  111.  '2117 
of  soil  pal.ili'.  '.«H( 

-\'fiiptiiin-  111 .  II'HI 
trralllli'llt  of.  tl'.H) 
of  tliroal.  |ialliiiloirv  of.  71(1 
of  Iiiii-il-.  |IK):i 

iliairiiiisi-  of,   IIMM 
iliiil.ii:y  ..I.   HKll 
-VMipli'llll-  I.I,   IIMM 
tn'.'iiiui'iil  i.i.  lllii  . 
of  lIMll.l.  'I'HI 

s\Illp'iilll-  III,   IIIHI 
ll-i-.'llllii'lil  of.  !»!MI 
Si-arlati;ia.  M'i.'il  imi  of.  to  ili-i'.'isi's  of  ll 

I'Vi',  lilU 
Si'lili-ii'li's  iiililiialioii  alKi'-tlii'-la   in   opi 

nitioiis  on  I  111'  I'M*,  ''itil 
Si'lili'inni's  I'.iiial.  :i2.-i.  Xi'>.  :ii:!,  :!ll,  ;il.' 
"  Si'liool  invopi.'i,"  ss 
Si'lr.-a,    :(2i 

.'inaloMi\  I.I.  :t21 
ili'Vilopiiinii  of.  :(:i."i 
foi'i'ii;ii  lioiliis  ill,  :i:{l) 
injiirir-  III.  :{2!l 
laii'ialini;  woiinil-  ol.  H'J'.I 
inpliiii'  of.  ;{:ti) 
-iiipii V ioiii.i  "I,  -V^^ 

svpliilis  of.  :i2S 

Iri'aliiii'iit  of,  :i2".t 
Scli'ral  I'ltasia',  ;J2S 

r,'llisi..  ol',  :i2s 


I'asi's  III  till'  r\  I',  I*»<I7 
St'oloii  a,    ll!l 

ri'nlral,  in  tii\ir  amlilyopia,  i\X 
iirKativi'.    l.'ili 
(Kisitivr.  4.'it) 
si'iiitillatiin;,   ."n!! 
Sooloinata,    in   ilissi'iiiinnli'tl   choroiditi.s, 

It.S 
Seiirvv  of  llosr,  liiMI 

of  throat.  li'HI 
Si'liorrliii'ii,  rrlatioii  ol,  to  ilisiasi's  of  tlic 

i-yi',  030 
"  .Siiond  -ielit."    I!'2 
Si'ili'r's  tuliiilar  forrrps.  '.117 
.s,.|,i|i.  I'.'itarait,  |HS.  isd,  .|!M).  lltl 
Sipiica'tiiia.  rrlation  of.  to  ilisfascs  ol  the 

i.yc.till 
Siptuni,  blcriliiii:  iiolvpiis  of,  SH8 
ilLiUnosi'-,  of,  ,S',H) 
i'li..liii:\,  of  ss',t 
pallioloKy  of,  KV.I 
proirnosis  of,  MM) 
syiiiptoiiis  of,  H*M^ 
tri'atiiirni    of.  SiM) 

ill-,  ..ill if.  7.'ili 

liiiiiliiiiiilrilis  of.  lilMi 
liy)M'rplastir.  7ll'.l 
IH-riosliiis  ol.  7W 
|.ioliiiiKatiiiii  of.  forwaril,  7li'2 
sytiiptoiiis  of,  7li2 
trralniiiit   of,  7ti3 

I'aiiow's  o|)i'ratii.ii. 
71.2 
^i  rai^iili'iiiiifi  of.  7.''i1l 
.Si'xii.n's  fori'luii  lioilv   forri'p-,  lltlU 
S'xnal  oritaiis,  I'tfi  rl- 111  .lix'asi- ol.  upon 

I  hi'  cvi',  litM 
Shallow  ti'.-l.   1211 
Shui'li-v's  powilir  Mow.  r.  1112 
>iili'rosis,  l(i:{ 

■^;'-;;!<'n  pli.-tliii:i<!'-  -Iw-i'ii'iiHr.,    !!77 
.■^iiimoiil   sinus,    infi'i'tivo   iliii'iiilio-i-   oi, 

lHi:t 

ilia^nosi-  of.  IIi'm 
proiriii.*i-  of.  1  It'iti 


/.V/)/..\ 


iS.i\ 


>iKm..i.l  Miiii-.  MMipliMM-  ..1.   ll(i:t  Sinn-"-.  .|,lMn,,j.|.il.  .Iiri.iii.    Mipimr  ition 

Inatm.iit  .,1,  M,Kr,-,lni-.  lllMi  in.  .vii.,,i,,i.,.  ,,|    <tT.t 

filvpr  sali^,  |Hii>iiiiiiik:  l.v.  rihiiii t,  td  .lliifiiip-ii  o'    'i;  J 

di*x*.,  .,1    t|,r   .vr.   .Ml.-,  ,l.-v,.|.,,,n,.Mi    nl'.    •rjS 

Slllgerf.    ii.mI.^  S2,  .Hii|.|Hii:ili,.i,  ..I,  !t:iO 

■  li:itfiin-i»..l.  SJs  liiiilfri..l..Kv  .,1.  !i:i-J 

"•llnli.ny    III.    S2S  llioluliv    nl,   H:|(l 

.iiiil    parliMl.itni.i.    iiiiiimil    oC,  iiiiirliiil  aiml.Miiv  Ml,  it:t:t 

'"•''•  '""  SiiiiHitis,   (•.•il.irrliiil.   cliniiiic,'  1.17!)       (>V, 

i\in|iliiiii-  ..I.  S2S  .Miiciicrlc.i 

Ir.'iilni.'iii   ..I.  S2S  wrciiH,  '.•7il.      lS,r  Mii<-<„tI.'  1 

""""*•"■  ••"  "-"HV.  !t.s(l  with  im-.,\  |H.K|.u.,  H.S2 

ili«'!iM.t  III.  <fJ2  Skia.Hc-opv.  120 

.limTriili,ilili:iniiii-i-iil,  ••S'i  appriciition     of,    with     tlif    coriiaM- 


miirniH  liniiiit  ol.  '.rj'.i 
plivsiiiliiity  111.  !I2!» 
^iippnr  itiiiii  ill.  iiiinf,  !»:<;{ 
.liiilmry  III'.  !i:»M 
lyniptiiiii.s  (il.  IKtl 
trciitiniMiI  III.  lUI 
siirKiiiil  HiiatDiiiy  nl,  !t2:i 
tllMlllls  111.   <IS(I 
ctliniiiiil.  <ISI 
Iniiitiil,  !IS1 
iiiaxillarv.  ilSI 
i>|ilii|ii>iil.i».Sl 


ini.riir,   120 
with  llic  plaiir  inirrdr.   121 
fi'iitral  ami  [MTiphiTal  nIiuiIhwi,  12.1 
rhnrailiT  of  tlif  ri'flrs,  122 
iw  II  niiilirinatory  ti'sf,  121 
ilctcriiiinatlon    iif    a.itii{iiiatisin    bv 
1^2 
of  irri'Kiilar  aitiKinatisin  liv,  123 
(IlKtancr  at   wliirli  ti-st   Is  madi-,   122 
f)i>iiit  of  ri'V<"r«>l,  120 
li'stiiiK  llu>  n'r<iilt.   122 
ll!<«-  of  cvclopIi'Kiis,  121 
ivernoiiv,   mliitiv.'  ihniiiil.i.Ms  of,    ,skin,   .lis<-a«'.-i   of   tlir.   .HV.w  of     upon 
■'*>**  the  o\v,  112!) 

etIunoiiUI,    -itriTliiiim  of.    inal.n.'iit    Skull,  .Irfomiitics  of,  iilalion  of,  to  di,- 

"',-'■'  eases  of  the  fvc,  (ill 

fronfal,  <>2t;  Srnell,  e.vn«li'Talioii  of.  10;{H.   (.sv,  Hvi 

ehroiiic  >inipiiiatioii  in.  )t.Vi  osinia.) 

roiiiplirations  of.  IMiO  loss  of,  KKJ.S.     (.SV,    \iiosniia  ) 

.li;i(rn.,sis  of,  it.Vl  |.erv.-i>ion  of.  I0,«».    (.>>,■  rarosniia.i 

iinpiilatiiiM  III    niiilillr  si'nsc  oi.  10,'<7 

lurliinaliil.  !r>s  ilist'urliniiii-  of,   10:{s 

liy   I'Mliision.   il.V.I  Sneezing,  exiessivr.   101,! 

nasal  e\-iiiiiinat ion,  <J.J7    Snellen's  Iran-parent  tivt-li'tter-    use  of 
-mnihnc     llie     Irontal         in   ileteilii.n   of   Miiiiilaled   aniiilvopia 


lyper- 


I  lansillninin.-Ltioti   li'.st,    Snow  lilinili 


!I.Vi 

olij.Tlioii>   lo.  !l.'',7 
trealiMint  ni.  MliO 

exiernal  nprr.Mlion. 

■Itil 
inli'.'iiiasal.  IHMI 
ral  lii'liTizinjJ 
anil  washing: 
out      fniiilal 
-imis.  ItfiO 
punrnire      of 
I  I  on  r       of 


.-.SI 


spasm,  laryntteal.  in  ailiilts.   lOPl 
ili.illiiosis  of,    lopi 
iliiiloiiy  of.    1(M!I 
syniptmns  of,    lOpi 
Irralmi'iii  of.   lot!) 
in  rliildhooil,  1017 

iliatinosis  of.   lfM8 
etiology  of.  1017 
■^yniptiinis  of.    I017 

treal nl  of.   lOl.N 

phonatiirv.  lOlil 
of  phar\ii\.   101", 
Spasmodic  entiopioii.  21!t 
heteiophoria.    IS} 


-inn-,  !MiO 
ili'Vi'lopinenl  uf.  !I27 

..•;!xi_llary,  !tsi  Sp,is.i,.  l„.,-,.r.,pl,„ri:,.  ls| 

tumors  ot.  !IM  iiiv,lria-i>.  .{2 

petrosal,     inlerliM'     ilinunlio-i-     of.  nivo-is    :il    :{2 

.  :',  Specillmn.  eve.  ,VXi 

siptnoid.     n.teHivi.     il,ron,l.i,-i-     of,  .s; ,„,    Watson's   ini-thml   in   tr..a.n„.n, 

'"'•>.      .  of  trii  iiiasis    2(s 

-pl.-Mioidal.  H'iS  >ph,.nii„|al  sinus,  !»2S 

:f!!".""'  ';''i.'.s'""""'   '"■   -'^  ifTeerion-  of.  trealinen,  of,  2n 

.■tnalotny  ol.  l»2s  anatoinv  ol.  !I2S 

ilininie  siippnr.-iuon  ni.  !)7H  deM'lop'm.'nt  ol.  !l2s 

i-van^ination  of.  1174   77 


if 


etioli 


iL'v  III.  !l7:f 


. 


iSf2 


I.MthX 


^|>ll^■|ll.i||lll    1.111     -.  ullllioll  111     ilii«-|li>-<  1 

111  ill-<'ii«i--.  !■■    ill''  "•>'\  .VM 
>Iilii'ni.il  iilitri  iihin,  •>.'> 

Splii'r(w\  liiiil  '     III! 
!*pliiini«rch -1-  iiiii'iiiir,  -tTtl 

Spilllll    inlil,    I'lTl  ,     •<   of    .1   -illll"^   111.    HI" 

llii'  eve.  iit,> 


Slr:»liisiiiii».  ilmTH''iil.  ninliii'ii'  nl.lTft 
ihiiiiitiii',  l.'iM 
(Kinks.    il;j 

illt'Timl  or  niin'ruiiii     ili.iL'ii'^'.ii  "U 
172 
.'  iiipliiii.-  !■'     I7'J 
I!"'  .'itin'-iit  '  i    17^t 
^iri-iilli'iM  i>|MT.iii(in  Kir  'ii.liiii>i-.  'J.Vt 


II II-     1-^1.       -'Tl* , 

iif    iiiiH'rii-"    III,    mwiii    till     «ilrf|>liiiiiriii«  pMiiJiiii-.  .l.-irni)iion  anil 
—  li.iltiiiloKiciil  Hiiiiiiliriiiiii-   ill  ili««a.-«'». of 


r\f,  *mI 
Spli-nir   hM-r.    Iil.lliull   III.    !■■  ili-<'»W 
I  III'   l'\r.    Ill  I 

Spt.i\-.  7  111 

liilllllll.r   111.    710 

llllllluil-i      "I       rllMII-illll!      III1-* 

I  111.. 111.  712 
^^|^rilll^  iiitiirrli,  -'lil 
eSpiirs  III'  111!'"'.  7'i'i 

il  iiriiii"!'  III.  7."i'i 
|i.'illiiiloi;\   III.  7,Vi 
Iri-iliiiiiii  111.  7'<i 
S)uiiii.   17'-' 

11(111.1:1111.    172 
ciin'.i'rji:*'.  '     172 
t'Mi'rii.'il.   1  ,  ') 

iiii-M-uiiiiii'iil  I'!.  Hiili  pt'riiiKti-i    17:! 
niiM>-niil:ii,  172 
Staiiiiiirriii!;.   IHI" 
iiii,lii«v  III.   lOHl 
Kviiiploiii-  111.  HM(t.   H).-.ll 
in-iiiiiii'iit  111.  IM'iO 
S(nj)i'.|,  lixutiiiii  III'.   ll"'> 
Staplivliiciiriic     pyi)^rni-<     aiin    -      li' - 
scniliun  ••iml  palliolucii'al  sipiifioaiH  •■ 

in   li;-':ls<"H  of    til"'   I'M-.    'iM 

Staph* I      '1,  ill" 

rnn  •■    |Ui*nc«'>  nf.  itl*^ 
((.-lliiii.ia,  ;U!t 
priiiiai>.    Ml 
rarrmiisi*,  HI 7 
of  sill  ra.  :i2S 
Hi'riiiniarv.  1117 
Ircalniini    nl.  HIS; 
StapliylotiiiiiN .  :t70 
Stcllaif  piiiii  11  liirri'P'<,  7l'2 
Sli-llwat'-  ^iu"    ill  i-\i'pli'li:iliiiii'  liiiii'' 

20".  I 
f^tchiifls  lit  lar\  ii\.  Mi7 

iliiilnyy  iif,  Mi7 
patliiiliiuy  iif,  S(i7 
syiiipliini-  of,  NlW 
Ircalinnil   of,   HIW 
ol  phani  \.  KKIS 
StenH)sr(i|)i'. 

190 
Stcrmitatiiii'.  HiCi 
■Stevens'  pi    'ronii-tiT.    H'lO.  li'il 

tnipiiii:' !•  r.   l."i'i 
.Stralii.'.imi'..   172 

altiTiialini:  roiiM-i;"  ni.  171 
liiaiiiiosis  '       171 

iX  lUpIiiMlS  III,    1  7  « 

tnaliii'iil  of.  17.'i 
ili\<'rji»'nt.   I7."i 

rtinlojiy  of.    1  7."i 
syiiiptnniM  III.   17i 


if         I  Iif  •■>!■,  liM 

Sirii".i*liiMii'^  Husk,   *iii! 
-tvc.  21J 
.-tvl's.  '2'2(l 
III    Siiliiliiral  al.M.    ■    lliil 

symploiiis  III     I  It'll 
tn'Btiiirnt  ol.  o|MraliM'.  11''2 
Sulilivaiiilil  liciiKirrliairr.   i'W 
Siilimiiriiii"  iiill.'iiiiiii.'iliiiii    li'l'i 

patholoKy  nl,  li'l.'. 
Kiil.^tamia  piopria.  2".t'i 
Slllrlls  iiliTW.  21M 
Sulplieiiial-iKiisoiiiin:.  ii-liiiioii  "i    lo  'lin- 

I'aM'.s  of  till'  I'M'.  ti<Ki 
Siippiiialiiiii  ill  Mrii's.«irv  i:i\iiii'^.  I'^o 

In  .|iii'iii'y  lit.  ".«"..  <.«ti.  9.17 
-.  iiipliiiii-  111.  ''H7  "^ 

111   aiilrriiH    crimp  of   -imis<'s,   coiii- 
hini'il.  ".»72 
itiafc[ini*is  of.  97*2 
ii'i'iiliiniit  of.  972 
iiiiliialions    for, 
972 
rlii'oiiii',  in  arii-'-Miry  -imis«"s,  93.'> 
ill  splifiioiilal  siinis,  97H 

iliairiio-is  of.  9".'H 
itiiiloi.'\  of.  97;{ 
I'xaiiiiliatioii  of.  97 1 
laiiula  fill'     wasli- 
iii(!    out    splicii- 
iiidal  sinus,  971 
iiiitlioils  of.  971 
symptoms  of,  97H 
tn'atnuiil   of.  977 
of  sinii-i  -.  9:«> 
Supr.ailuilioii.  iiii'asiirciiiiiii   ol.   I.tI 
Siipra-orliilal  iiotili,   192 
Siiprarcnal  i-vtract.  ilss'  ol,  in  ili-i';iscs  of 

ilir  niw  an.!  throat,  7 1."! 
.'^iipravairiii    '    'mi'I',  iil.'i 
.".iirsuiiivrir   M  •  .    I.V2 

Swrt't's    ipji.-i.a'us  for   loi'ali/iii>r  lorciffn 
,„„,  lidilios  in  till-  ryi'.  40<i 

i|   till',  ill  iH'tt'iotropia,    Svrrilili-pliaron,  '2."i.->.  ■29:< 
tri'atmcnt  of,  29;» 
Synipatliitir  opiithalmia.  S90 
Synrliisis  i-orpnris  \  HS7 

scintillaiis.  ;i.s7 
•Syneohia'.  anterior,  of  in ,  '      !  tiu'inliranc 
of  tlir  \ili'i'oi.        .aiH'Oiiia  fol- 
lowiiii!.  .'vlH 
of  iris,  ^laltroiiia  ioitoMiii^.  o4't 
of  l«'ii>  rapsuli',  iilaiii'onia  follow- 
ilifl.  .-.4H 
IHislerior,  .'t.">(l 
aiiiiiilar.  .'{.''id 


i.mh  \ 


ia;i 


.>Mi.'.|,,;. ,  |Mi«ii nor.  Ill  111.    uliiiii.iii.a  fdl 
li'WiiiK,   '>!<• 
Iiilal  ixi-liTKM,  .i.'i'J 
N.V|>hili«.   c'liiiKi'iiiiiil.   rflntmii  .■!     '„  clin- 
•  aws  (it  till'  1M-.  ()2ti 
of  riitijiih(ti\ii.  'J>f.i 
111  iv.|i,|,.  211 

inlHiilcil    (uTiii.iriiiii  iMii«ir-i  111    ;ii;i 
'II  iMrViix.HlS 

•«"nitii|nry.  SIS 

llilllflliwi.  Ill,    SIH 

|mlliii|iiu\   iif.  HS 
•vmiitdiiK  III,  Ms 
irialiiiiiii  I.I.  siH 
liTiiarv,  .Vil 

|>iitliiiliifi\    of,   KTil 
tri'Ht Ill  of.  H.jl 

of  IIOH..,  HKi 

acc|iiirr(|,  SI7 
iiiiiUi'iiital,  Mli 
rvitdiiloifinil  .iiiatonn  of,  7l);i 
-I  Toiiilarv,  HIT 

<lia({ii(i«i-i  of.  ms 
pallioloity  of.  HIT 
>viM|il<iiiis  of,  M7 
'i-tiiarv,  s|(t 

(liai-iiiiswof,  H4!t 
pallioloKv  of.  SV.t 
•,vm|it(iiiH  of,  Ml» 
ri'almi-iil  of,  Sl<» 
"I  |iharvii\,  .S.V) 
tiTliarv,  S.TO 

iliaRiiosis     iti.i     ililTiTonliai 

iliaKiiiisi.  of,  ,H,V> 
|iat!ioIo)ty  of.  S.lll 
<.viii|iioiii-iof.  .S.'iO 
'ri'iitmi'iil  of,  s.'iO 
rHlatioii  III,  loili-*ca>i'>of  iliiMvr  (121 
"f  "clcra.  .■12s 
I'f  throat.  Mti 

ao<niir»'(|,  S47 

I'niigonital.  HICi 

IHitholoifical  aiiatoiiiv  ol,  70;} 

SHiNiiidarv,  K17 

tcrtinrv,  Hl!t 

■  liaf;lI<|^^i^4  ol.  si<) 
patlioloKV  of.  H^l!» 
i.vmptoiiis  of.  S49 
treatiiii'iil  of.  H|9 
>.vpliilitic  I  'iiiriori'liiiitis,  :i7t 
irilii.  X',."i 
n-linilis.   121 
>vriiif?omyclia,  nlation  ni.  t,,  ,|i.*.a.s<s  of 
the  «'ye,  M.-f 

TABKS  ilors.ilis,  ii-lalion  of.  to  <li»f'«..-s 
1       of  the  cvr.  in.") 
Iifiiia    iiK'dioi'aiicllata     in    llif    vitrpoiis, 

'I'arsal  nstlit'iiopla.  KKt 

i-onjuiictiva.  2.W 
i'ijrsi.  Zil 

Tarsiti.s  sypliililiia.  211 
I'arsorrliapliy.  2;12 
IVnoiiilis.  I!J7 
I  "lion's  (•ap^■ll<■,  14!( 

78 


lt'lioii\  -|,a(i  ,  :il|,  ;tl.- 
IVtiof..|in,    partial,   in   Inalni.-ni    ul   ,.n« 
plioriit.  ItiH 
111  tr  ■itmi'iii  of  ivuplioria,  llitt 
I  I  liviM'rplii.ria.  171 
I'fUsioii,    •,   riiiiil  miliar,    iiiicliaiii^m   ii.r 
ill!    iiiainti  i.aiiif  ol.  ."i2l 
o'cilar.    I'fTi .  I    of   iiicri'a«,|     on    ili. 
"Inn  till         of     iln'    .M.    :,|„| 
tli<irn'>(»iiivi   Inn. lions.  r.2H 
met  h.  Ill  of  iiiilln(tiiiB,(|ii{i«i».  I, 
•'Iti 
Trrtiary  ■.^philisoi   iki-k',  H4!I 
ili,i)jii..-.in  of.  H4H 
p!illi.ilii)fy  of.  Ht!( 
•VI  ipliillis  of,    S  |i,| 
lri-:iliiiiiit    ,if.   Mil 
rent,  iT(|  (fli^>,  I  fit) 

I'liii-li,  177 
Ii'^t-cards.  lis.-  1,1.  1,1  ili'i.  rniiniiiit  rffra-f- 

li'in,   I2ii 
li-st-litlirv.    cstiiiialioi,    ol     n       inin.KJn- 
live  iHiui-r  In  iiiran    of,  7a 
of  n-fraclivi'  rii.iiliilon  In  inean>i 
of.  7;i 
nii'itioii  of   iiiraiiMiii;       .ii;.|  aciiilv 
with,  72 
TheobaUi  <  [>ni|)i  s.  21!> 
I  hoiiia^'  iitoiiiiziiit!  \a|ior'"  r,  !lll 
Thoni*m's  iiii"i'!i,»iio,i    ,,|    HolniKifiiM 
wmil-tf-.!    for  ilctrciion  ,,|   clor  hlind- 
nejw,  ,i7J 
rhroBt_a(liii,ii.iniiiiiiiia  o|'.  |)at|„,lo(fy  of. 

.uli'iioma  of.  pallu  l.itsy  of,  72* 
aiifcionia  of,  pailmlouv  o|,  721 
applicaiiiinsii,.  7U 
atrophy  of,  7 1 II 

I'lnillonia  •,!,  patliolom-  ol.  Vl^ 
oliomlroina  of,  pathol.ijiv  of.  721 
•  '.yulMof.  palhi|.ic\  of,  722 
diphtheria  .       s2l» 
di.-«'uws  of .  lii-t,,lo(jy  of.  lisd 

pailioloify  of,  livi 
i-Iiithelioma  of.  patlioloj[\     i,  71s 
'•''aiiiination  of.  iniiliod*  .i,  727 
Mliroanpioma  of.  |iai  IioIokv  of.  722 
lilironia  of.  patholoav  of,'72tl 
forfiitn  liodii's  in.  ,H7i 

diauiioKi.s  of,  ,S7 1 
removal  of,  S71 
hfinorrliaKfi  ol.  IHK) 
inflaninmtioii.s  ,ii.  ntNl 
leprosy  of.  Nti7 

pathology  of.  7(M 
lipoma  of.  paihologv  of  7211 
lupus  of.  HliTf 

hiHtolnKical  patholo^'v  of.  702 
invxoma  of,  patliolouy  of.  720 
papilloma  of,  liistolugv  of,  71(i 
«arc!!!ii;i  of    ;-.ti)}»-.li-.g\' .,i.  71;) 
sourx  y  of.  liiio 
."yphiiis  of.  Klii 

patholoRical  anatonn  of.  70;i 
seeondarv,  S4,s 
lertiarv,.S4<i 


l-2:;\ 


tM)h:X. 


Thnml.  tiihonulosisof,  patln>li>):vi>l',  099, 
-0() 
t>imors  of.  honign.  "lit 
mnligiiant,  71 M 
rt'ti'iitinn.  722 
Thromliiisis  of  caviTiioua  smiis,  201 
of  cwitral  artery  of  n-tiiia,  433 
of  ccrobral  \ossrls,  rolalioii  of.  to  ilis- 

casi's  of  the  i-ye,  '"33 
infi'etive,  of  cavi-riious  sinus.  IIGS 
ftioloKy  of,  litis 
syiuptoins  of.   lltiS 
I)roKnosis  of,  1 11)8 
of  (lotrosal  sinuses,  lltil) 
i>f  iijrtnoiil  sinus,  1122,  lll>3 
iliagnosis  of,  lltiS 
propiiosis  of,  lllVi 
symptoms  of,  llf>3 
iri-.ii  •lint    of,  opera- 
tive,  lltiti 
of  retinal  veins,  (jlaucoina  foUowinR, 
.•)52 
Thrombotic  retinitis.  127.  42S,  42!) 
Ihnish,    1014 

symptoms  of,  lOM 
treatment  of,  1014 
Todd's  "tucker,"  18i» 
Tonttue  depressors,  73."i 
Tonometers,   3(> 
'I'onsillar  abscess,  !)il3 

etiolopy  of,  !•!•.{ 
svmptoms  of,  '.IH3 
treatment  of.  il!t| 
tuberrulosis.   700 

ap(K'aranees  of.  7(MI 
forms  of.  700 
Tonsilhtis.  .icute  latarrhal.  !t!M) 
etioloKV  .>f.  IHlii 
svmptoms  of,  <H)0,  991 
treatment  of,  991 
lacunar,  991 

etioloisy  of,  991 
svmptoms  of,  991 
treatment  of,  992 
uheralive,  99,"> 

symptoms  of,  99.") 
trealnient  of,  995 
Tonsillolitlis.  UKW 

definition  cf    1(KI3 
symptoms  of,  UK);< 
treat meiit  of.  1(K)3 
'J'oiisils,  larcitiom.'i  of,  l(Ht4 
diagnosis  of,  100.') 
patholoRy  of.  1004 
treatment  of,  100.") 
evslsof,  722 
liiseasi's  of.  9!HI 
lorciirii  boilies  in,  1003 
hv|)irlrophv  of,  990 
.tiolody  of,  •»!«; 
*\inpttin)s  of,  t)90 
In'atment   of,  997 
local.  9'.»7 
operative,  999 

after-|re:itment,   1002 
cold  wire  snare,   1001 


Tonsils,    hypertrophy   of,  treatment    of, 
op<>rative,       electric 
wire  snare,  1001 
eimcleation,  10().'t 
(Tuillotine,  999 
lineual,  UH)5 

hypertrophy  of,  10O."> 
location  of,  lOO.'i 
operations  on,  !M(9 
sarcomata  of,    1(K)3 
diiiKuosis  of,  1(X)4 
etiology  of.  1003 
svmptoms  of,  1004 
treatment  of,  1004 
tumors  of,  1003 
benign.  1003 

angioma,  1003 
echinococi'us  cysts,  UK)3 
fibrochondroma,  1003 
fibroma,  1003 
papilloma,  1003 
m:dignant,  l(K)3 

carcinoin:-.,  1(X)4 
sarcoma,  1003 
wounds  of.  lOOS 
Toric  lenses,  (10 
"Touch  test,"  177 

Toxalbumin-poisoning,  relation  of,  to  dis- 
eases of  the  eye,  (i08 
Trachea,  relation  of  diseases  of,  to  dis- 
eases of  the  eye,  .WS 
thyroid  tumor  of,  '.K)3 
Tracheal  injections,  .*<(K) 
Trachoma,  2<')2 
Traumatism  of  larynx,  919 
Treatment  of  adenoid  vegetations,  102,\ 
of  adenoiiia  papillare,  SSS 
of  albinism,  371 
of  anasthesia  of  pharynx.  1043 
of  anosmia,  1039 
of  anosphn-sia.   1039 
of  asthma.  H09 
of  atrophic  catarrh  of  middle  ear, 

1197 
of  benign  Lunors  of  iris,  3.')9 
of  bleeding  poivpns  of  sept'im.  SK) 
of  blepharitis,  242 
of  blephan)spasm,  234 
of  blooil-staining  of  cornea,  322 
of  carcinoma  of  larvnx,  90t) 
of  nast)pharynx,  103.") 
o.  tonsils.  U)0') 
of  cataract.  .")03 

complicated,  .M)ti 
lenticular,   .Wl 
tramuatic.  ls;t 
zonular.  .101 
of  iilhilitis  of  orbit,  19.') 
of  cerebellar  abs.X'ss,  otic.  1171 
•  if  cerebral  abscn.ss,  otii'.  1171 
of  cerebrii-s[)inal  rhiTiorrhiea,  1043 
of  chalazion.  243 
of  chondroma  of  larynx,  !K)3 
of  chorea  of  h.rvnx,  1(M9 
of  choroidcl  ci>l"boma.  .171 
of  choroiditis,  ai  ute  exudative.  373 


i\ni:x. 


1 2:i.") 


Treatment  of  tlioruiilitin  noiliwii,  S28 
mipptirativf,  ;}7« 
of   chronic    9upp\irntiim    of    frontal 

sinus,  (HK) 
of    circiinisi  rilK^I    inHaiiitnation    nf 

auditory  iiifatus,  1080 
of  roncavi-  vertical  dcforniitv  of  nose, 

1000 
of  congenital  aiionialies  of  tlie  eye- 
lids, 2:i8 
of  conjuRnlc  paralysis.  1.S2 
of  conjunctiviiis,  ni'ute  contaj?ious, 
209 
chronic,  2H.') 
diphtheritii ,  277 
follicular,  2(i2 
gonorrho'iil,  272 

ffranular,  20,5 
acrvmal,  2(i0 

lithiasia,  2U1 

menihranous,  27S 

phlyctenular,  281 

.simple,  2(iO 

subai'ute,  270 

toxic,  281) 

vernal,  2t)2 
of  cyclitis    3.5ti 
of  cyclr.piioria.  171 
of  dacryoaiicnitis,  acute,  216 

chronic,  210 
of  dacryocystitis,  228 
of  deaf  nuit  ism,  1107 
of  diffuse  inllaniniation  of  auditory 

meatus,  lOlM 
of  diplit  heria  of  nose,  834 

of  pharynx,  834 
of  disi'ases  of  uvula.  987 
of  eczema  of  external  ear.  1081 
of  elonpition  of  uvula,  988 
of  emphysema  of  conjunctiva,  287 
of    cmpvema    of    anterior    ethmoid 
cells,  !«i8 

of  antrinn  of  Hijjhmore,  948 
of  entozoa  in  vitreous  humor,  389 
of  epiphora.  221 
of  episcleritis,  :l2."i 

liersisteiit,  320 
of  epistaxi>.  749 
of  esophoria,  107 
of  ethmoidal  siippuraiion.  972 
of  Eustachian  <atarrh,  chronic,  1185 
of  exophoria,  10."> 
of  exophthalmic  goitre,  209 
of  fibroma  of  nasopharynx,  1033 
of  fistula  of  cornea.  3(N1 
of  foreign  bodies  in  cornea.  322 
ill  external  ear.  1093 
in  nose.  7.">0 
in  lubit.  199 
of  forward  prolongation  of  si-ptuni, 

702 
of  fraetun'S  of  mo.s(>,  1050 

neplecled.  liHil 
of  frontiU  sinus  suppuratio.i,  972 
of  plauconia,  primary,  ."i.Vi 
of  gout  of  ll oiijiiiiili.a,  2t)7 


Treatmeiit  of  lia\   fever,  802 

of  hemorrhage  into  vitnuus  humor, 

388 
of  herpes  cornea',  310 
of  pharvnx,  1014 
of  hvahtis.  .iso 

hygienic,  of  ref>-active  errors,   141 
of  hypera'Sthesia  of  larynx.  ItHO 
of  nose.  1041 
of  pharynx,  1044 
of  hyi«>rosniia,  1038 
of  hyiK'iosphresia,  103^ 
of  hyperphoria,  170 
of  hypertro|)hy  of  tonsils,  997 
of  impacted  cerumen,  1088 
oi    infective   thrombosis  of   sigmoid 

sinus,  II  (iO 
of  influenita,  807 
of  injuries  of  conjunctiva,  287 

of  orbit,  199 
of  intrana.sid  adenoma.  891 
adhesions.  751 
fibrom.i.  887 
Jiapilloma.  888 
sarcoma.  896 
of  iritis,  ,350 

diabetica,  358 
Konorrlueica,  358 
rheumatica,  3.">8 
syphilitii',  3.58 
of  kei7\lectasia.  319 
of  keratitis,  bullous.  311 
deej)  vascular,  310 
desiccation,  30S 
eczematous,  2it9 
filamentous,  .300 
marKinal,  302 
neuroparalytic,  309 
parenchymatous.  314 
selerosinft,  315 
of  keratoconus,  320 
of  lagophthalmos.  233 
of  laryngeal  \erti(fo.  1052 
of  luryngitis,  acute.  810 

in  childhood.  81t> 
clironic.  821 
dry.  825 
hyiMiKlottic.  S23 
hiemorrh.'iisica.  810 
hypoulottica.  MO 
pachydermia.  827 
rheumatic,  816 
sicca  acuta.  810 
of  leplomeiiiiigitis.  purulent,  1103 

serous,  1102 
of  loss  of  vitreous  humor,  3.S8 
of  lupus  of  larynx,  807 
of  iios*'.  S07 
of  throat,  ,S07 
of  lyinphaiiKiectasis.  290 
of  malittnanl  tumors  of  irjn.  300 
of  mastoiditis,  1 148 
of  maxillary  suppuration.  972 
of  mcmbianous  u   (jina.  990 
of  nuicfxi'le,  211.  224,  9SII 
in  infant'^,  220 


12.S« 


IM>KX. 


Tn-iitmcnt  i<\  iiivi<'<is.  lol."> 

of  ii;i>al  hviiio.Tliu'.i    1(H2 

liyiMTllopiiir-i.  7t).") 

IMilyps.  7li."> 

with  siiiiisili-i,  SS) 
iif  ii:iMi|)li,iryii(jili  i,  .•icuti',  10'2() 

chroiiii-.  11(22 
i>i  nciiativr  |>rrssiii('  of  tvmpiiniim, 

I  lit!) 
Ill'  iii'cipl!iMii>  111'  Ijiryiix.  '.KM) 

of  M()s<'-I)l 1.  7l'.t 

of  opa^iti('^  in  vilri'oiis  humor,  386 

oiK'nitivi'.  Ill  ^uiMl'iral  absci'ss.  111)2 

of  ophihahniu  nt'onatoruni,  275 

of  ortha'inalon.i.  lOSd 

of  osteitis  of  orbit.  197 

of  iisti'i-ma  of  orbit.  206 

of  otitis  ini'dia  iiuiiilriita  ai-.ita.  1129 

I'liroiiica.  Il^.'i 
af    111'    lyrosis,  1()!»2 
<ii  [lachyiiiciiiiDsitis  cxIiTiia.  1161 
I  f  paiiims.  ;1U( 
of  pnrnsinia.  I(I4(( 
of  iM'tiiphiRus,  2t>.S 
of  |H'riiistitis  of  orbii.  1(17 
of  poritonsillar  aliM-rss.  !)!)4 
of  pharyngitis,  aiutc.  1009 

acute  phle^iuouiiiis.  101.3 

••itrophii',  \U\2 

rhroiiir  trraiiular.  101 1 
simple,   1010 
of  (Kilypoiil  lysts.  SHI 
of  pseiidoiiiiiip.  siti 
of  pteryciuni,  2.H9 
of  ptosis.  2:i."> 

of  puls;itiinr  i\ii|ilii(ialiiios,  2IX) 
of  n'troph.-iryiiseal  al)scess.    .,)ls 
of  rhiiiilis.  arule.  771 

alropliii-.  79.") 

fibrinous.  7W 

hyixTtrophic.  7S2 

simplex,  7.S2 
of  rhinolilhs,  S7.t 
of  rhinorrhu'a.  SOii 
of  rupture  of  ihoroiil.  A-" 
of  .sareotna  oi  larynx,  ihiii 

of  nas  ipharvnx.   lOli.") 

of  iiriiit.  207 

of  soil    p;llale.  !I!HI 

of  tonsils.  llM),-> 

of  u\ula,  9'.M) 
of  sileral  iilasia-,  :V2S 
of  silero-kerilo-iritis.  :!27 
of  sp..,vni  of  larvnx  in  adults.  1019 

ill  ellililhnoil,    lots 
oi  spurs  of  nosi',  7.''!l) 
ot  si.ainnierintr.  lO.'iO 
ol  st.iphyloina,  .ils 
of  stenosis  of  1,-iryiix.  MiN 
of    strabismus,    allenintiiu;    lonver- 
(fenl.   17-") 

i|i\er({ent.  17.") 

internal  eonvere 'lit,   17K 
ol  striated  opaiilies  oi  cornea,  316 
"f  siippuralioii.  acute,  of  accessor)- 
-iniisi's.  >>:» 


Tn^atiuenf    of    sup|iuratii)n    in   anterior 
){rou|)  ol  sinuses,  972 
chronic,  in  sphenoidal  sinus.  977 
of  .symblepharoii.  293 
of  sympathetic  ophthalmia,  '.Wi 
of  syphilis  of  larynx.  S,")l 
secoinlary,  H4H 
of  nose,  tertiary.  HA'J 
of  pharynx.  H'A) 
of  sclera,  329 
of  throat,  tiTtiary.  H49 
of  t'jrombosis  of  cavernous  simis,  202 
of  thrush.  101.') 
of  tonsillar  abscess.  994 
of  tonsillitis,  .•icule  catarrhal,  991 
lacunar,  992 
ulcerative,  99.") 
of  tonsilloliths.  KNU 
of  trichiasis.  24S 
of  tuberculosis  of  nose.  H.W 

of  larynx.  H.")9 
of  tumors  of  accessory  sinuses.  9Sl 
of  maxillary  sinus.  9H1 
of  optic  nerves.  20.") 
of  uviilitis.  9.H7 

of   wounds   of   iiieiubrana  tvnipani, 
1096 
Trial  ease,  use  of.  in  determining  n-frac- 

tion,  126 
Frichiasis.  treatment  of,  24H 
Trochlciris  palsy.  ISO 
I'rophoneuroses,  etTccI   of,  uixin  the  eve, 

(H9 
r-'heriiing's  theory  ol  the  mechanism  of 

.accommodation.  OH 
I'ubercular  disease  of  the  middle  ear,  1121 
leptomeniiiKilis  in  mastoiditis,   1121 
iiuningitis.  relation  of,  to  disi^asi's  of 
the  eye,  (i.'V.I 
luberculosis.  adenoid.  701 
of  eonjimctiv,!.  •2.H2 
of  larynx.  701.  s-,:i 
pathology  of,  702 
clinical  apiH'arancc  ol.  702 
of  nose.  ,s.")l 

pathoIog\   of,  ti99.  700 
of  pharynx.  S.")2 

relation  of.  to  diwases  of  the  eve,  628 
tonsillar.  7(K) 
I'limores  cavernosi  of  eyelids,  241 
1     mors  of  ,aceessor\*  sinuses.  9.S1 
diairnosis  of.  OKI 
ireatneiit  of,  !)S1 
benign,  of  eMi-rn.al  car,   lOsH 
of  nose,   719 
of  palate,  9S9 
of  tliro.n,  719 
of  UMila,  9,S9 
of  ethmoid  sinus,  9M 
of  frontal  ^iiius.  9H1 
of  internal  ear.  1 104 
of  laruix.  H97 

adenoma.  9t)3 
angioma.  <H)2 
cnreinonia.  !K)1 
ehondroniM    902 


iM>h:\. 


li'M 


Tiliiiiir*  111    l.irviix,  (■v^«l^^  of.  !H11 
Hbroiim.  !K)l 
li|H>in!i,  •NI2 
myxoma.  901 
pHpilloma,  S!»7 
^aic'omn,  DOS 
ll  vroid,  '.KM 
njitli)!imiit.  of  nos)',  TIH 

of  (hroiit.  71S 
of  iiKixilltiry  sinus,  9S1 

iliaKiiosis  of.  UfSl 
treatment  of.  OHl 
of  nasopliarynx,  10;t2 
lieniKn.   I0H2 
tihroniata.   KKi'J 
filironiui'oiis  polypi.  104.5 
nialiKiiant.  IDH.'i 
of  nose.   .S77 

ni:ili)rnant.  S".(2 
of  oiopliaiytix.  1017 
ri'teiitiofi.  of  nnicosa.  722 
of  nos<'.  722 
of  throiit,  722 
of  sphenoid  sinus.  '.tHl 
of  tonsil.  UKIS.     Off  Tonsil,  Tnniors 
of,) 
Tunii'a  vasenlo^a  lentis.  :W2 
Tiirek's  i  inpiie  depressor,  7Ho 
TvMipiinie  nienilirane,  inas.sape  of,    lisl 
Tyinpanoloiiiy.  I'xploratory,  1V92 
Tvinpaninn     nepitive  pressure  in.    lUI.S 
causation  of.  ll!tS 
diagnosis  of.   ll'.d* 
palliolojjy  of,  ll!»s 
[irognosis  of.  ll'.HI 
^\'niptouis  of,   WM) 
treatment  of,  1  l!HI 
varialionv    in    atinospherie    press.itr 
in,  11(».S 
lausation  of,  111)8 
elianfces   proc'  lO'd    liv, 

119S 
diagnosis  of,  110'' 
nepilive  pressure,  I  l(»s 
patlmlogy  of.  1  \**^ 
propn<»sis  (tf,  1 109 
svmptoins  and  signs  of. 

1199 
tre.atnieiu  of,  ll91t 
Tvplioid  fever,  leLilion  of,  to  diseases  of 

the  I've,  tiHi 
Typhus  fever,  relation  of.  lo  disi'uses  of 
,  '  till'  I've,  (il7 

reeurn'iis.  relation  ol ,  lo  diM-ax-^  t-i 
the  eve,  (517 
ryr.ll'~  hlnnt  hook,  ,">1 1 

II.Ml.ArKH AI.  paralvH-  ol  lie-  orhiial 
I'  muscle-.   179 

reflex  iridoph-gia,  :t2 
I  rami c  ^iniaurosis,  424 

amlilviipia,  ,"i77 
Urie-ai'id   diathesis,   relation   of,   to  dis- 

ease«  of  the  eyi',  (iOl 
Urinai>    ingans,    ellects   of    iliseasi's   of. 
upon  the  eye,  .")9S 


I  rliearia.   relation  of,  lo  di»eas<'s  of  the 

eye,  tWl 
Ivca,  anatomy  and  physi")logy  of,  H3t> 

nerves  of.  :{43 
Uveal  tract,  development  of.  HH.'i 
I'veitis.  anterior,  ;{27 
Ivtda,  9S9 

ailenoma  of,  9H9 
aiifiioma  of,  9S9 
benign  growths  of,  9X9 
degeneration  of  iniisculur  fiUn's  in, 

724 
diseases  of,  9.S7 

diagnosis  of,  9X7 
etiology  of,  987 
.symptoms  of,  987 
lr("Htment  of,  987 
ilongation  of,  987 
causes  of,  987 
symptoms  of,  987 
treatment  of,  988 
JKcinatoma  of.  988 
m.alfonttations  of,  08.5 

congenital,  985 
Mialigiuiiit  growths  of,  9.S9 
carcinoma  of,  989 
papilloma  of,  989 
sarcoma  of,  !*90 
1  \ulitis,  987 

iliagnosis  of,  987 
itiology  of,  987 
symptoms  of,  987 
tn'atinent  of,  087 

Y  \rcr\AI'I(>N,  n'lation  of,  to  <lise:ises 
'       of  the  eye,  lilt) 
Vaccinia  of  the  evelid.  210 
Valve,  Hasner's,  210 
\  an  Ciieson's  methoil  tor  preparing  .■■<'c- 

tions  of  the  eyehall,  •)7<) 
\'an  Milligen  operation  for  trichiasis,  252 
\'aricella,   relation  of,  to  diseases  of  the 

exe.   010 
X'aricose  veins  in  the  orliit,  2(H 
Variola,    relalion   of.    to  di.seases  of   the 

lye.  01  J 
\'arioloiis  eruptions  n|M>ti  the  eyelid-.  210 
\  ascular  engorgi'ment,  chronic,  of  niiildle 
ear.     with    exu- 
dation,  IISO 
diagnosis  of.   1 1.S8 
etiology  of.    lIHIi 
prognosis  ui.  1 IS7 
symptoms  ol.U.87 
\  .i-oniotor  catarrh      '  .nVc  Hay  Kever.f 
rhinitis.  091 

p.'ithology  of,  091 
\  ra-i  \  s  portable'  sterilizer.  0.5(i 
Veniricle.  laryngeal,  prol.ipse  of,  903 
\  inlricular  hyix'rtrophv.  713 
Vernal  conjunctivitis,  2t)l 
\ertigo,  laryngeal.  1051 

etiologv  of,  1(1.51 
prognosis  of,  10.52 
symptoms  of,  1052 
treatment  of.  10.52 


12»8 


i.\jn:x. 


^'irtual  focus,  /i" 
Vision  in  astifnn.-itism,  101 
binocular,  74 
cell?,  3.34 
ilislurbaiii'cs  of,    witlioul    apjiurent 

Ir'sion,  M\S 
pliysiolopy  of,  53 
Visual  acuity,  71 

cxcccdiiii;  the  .•.taiidanl,  7.S 
method  of  mcii^uriiiE,  with  Icst- 
Itttors,  72 
anulc,  71 

field,    cccTiitrio    contrai-tioii    of.    in 
prav  atrophv  of  optic  nerve, 
440" 
lionionyniuu.s  (juadrant  hemian- 
opsia. 447 
normal.  44.5 
.sen.sation,  duration  of  the.  74 
Vitreous   humor,   bloodvessel   formation 
in,  3S7 
clmnKes  in  the,  in  primary  glau- 
coma. 'hi'A 
eholesterin  crystals  in,  3^7 
eonpenital  anomalies  of,  3S.5 
de(5en<'ralionK  of,  3S7 
detachment  of,  3S7 
development  of.  V.^? 
ento/oa  in,  38S 

In-atmenl  of.  3W.( 
exudation  uito,  in  cyclitis,  3.52 
fattv  defeneration  of,  387 
fluidity  of,  387 
hcinorrhape  into.  .388 
treatment  of,  388 
injuries  of.  38" 
loss  of.  387 

tnatment  of,  388 
macroscopic  anatomy.  ,384 
tnicro-Hcopic  anatomy.  38,5 
opacities  in  the,  3H.5 

treatment  of.  38t'i 
physioloEV  of.  3.84 
pseudofslioma  of.  .387 
Vocal  rords.  carcinoma  ))oly)xiides  of,  905 
pachvdcrmia  of.  713 

hi.stolo)tical    pathologv    of, 
713 
nodules,  71') 
Von  Graefe's  cvslotomc,  .511 


\'oii  tiraefe's  linear  knife,  3t)4 

sipn  iti  exophthalmic  Roitre,  20!» 

W.VTSON  o|K.-ration,  701 
Weber's  canaliculus  knife,  222 

Weeks'  scarificator,  2t)0 

Weigert's    method    for    staining    nerve 
sheaths,  (177 

Wernicke's  sign,  34 

Whistler's  cutting  dilator,  8t)9 

White's  jialate  retractor,  734 

Whooping-cough,  relation  of.  to  diseases 
of  the  eye.  020 

Wilder's    ojH'ratioii     for    correction    of 
ptosis,  237 

Wilkinson's  disease,  relation  of,  to  dis- 
eases of  the  eye,  (>42 

Wolfe's  method  of  blepharoplasty,  240 

WollT's  oi)eration  for  I'orrection  of  ptosis. 
230 

Wright's  na.»jil  snaii',  704 

X-HAYt5,    use  of,  in    locating    foreign 
bodies  in  the  eye,  405 
Xanthela.sma,  244 
Xanthoma  palpebrarum,  592 
Xerophthalmia,  285 
Xerosis  bacillus,  684 
epithelia'is,  278 
cause  of,  278 
complications  of,  279 
description  and    svmptoms  of. 

278 
diagnosis  of,  279 
pathology  of,  279 
treatment  of,  279 
infantilis,  278 
triangularis,  27S 

\''ELLOW  fever,  relation  of,  to  diseases 
of  the  e-o,  621 
Young-Helniholtz  theory  of  color  \  ision, 
.570 
of  production  of  coloi-.  54 

yEISS.  glands  of.  231 
/j     Ziegler's  pri.sni-scale,  140 
Z'nn,  zonule  of,  340.  470 
Zonular  cataract,  41K),  ,504 
Zonule  of  Zinn,  310,   170 


f&f 


mm 


